1. Two days after delivery, a postpartum client prepares for discharge. What should
the nurse teach her about lochia flow?
Incorrect: Lochia does change
... [Show More] color but goes from lochia rubra (bright red) on days
1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white)
days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate
postpartum hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright
red, to pinkish brown, to creamy white.
The color of the lochia changes from a bright red to white after four daysNumerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the peak
of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below
the baseline. Late decelerations are suspected and the nurse notifies the physician.
Which is the rationale for this action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable
decelerations, not late decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord
compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the
strength of maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency
and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal
distress.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who is
scheduled to have an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are
postoperative interventions.Incorrect: Taking vital signs every 15 minutes is a postoperative intervention.
Instructing the client regarding breathing exercises is not appropriate in a crisis
situation when the client's anxiety is high, because information would probably not
be retained. In an emergency, there is time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly.
Anxiety of the client and the family will be high. Inserting an indwelling
catheter helps to keep the bladder empty and free from injury when the
incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath
sounds are important if the client is to receive general anesthesia, but the
anesthesiologist will be listening to breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother regarding
care of the breasts after discharge?
Incorrect: Engorgement occurs on about the third or fourth postpartum day
and is a result of the breast milk formation. The primary way to relieve
engorgement is by pumping or longer nursing. Giving a bottle of formula will
compound the problem because the baby will not be hungry and will not
empty the breasts well.
Incorrect: Applying lotion to the nipples is not effective for keeping them soft.
Excessive amounts of lotion may harbor microorganisms.
Correct: In order to stimulate adequate milk production, the breasts should
be pumped if the infant is not sucking or eating well, or if the breasts are not
fully emptied.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking.The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which classification of
drugs should the nurse anticipate administering?
Correct: Tocolytics are used to stop labor. One of the most commonly used
tocolytic drugs is ritodrine (Yutopar).
Incorrect: Anticonvulsants are used for clients with pregnancy-induced
hypertension who are likely to seize.
Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are used
for accelerating fetal lung maturation and production of surfactant. They are
commonly used if the membranes are ruptured or labor cannot be stopped.
Incorrect: Anti-infective are used if there is infection. Preterm labor may or may
not involve ruptured membranes with its accompanying risk of infection.
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating pregnancy?
Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy;
quickening is a presumptive Sign of pregnancy.
Incorrect: These are presumptive signs. They may indicate pregnancy or they may
be caused by other conditions, such as disease processes.Correct: These are probable signs that strongly indicate pregnancy. Hegar’s
sign is a softening of the lower uterine segment, and Chadwick's sign is the
bluish or purplish color of the cervix as a result of the increased blood supply
and increased estrogen. Ballottement occurs when the cervix is tapped by an
examiner's finger and the fetus floats upward in the amniotic fluid and then
falls downward.
Incorrect: These are presumptive signs that might indicate pregnancy, but they
might be caused by other conditions, such as disease processes.
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents that the
fundus is soft, boggy, above the level of the umbilicus, and displaced to the right
side. The nurse encourages the client to void. Which is the rationale for this
nursing action?
Correct: Bladder distention can lead to postpartum hemorrhage. A full
bladder displaces the uterus causing it not to contract properly. Emptying the
bladder allows the uterus to contract more firmly.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be
displaced and increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This,
however, does not relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or
not. A full bladder displaces the uterus causing it not to contract properly, which
may lead to postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Correct: The middle third of the vastus lateralis is the preferred site for
injections.
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred
site for injections in the newborn because of lack of muscle mass.
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus
maximus) due to decreased muscle mass.
Ventrogluteal
Vastus lateralis
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the client
voids 2,000 mL of urine. How should the nurse interpret this finding?
Incorrect: Urinary tract infections are common during pregnancy and in the
postpartum period. Urinary frequency is a common finding. However, voiding
large amounts of urine is not a sign of a UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There
has been no damage to the kidneys. Incorrect: Most women do receive some IV
fluids during labor and delivery, however the IV rates are carefully calculated
according to weight.Correct: During pregnancy, the circulating blood volume increases by about
50%. In order to get rid of the excess fluid volume after delivery, the woman
experiences an increased amount of urine output during the first few hours.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot maintain control
of her blood sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the
placenta and can cause damage to the fetus. They are not used in gestational
diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe
hypoglycemia. Clients with gestational diabetes have hyperglycemia.
Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers
the client's blood sugar without harming the fetus.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross
the placenta and can cause damage to the fetus. They are not used for gestational
diabetes for that reason.
Metformin (Glucophage)
Glucagon
Insulin
Glyburide (DiaBeta) [Show Less]