Question

A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

Answer 1

Correct Answers:

Saturated perineal pad in 30 minutes

Rationale :

🔴 A perineal pad saturated in 30 minutes is a sign of excessive postpartum bleeding and should be prioritized.

🔴 This could indicate postpartum hemorrhage, a leading cause of maternal morbidity and mortality.

🔴 The nurse should immediately assess the fundus, massage if boggy, and notify the provider.

🔴 Timely intervention is critical to prevent hypovolemic shock.

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Answer 2

Correct Answers:

Dry the skin

Rationale :

🟡 After ensuring a patent airway, the nurse’s next priority is to dry the newborn to reduce heat loss via evaporation.

🟡 Newborns are prone to hypothermia, which can lead to hypoglycemia and respiratory distress.

🟡 Drying also stimulates spontaneous respirations and helps transition to extrauterine life.

🟡 Other interventions like Vitamin K and eye prophylaxis can be done after thermoregulation is ensured.

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Answer 3

Correct Answers:

Start breastfeeding with the nipple that is less sore
Change the infants position on the nipples
Apply breast milk to the nipples before each feeding

Rationale :

Start breastfeeding with the nipple that is less sore

💠 The infant sucks more vigorously at the beginning of a feed; using the less sore side first helps reduce discomfort.

💠 This technique also helps ensure adequate emptying of both breasts without over-irritating the sore side.

Change the infant’s position on the nipples

💠 Frequent repositioning reduces repetitive trauma to the same area of the nipple.

💠 Correct latching in different positions can minimize friction and soreness.

Apply breast milk to the nipples before each feeding

💠 Breast milk contains natural antibodies and healing enzymes that help soothe and protect irritated nipples.

💠 It serves as a natural barrier and speeds up healing.

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Answer 4

Correct Answers:

Discontinue the medication infusion

Rationale :

🔷 A respiratory rate <12/min and absent reflexes are signs of magnesium sulfate toxicity.

🔷 The nurse’s immediate action is to stop the infusion to prevent further central nervous system depression.

🔷 Calcium gluconate should be kept readily available as an antidote.

🔷 Continuing the infusion risks respiratory arrest and cardiac complications.

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Answer 5

Correct Answers:

Changes in the cervix

Rationale :

🟣 True labor is characterized by progressive cervical dilation and effacement.

🟣 Contractions alone are not definitive unless they cause cervical change.

🟣 Other signs like membrane rupture or fetal station may occur during labor but are not exclusive indicators.

🟣 Cervical exam is the most reliable confirmation of labor status.

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Answer 6

Correct Answers:

Meconium aspiration syndrome

Rationale :

🟢 Meconium-stained amniotic fluid increases the risk for meconium aspiration syndrome (MAS).

🟢 MAS can cause respiratory distress, hypoxia, and may require NICU care or ventilation.

🟢 Early symptoms include tachypnea, grunting, and nasal flaring.

🟢 It is more immediately dangerous than jaundice or ileus in the first 30 minutes.

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Answer 7

Correct Answers:

Variable decelerations

Rationale :

🔵 Variable decelerations are abrupt drops in fetal heart rate often caused by umbilical cord compression.

🔵 This can lead to fetal hypoxia, and nursing interventions such as position changes may be needed.

🔵 Persistent or severe variables may require amnioinfusion or expedited delivery.

🔵 Recognizing this pattern helps protect fetal oxygenation.

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Answer 8

Correct Answers:

Ask the client it she has considered harming her newborn.

Rationale :

🟠 The priority in this situation is to assess for risk of harm to self or baby, a key sign of postpartum depression or psychosis.

🟠 Asking directly about harmful thoughts helps determine the level of urgency and intervention needed.

🟠 Early identification can prevent tragic outcomes and lead to timely psychiatric referral.

🟠 The nurse must create a safe, nonjudgmental environment during this assessment.

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Answer 9

Correct Answers:

Meconium aspiration syndrome due to the color of amniotic fluid.

Rationale :

🔶 Meconium-stained fluid is an indicator that the fetus may have passed stool in utero, risking meconium aspiration.

🔶 This condition can impair gas exchange and lung compliance, leading to serious respiratory complications.

🔶 Immediate assessment and possible airway suctioning or respiratory support may be needed.

🔶 It poses a greater acute risk compared to birth weight or fetal anomaly in the immediate neonatal period.

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Answer 10

Correct Answers:

Change the client's position

Rationale :

⚪ With late decelerations, the initial action is to change maternal position (e.g., left side) to improve uteroplacental blood flow.

⚪ Positional changes can relieve vena cava compression and enhance oxygen delivery to the fetus.

⚪ If ineffective, the nurse then proceeds with oxygen, IV fluids, and notifying the provider.

⚪ Late decels indicate uteroplacental insufficiency, so interventions aim to maximize perfusion.

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QLexNursing

1 :
A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

2 :
A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse's priority action?

3 :
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

4 :
A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

5 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is unsure if she is in labor. Which of the following should the nurse recognize as a sign of true labor?

6 :
A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

7 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

8 :
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse's priority action?

9 :
A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

10 :
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

2 : A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse's priority action?

3 : A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

4 : A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

5 : A nurse is caring for a client who is a primigravida, at term, and having contractions but is unsure if she is in labor. Which of the following should the nurse recognize as a sign of true labor?

6 : A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

7 : A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

8 : A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse's priority action?

9 : A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

10 : A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?

1 :
A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

2 :
A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse's priority action?

3 :
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to reduce discomfort during breastfeeding? (Select all that apply.)

4 :
A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

5 :
A nurse is caring for a client who is a primigravida, at term, and having contractions but is unsure if she is in labor. Which of the following should the nurse recognize as a sign of true labor?

6 :
A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

7 :
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?

8 :
A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling down and sad, having no energy, and wanting to cry. What should be the nurse's priority action?

9 :
A nurse is caring for a newborn who is 30 minutes old. After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk?

10 :
A nurse is caring for a client who is in active labor and notes late decelerations in the FHR. Which of the following actions should the nurse take first?