Question

A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

Answer 1

Correct Answers:

Palpate the client's uterine fundus.

Rationale :

🥟The priority in postpartum hemorrhage is to assess for uterine atony, the most common cause.

🥟A boggy, non-firm uterus fails to contract effectively and leads to excessive bleeding.

🥟Palpating the fundus allows the nurse to determine whether it’s firm and midline, guiding the next steps.

🥟 Fundal massage may follow if the uterus is atonic.

🥟Oxytocics can be given afterward, but assessment always comes first.

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Answer 2

Correct Answers:

Fundus palpable to right of midline

Rationale :

🧨A displaced fundus, especially to the right of midline, often indicates a distended bladder.

🧨This displacement can inhibit uterine contraction, increasing the risk of postpartum hemorrhage.

🧨Thirst and lochia changes are nonspecific. Frequent uterine contractions do not signify bladder distension.

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Answer 3

Correct Answers:

Initiate early feeding.

Rationale :

💠Early feeding promotes excretion of bilirubin through stool and urine, reducing the risk of hyperbilirubinemia and jaundice.

💠Feeding also supports hepatic conjugation of bilirubin.

💠Phototherapy and exchange transfusion are interventions for established jaundice—not prevention.

💠Suctioning addresses respiratory clearance, not bilirubin.

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Answer 4

Correct Answers:

Cephalhematoma

Rationale :

🧩A cephalhematoma is a collection of blood between the skull and periosteum that appears as a raised, bruised area and does not cross suture lines.

🧩 It typically results from birth trauma.

🧩Caput succedaneum is softer, crosses suture lines, and appears earlier. |

🧩Pilonidal dimples occur near the sacrum, and molding refers to skull shape changes.

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Answer 5

Correct Answers:

"The primary consideration is what type of incision was performed this time."

Rationale :

🎇 The type of uterine incision (e.g., low-transverse vs. vertical/classical) greatly influences eligibility for a trial of labor after cesarean (TOLAC).

🎇 A low-transverse incision carries the lowest risk of uterine rupture.

🎇Skin incision type is not the main determinant.

🎇The client’s concern is valid and should not be dismissed.

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Answer 6

Correct Answers:

Dry the skin.

Rationale :

📌 After establishing a patent airway, drying the newborn is essential to prevent heat loss, which can lead to cold stress and metabolic instability.

📌Eye prophylaxis and vitamin K are important but can be delayed.

📌 Identification is also necessary but not an immediate priority after birth.

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Answer 7

Correct Answers:

"I'll make sure his diaper is loose in the front:
"I'll expect the plastic ring to fall off by itself within a week."
"I'll call the doctor if I see any bleeding."

Rationale :

✔️ "I’ll make sure his diaper is loose in the front."

◼ A loose diaper prevents pressure or friction on the Plastibell ring, reducing the risk of irritation, dislodgement, and discomfort.

◼Tight diapers can compromise circulation and may interfere with the healing process.

◼Teaching parents to loosely fasten diapers over the site is an essential part of discharge education.

✔️ "I’ll expect the plastic ring to fall off by itself within a week."

◼The Plastibell device is designed to fall off naturally, usually within 5 to 8 days post-procedure.

◼This is expected and does not require any pulling or manual removal.

◼Parents should be reassured that this is a normal part of healing and that no intervention is needed unless signs of infection or bleeding occur.

✔️ "I’ll call the doctor if I see any bleeding."

◼ Bleeding after circumcision, especially beyond a few drops, is not normal and may indicate a complication such as improper placement, infection, or separation of the ring.

◼ Prompt reporting ensures the provider can evaluate and intervene if needed.

◼Teaching parents to monitor for bleeding is critical to avoid delay in care.

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Answer 8

Correct Answers:

"You can push the baby to the room in a wheeled bassinet."

Rationale :

💨Security protocols in the newborn nursery require that infants are transported only in wheeled bassinets to prevent infant abduction or mishandling.

💨Only staff with proper ID typically transfer infants.

💨Allowing family to carry the newborn violates safety standards.

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Answer 9

Correct Answers:

"l should remove extra blankets from my babys crib."

Rationale :

🦠Removing extra blankets and soft items from a newborn’s crib reduces the risk of suffocation and sudden infant death syndrome (SIDS).

🦠Crib safety includes firm mattress, no padding, and back sleeping.

🦠Placing cribs near heaters, adding padding, or placing infants on their stomachs are unsafe practices.

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Answer 10

Correct Answers:

The client requires a rubella immunization following delivery.

Rationale :

🌞A negative rubella titer indicates no immunity, placing the client at risk if infected during future pregnancies.

🌞Because rubella vaccine is live, it is contraindicated during pregnancy and is safely given postpartum.

🌞Immunization protects future pregnancies. A negative titer does not indicate current infection.

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QLexNursing

1 :
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

2 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

3 :
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

4 :
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

5 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

6 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

7 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

8 :
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

9 :
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

10 :
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

QLexNursing

1 : A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

2 : A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

3 : A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

4 : A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

5 : A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

6 : A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

7 : A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

8 : A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

9 : A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

10 : A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?

1 :
A nurse is caring for a client 2 hr after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time?

2 :
A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

3 :
A nurse is caring for a newborn 4 hr after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?

4 :
A nurse is assessing a newborn the day after delivery. The nurse notes a raised, bruised area on the left side of the scalp that does not cross the suture line. How should the nurse document this finding?

5 :
A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?' Which of the following responses should the nurse provide?

6 :
A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

7 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with the Plastibell technique. Which of the following client statements indicates understanding of circumcision care? (Select all that apply.)

8 :
A nurse in the nursery is caring for a newborn. The grandmother of the newborn asks if she can take the newborn to the mother's room. Which of the following is an appropriate response by the nurse?

9 :
A nurse is teaching about crib safety with the parent of a newborn. Which of the following statements by the client indicates understanding of the teaching?

10 :
A nurse is caring for an antepartum client whose laboratory findings indicate a negative rubella titer. Which of the following is the correct interpretation of this data?