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Showing 20 questions, Sign in for more(from search results) A nurse discovers a postpartum client with a boggy uterus, displaced above the right of the umbilicus.
What nursing action is indicated?
Explanation
The correct answer is choice D. Both A and B.A boggy uterus is a uterus that is enlarged, soft, and tender due to the failure of the uterus to contract sufficiently after delivery.This condition is called uterine atony and it is the most common cause of postpartum hemorrhage.Postpartum hemorrhage is excessive bleeding after childbirth that can lead to shock and death if not treated promptly.
The nursing actions indicated for a boggy uterus are:
• Perform immediate fundal massage: This helps to stimulate uterine contractions and reduce bleeding.
• Ambulate to the bathroom or use bedpan to empty bladder: This helps to reduce bladder distension and allow the uterus to contract and descend into the pelvis.
Choice A is partially correct but not sufficient by itself.
Choice B is also partially correct but not sufficient by itself.Choice C is incorrect because administering oxytocin alone may not be effective in restoring uterine tone if there are other factors contributing to uterine atony, such as overdistension, prolonged labor, or infection.Oxytocin is a hormone that stimulates uterine contractions.
(from search results) What factor places the postpartum client at risk for thromboembolism?
Explanation
The correct answer is choice A. Increased clotting factors.Increased clotting factors are a physiological adaptation to pregnancy that reduces the risk of hemorrhage during delivery, but also increases the risk of venous thromboembolism (VTE) in pregnancy and postpartum.The risk of VTE is highest in the first week after delivery and gradually declines over the next 12 weeks.
Choice B is wrong because decreased blood volume is not a risk factor for VTE.In fact, blood volume increases by about 50% during pregnancy to meet the increased metabolic demands of the mother and fetus.
Choice C is wrong because increased cardiac output is not a risk factor for VTE.
Cardiac output also
(select all that apply, from search results) What are three signs of positive bonding between parents and newborn?
Explanation
The correct answer is choices A, B and C.These are three signs of positive bonding between parents and newborn.
Calling infant by name shows recognition and affection.
Exploration of newborn head-to-toe shows curiosity and interest.
In face position shows eye contact and communication.
Choice D is wrong because avoiding eye contact with newborn is a sign of detachment or depression.Choice E is wrong because holding newborn close to chest may prevent eye contact and facial expressions.
Positive bonding is essential for a baby’s healthy development and attachment.
It makes parents want to shower their baby with love and care, and it makes babies feel secure and confident.Bonding can happen at any time, but it usually starts right after birth or adoption.
A nurse is assessing a client who delivered an infant vaginally 2 days ago and notes that the fundus is firm, midline, and at the level of the umbilicus, lochia rubra is moderate, and there are no clots present in the lochia flow.
Which of the following actions should the nurse take?
Explanation
The correct answer is choice A) Document findings as normal.
The fundus is the upper part of the uterus that contracts after delivery to prevent bleeding.The fundus should be firm, midline, and at the level of the umbilicus or lower on the second postpartum day.Lochia rubra is the normal bloody discharge that occurs for the first few days after delivery and should not contain large clots.The normal range of lochia rubra is scant to moderate.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm and does not need further stimulation.
Choice C) Administer oxytocin (Pitocin) is wrong because oxytocin is a medication that helps the uterus contract and is not indicated for a firm fundus.
Choice D) Increase IV fluid rate is wrong because IV fluids are not related to the assessment of the fundus and lochia and may cause fluid overload.
A nurse is caring for a client who delivered an infant vaginally 2 days ago and notes that there are no clots present in the lochia flow, but there is moderate bleeding with bright red blood and small clots present when massaging the fundus which is firm, midline, and at the level of the umbilicus.
Explanation
The correct answer is choice C) Administer oxytocin (Pitocin).Oxytocin is a hormone that stimulates uterine contractions and helps reduce postpartum bleeding by closing off the blood vessels that were attached to the placenta.
The nurse should administer oxytocin as ordered by the provider to help the client’s uterus contract and prevent hemorrhage.
Choice A) Document findings as normal is wrong because moderate bleeding with bright red blood and small clots is not normal for lochia flow 2 days after delivery.Lochia is the vaginal discharge that occurs after birth and consists of blood, tissue, mucus and bacteria.Lochia should be dark or bright red for the first 3 to 4 days, but the flow should be light and there should be no clots.Moderate bleeding with bright red blood and small clots indicates that the client may have retained placental fragments or uterine atony.
Choice B) Massage fundus until it becomes firm is wrong because the fundus is already firm, midline and at the level of the umbilicus, which indicates that the uterus is contracted properly.Massaging the fundus when it is already firm can cause more bleeding and pain.
Choice D) Increase IV fluid rate is wrong because increasing IV fluid rate will not stop the bleeding or address the underlying cause.Increasing IV fluid rate may also cause fluid overload or dilutional coagulopathy.The nurse should monitor the client’s vital signs, urine output and hematocrit levels to assess for signs of hypovolemia or anemia due to blood loss.
A nurse is assessing a postpartum client who delivered vaginally 2 days ago and notes that her fundus is boggy and displaced to the right side of her abdomen.
Which of the following actions should the nurse take first?
Explanation
The correct answer is choice D. Massage her fundus.
This is because a boggy and displaced fundus indicates uterine atony, which is the failure of the uterus to contract sufficiently after delivery.
This can lead to excessive bleeding and postpartum hemorrhage.Massaging the fundus can help stimulate uterine contractions and reduce blood loss.
Choice A is wrong because administering oxytocin is not the first action the nurse should take.Oxytocin is a medication that can also help the uterus contract, but it should be given after massaging the fundus and assessing the bleeding.
Choice B is wrong because assisting with ambulation is not appropriate for a client with a boggy and displaced fundus.Ambulation can increase bleeding and cause orthostatic hypotension due to blood loss.
Choice C is wrong because encouraging frequent voiding is not the first action the nurse should take.
A full bladder can displace the uterus and prevent effective contractions, so voiding can help the uterus return to its normal position.However, this should be done after massaging the fundus and assessing the bleeding.
A nurse is caring for a postpartum client who reports heavy vaginal bleeding and passing large clots since delivery 2 days ago.
Which of the following actions should the nurse take first?
Explanation
The correct answer is choice B. Palpate fundus.The nurse should first assess the tone of the uterus by palpating the fundus, as uterine atony is the most common cause of postpartum hemorrhage.
If the uterus is boggy or soft, the nurse should massage it gently until it becomes firm and contracts.
This will help control the bleeding from the placental site.
Choice A is wrong because assessing vital signs is not the first priority in this situation.Vital signs may not reflect the severity of blood loss until late in the process of hemorrhage.
The nurse should monitor vital signs after ensuring that the uterus is contracted.
Choice C is wrong because administering oxytocin as prescribed is not the first action the nurse should take.
Oxytocin is a medication that stimulates uterine contractions and reduces bleeding, but it should be given
A nurse is caring for a postpartum client who delivered vaginally yesterday and has been experiencing heavy vaginal bleeding since delivery.
Which of the following actions should the nurse take first?
Explanation
The correct answer is B. Palpate fundus.
The nurse should first assess the fundus to determine if it is firm and at the expected level of involution.
A boggy or displaced fundus can indicate uterine atony, which is the most common cause of postpartum hemorrhage.
By massaging the fundus, the nurse can stimulate uterine contractions and reduce bleeding.
A. Assess vital signs.
This statement is wrong because assessing vital signs is not the first action the nurse should take.
Vital signs can indicate the severity of blood loss and shock, but they do not address the cause of bleeding.
C. Administer oxytocin as prescribed.
This statement is wrong because administering oxytocin is not the first action the nurse should take.
Oxytocin is a medication that can enhance uterine contractions and reduce bleeding, but it should be given after assessing and massaging the fundus.
D. Check perineal pad.
This statement is wrong because checking perineal pad is not the first action the nurse should take.
Checking perineal pad can help estimate the amount of blood loss, but it does not address the cause of bleeding.
A nurse is caring for a client who has postpartum endometritis and is receiving IV antibiotics.
Which of the following findings indicates that the treatment is effective? A) Decreased vaginal bleeding.
Explanation
The correct answer is D) Decreased white blood cell count.Postpartum endometritis is an infection of the lining of the uterus that causes fever, abdominal pain, uterine tenderness and sometimes discharge.It is usually caused by bacteria from the lower genital or gastrointestinal tract.White blood cell count is a marker of inflammation and infection, so a decreased white blood cell count indicates that the treatment is effective and the infection is resolving.
A) Decreased vaginal bleeding is not a sign of effective treatment for postpartum endometritis.
Vaginal bleeding after delivery is normal and gradually decreases over time.It is not related to the infection of the uterus.
B) Increased abdominal pain is a sign of worsening infection, not effective treatment.Abdominal pain is one of the symptoms of postpartum endometritis and should improve with antibiotic therapy.
C) Increased temperature is also a sign of worsening infection, not effective treatment.Fever is another symptom of postpartum endometritis and should decrease with antibiotic therapy.
A nurse is caring for a client who has postpartum endometritis and is receiving IV antibiotics.
Which of the following instructions should the nurse include in the plan of care? A) Encourage fluid intake to promote hydration.
Explanation
The correct answer is choice A) Encourage fluid intake to promote hydration.
This is because hydration helps to flush out the infection and prevent dehydration from fever.
Fluid intake also supports milk production for breastfeeding.
Choice B) Instruct the client to avoid ambulation until symptoms resolve is wrong because ambulation promotes blood circulation and prevents thrombosis.
Ambulation also helps to expel lochia and reduce uterine cramping.
Choice C) Administer analgesics as prescribed to manage pain is correct but not the best answer.
Pain management is important for comfort and healing, but it does not address the underlying infection.
Choice D) Instruct the client to avoid breastfeeding until symptoms resolve is wrong because breastfeeding helps to contract the uterus and prevent bleeding.
Breastfeeding also provides immunity and nutrition to the newborn.
The infection is not transmitted through breast milk.
Choice E) Encourage frequent voiding is correct but not the best answer.
Frequent voiding helps to prevent urinary tract infections and bladder distension.
However, it does not directly affect the endometrial infection.
A nurse is caring for a client who has postpartum endometritis and is receiving IV antibiotics.
Which of the following findings indicates that the client is experiencing an adverse effect of the medication?
Explanation
The correct answer is choice A) Nausea and vomiting.This is because nausea and vomiting are common adverse effects of many antibiotics, especially clindamycin and gentamicin, which are often used to treat postpartum endometritis.Nausea and vomiting can also indicate a more serious complication of antibiotic therapy, such as Clostridioides difficile infection.
Choice B) Increased appetite is wrong because antibiotics do not typically affect appetite, and postpartum endometritis may cause loss of appetite due to fever, pain, and inflammation.
Choice C) Increased urine output is wrong because antibiotics do not usually increase urine output, and postpartum endometritis may cause dehydration due to fever and vomiting.
Choice D) Decreased heart rate is wrong because antibiotics do not generally lower heart rate, and postpartum endometritis may cause tachycardia due to fever, infection, and sepsis.
Question 48.
A client who has undergone a cesarean section is experiencing abdominal pain and tenderness.
Which of the following should the nurse assess for?
Explanation
The correct answer is choice E) Signs of peritonitis.
Peritonitis is an inflammation of the lining of the abdominal cavity that can be caused by an infection or a perforation of an organ.
It can cause severe abdominal pain and tenderness, fever, nausea, vomiting, and decreased bowel sounds.Peritonitis is a medical emergency that requires immediate treatment with antibiotics and surgery
Choice A) Bowel sounds is wrong because bowel sounds are normal and expected after a cesarean section.
They indicate that the intestines are functioning properly and moving food and gas through the digestive tract.Bowel sounds may be decreased or absent if there is an obstruction, ileus, or peritonitis
Choice B) Lochia amount is wrong because lochia is the vaginal discharge that occurs after childbirth.
It consists of blood, mucus, and tissue from the uterus.
Lochia amount is not related to abdominal pain and tenderness after a cesarean section.
Lochia amount may vary depending on the stage of lochia (rubra, serosa
A nurse is caring for a postpartum client who has an episiotomy wound infection.
Which of the following should the nurse do? (Select all that apply.) A) Administer antibiotics as prescribed.
Explanation
The correct answer is choice A, B, C and D. Antibiotics, wound monitoring, wound care and wound culture are all appropriate interventions for a postpartum client who has an episiotomy wound infection.According to Mayo Clinic, an episiotomy wound infection can cause pain, fever, pus and wound breakdown.According to SpringerLink, an episiotomy wound infection is usually caused by a polymicrobial infection of Gram-negative and Gram-positive bacteria.
Therefore, administering antibiotics as prescribed can help treat the infection and prevent complications.
Monitoring wound healing can help detect any signs of worsening infection or dehiscence.
Teaching wound care can help the client prevent further contamination and promote healing.
Culturing the wound if indicated can help identify the causative organisms and guide antibiotic therapy.
Choice E is wrong because applying heat to the wound can increase inflammation and pain.According to NCBI, there is no evidence that heat therapy is beneficial for episiotomy wounds.
Instead, cold therapy may be more effective in reducing swelling and discomfort.
A nurse is assessing a postpartum client for signs of infection.
Which of the following should the nurse report immediately? A) Lochia with clots.
Explanation
The correct answer is choice E) Temperature greater than 38°C for more than 48 hours.This is because a fever higher than 38°C that lasts for more than two days can indicate a postpartum infection, which is a potentially serious complication that requires immediate medical attention.A postpartum infection can affect various parts of the body, such as the uterus, the breast, or the urinary tract.
Choice A) Lochia with clots is wrong because lochia is the normal vaginal discharge that occurs after childbirth and may contain some blood clots.However, if the lochia is foul-smelling, excessive, or bright red, it may be a sign of infection.
Choice B) Fundus firmness is wrong because a firm fundus (the top of the uterus) indicates that the uterus is contracting well and preventing excessive bleeding.A soft or boggy fundus can be a sign of infection or hemorrhage.
Choice C) Abdominal distension is wrong because some abdominal swelling is normal after delivery and may take several weeks to subside.However, if the abdomen is very tender, painful, or hard, it may be a sign of infection or other complications.
Choice D) Breast tenderness is wrong because some
(Select all that apply) A nurse is monitoring a postpartum woman who is taking codeine for severe pain after birth.
The nurse knows that codeine can pass through breastmilk and cause adverse effects in the baby.
Which signs and symptoms should the nurse watch for in the baby?
Explanation
Increased sleepiness and difficulty waking up are signs of central nervous system (CNS) depression in breastfed infants exposed to codeine through breast milk.Codeine is converted into morphine in the body, which can pass into breast milk and cause adverse effects in the baby.Codeine use by breastfeeding mothers can cause CNS depression in breastfed infants.
Therefore, the nurse should watch for increased sleepiness and difficulty waking up in the baby.
Choice A is wrong because increased alertness and activity are not signs of CNS depression.
They are more likely to be signs of stimulation or agitation.
Choice B is wrong because decreased appetite and weight gain are not specific signs of codeine exposure.
They can be caused by many other factors, such as illness, infection, or poor latch.
Choice C is wrong because increased respiratory rate and depth are not signs of CNS depression.
They are more likely to be signs of respiratory distress or infection.
Choice D is wrong because decreased heart rate and blood pressure are not signs of CNS depression.
They are more likely to be signs of shock or hypovolemia.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Respiratory rate: 30 to 60 breaths per minute
A nurse is evaluating a postpartum woman’s knowledge about pain management after birth.
The nurse asks the woman what she would do if she has uterine cramping while breastfeeding her baby.
Which response by the woman indicates a need for further teaching?
Explanation
The correct answer is choice D. I would stop feeding my baby until the pain goes away.This response indicates a need for further teaching because stopping breastfeeding can worsen the uterine cramping and also affect the milk supply and the baby’s nutrition.Uterine cramping or “afterpains” are normal after delivery and are caused by the uterus contracting and shrinking back to its normal size.Breastfeeding can trigger these contractions because it stimulates the release of oxytocin, a hormone that helps the uterus contract.
Choice A is wrong because ibuprofen is a safe and effective pain reliever for postpartum women and can be taken before feeding the baby.Choice B is wrong because massaging the abdomen gently during feeding can help ease the afterpains by stimulating blood flow and relaxing the muscles.Choice C is wrong because relaxation and breathing techniques can also help reduce the pain by lowering stress and tension levels.These are some of the self-help treatments that can be used along with medications to manage postpartum pain.
A nurse is preparing a discharge plan for a postpartum woman who had a vaginal delivery with a second-degree perineal tear.
The nurse includes instructions on how to care for the perineum at home.
Which statement by the woman indicates that she understands the instructions?
Explanation
The correct answer is choice A.The woman should change her perineal pad every time she uses the bathroom to prevent infection and promote healing of the perineal area.
Some possible explanations for the other choices are:
• Choice B is wrong because the woman should wipe her perineum from front to back after urinating or defecating to avoid introducing bacteria from the anus to the vagina or urethra.
• Choice C is wrong because the woman should apply ice packs on her perineum for the first 24 hours after birth, not for the first week.
Ice packs help reduce swelling and pain in the per
A nurse is providing discharge teaching to a client who had a vaginal delivery with a midline episiotomy.
Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Explanation
The correct answer is choice A, C, D and E. These are the instructions that the nurse should include in the teaching for a client who had a vaginal delivery with a midline episiotomy.
• Choice A is correct because using a sitz bath three times per day and after each bowel movement can help reduce pain, swelling and infection of the perineum.
• Choice C is correct because applying ice packs to the perineum for the first 24 hours can help reduce inflammation and bleeding.
• Choice D is correct because performing Kegel exercises several times per day can help strengthen the pelvic floor muscles and improve urinary continence.
• Choice E is correct because reporting any increase in redness, swelling or discharge from the episiotomy site can help detect signs of infection or wound breakdown.
• Choice B is wrong because wiping from back to front after voiding or having a bowel movement can increase the risk of infection by introducing bacteria from the anal area to the vaginal area.The correct way to wipe is from front to back.
A nurse is caring for a client who received meperidine (Demerol) IV for pain relief during labor 2 hours ago and is now ready to deliver vaginally.
Which of the following medications should the nurse have available to reverse respiratory depression in the newborn?
Explanation
Naloxone (Narcan) is a specific opiate antagonist that can reverse respiratory depression in newborn infants that may be due to transplacentally acquired opiates.It can be given intravenously, intramuscularly, intraosseously or subcutaneously.The recommended dose is 100 microgram/kg.
Choice B is wrong because nalbuphine (Nubain) is a mixed opiate agonist-antagonist that can cause respiratory depression and withdrawal symptoms in opioid-dependent mothers and infants.
Choice C is wrong because butorphanol (Stadol) is another mixed opiate agonist-antagonist that can have similar effects as nalbuphine.
Choice D is wrong because fentanyl (Sublimaze) is a synthetic opioid that can cause respiratory depression and sedation in both mothers and infants.
Normal ranges for respiratory rate in newborn infants are 30 to 60 breaths per minute.
Normal ranges for oxygen saturation in newborn infants are 90% to 100%.
entanyl (Sublimaze) is a synthetic opioid that can cause respiratory depression and sedation in both mothers and infants.
Normal ranges for respiratory rate in newborn infants are 30 to 60 breaths per minute.
Normal ranges for oxygen saturation in newborn infants are 90% to 100%.
Explanation
The correct answer is choice A, C, D and E. These are all non-pharmacological methods of pain relief that can be used during labor.They work by providing natural pain relief, increasing endorphins, creating competing impulses in the nervous system, or reducing muscle tension and anxiety.
Choice B, biofeedback, is wrong because it is a technique that involves monitoring and controlling physiological responses such as heart rate, blood pressure, muscle tension, and brain waves.It requires special equipment and training and is not commonly used during labor.
Normal ranges for pain during labor vary depending on the individual, the stage of labor, and the method of pain relief.Some factors that can influence pain perception are fear, anxiety, fatigue, previous experiences, expectations, and coping skills.
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