Question

After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

Answer 1

Correct Answers:

A primigravida whose perineal pain has worsened one hour after being medicated.

Rationale :

🔷 Increased perineal pain following analgesia could suggest a developing hematoma, which may not be externally visible but can cause significant internal bleeding.

🔷 This is a priority concern because hematomas can rapidly enlarge, leading to hypovolemia and severe pain.

🔷 Prompt reassessment is necessary to evaluate for swelling, discoloration, or firmness in the perineal area.

🔷 Hematomas are more likely in primigravidas due to firmer tissue tone and lack of previous vaginal delivery.

🔷 Timely RN intervention helps prevent complications such as shock or the need for surgical evacuation.

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Answer 2

Correct Answers:

Retained placental fragments.

Rationale :

💎 Retained placental fragments prevent complete uterine involution and are a leading cause of early postpartum hemorrhage.

💎 They interfere with the uterus's ability to contract, which increases the risk for continued bleeding.

💎 Identification requires careful inspection of the placenta after delivery and monitoring for boggy uterus or excessive lochia.

💎 Risk is higher in cases of manual placental removal or incomplete separation.

💎 Prompt recognition helps initiate timely interventions like uterine massage, medications, or surgical removal.

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Answer 3

Correct Answers:

Bathe the newborn before initiating skin-to-skin contact.

Rationale :

🔶 Newborns of HIV-positive mothers should be bathed immediately to remove maternal blood and secretions, reducing the risk of vertical transmission.

🔶 Skin-to-skin contact can resume safely after the newborn is cleaned, maintaining both bonding and infection control.

🔶 The nurse should avoid invasive procedures like fetal scalp electrodes during labor due to increased transmission risk.

🔶 Antiretroviral therapy should continue throughout pregnancy to reduce perinatal HIV transmission.

🔶 Pneumococcal vaccination is not required within the first 4 hours unless otherwise indicated.

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Answer 4

Correct Answers:

"Your partner will apply upward pressure on you."

Rationale :

✳️ Counterpressure is the application of firm pressure to the sacral area during contractions, especially helpful for back labor.

✳️ Upward pressure on the sacrum relieves discomfort caused by fetal occiput posterior positioning.

✳️ Using a tennis ball or fist during contractions can help reduce pain perception.

✳️ Other options misrepresent the correct technique and are not anatomically appropriate for labor counterpressure.

✳️ Teaching the partner correct positioning helps support active labor participation and comfort.

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Answer 5

Correct Answers:

Baked chicken.

Rationale :

🍃 A low-fat, high-protein option like baked chicken is ideal for clients with cholelithiasis to reduce gallbladder stimulation.

🍃 High-fat foods (e.g., fried foods, bacon, full-fat dairy) worsen symptoms like abdominal pain and biliary colic.

🍃 Fat stimulates the release of bile, which may cause pain when the flow is obstructed by gallstones.

🍃 A lean protein diet supports both fetal development and maternal digestion.

🍃 Nutritional planning reduces the risk of gallbladder attacks during pregnancy.

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Answer 6

Correct Answers:

"Apply ice packs to your breasts using a 15 minutes on, 45 minutes off schedule."

Rationale :

✔️ Cold therapy like ice packs helps suppress lactation and relieve engorgement discomfort after choosing not to breastfeed.

✔️ Ice constricts blood vessels, reducing milk production and soothing inflammation.

✔️ Warm showers and pumping stimulate milk let-down, which is contraindicated in lactation suppression.

✔️ A tight-fitting, supportive bra (not loose-fitting) should also be worn continuously.

✔️ Education empowers clients to avoid mastitis and engorgement complications.

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Answer 7

Correct Answers:

Use an automatic puncture device on the heel.

Rationale :

🔷 The automatic device ensures consistent depth and prevents unnecessary trauma during newborn heel sticks.

🔷 Manual lancets risk deeper punctures and increase the chance of nerve or bone injury.

🔷 The outer lateral or medial aspects of the heel should be used, not the center or inner heel.

🔷 Alcohol is used before the procedure, not after; aftercare includes gentle pressure or sterile gauze.

🔷 Avoid ice packs as they constrict vessels and reduce blood flow.

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Answer 8

Correct Answers:

Single palmar creases.

Rationale :

🟠 A single palmar crease (simian crease) can be a normal variant but is often associated with Down syndrome and other congenital anomalies.

🟠 It warrants further evaluation, including genetic consultation or karyotype testing.

🟠 Other findings such as rust-stained urine (due to urate crystals) or transient cyanosis are benign in early newborn life.

🟠 Subconjunctival hemorrhages are common from birth trauma and resolve without treatment.

🟠 Early identification of anomalies ensures early intervention planning.

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Answer 9

Correct Answers:

Urine output 20 mL/hr.

Rationale :

🔴 A urine output <30 mL/hr indicates renal hypoperfusion, which is a sign of magnesium toxicity.

🔴 Magnesium is excreted by the kidneys; reduced output increases the risk of accumulation and toxicity.

🔴 Signs of toxicity also include respiratory depression, loss of reflexes, and hypotension.

🔴 Monitoring urine output is crucial during magnesium sulfate infusion in preeclamptic clients.

🔴 Early detection prevents complications like respiratory arrest or cardiac depression.

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Answer 10

Correct Answers:

Painless, vaginal bleeding.

Rationale :

⚪ Placenta previa typically presents with sudden, painless bright red vaginal bleeding in the second or third trimester.

⚪ The uterus remains soft and non-tender, unlike abruption, which causes firm, painful uterine tone.

⚪ Clients are at risk for hemorrhage, and vaginal exams are avoided until location is confirmed by ultrasound.

⚪ Early recognition supports interventions like C-section planning and maternal monitoring.

⚪ Persistent headaches are not characteristic of placenta previa but may occur with preeclampsia.

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QLexNursing

1 :
After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

2 :
A nurse is discussing risk factors of postpartum hemorrhage with a newly licensed nurse. Which of the following conditions is a risk factor for postpartum hemorrhage that the nurse should include in the teaching?

3 :
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

5 :
A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet?

6 :
A nurse is providing discharge instructions to a client who is 24 hours postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?

8 :
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

9 :
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

10 :
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

QLexNursing

1 : After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

2 : A nurse is discussing risk factors of postpartum hemorrhage with a newly licensed nurse. Which of the following conditions is a risk factor for postpartum hemorrhage that the nurse should include in the teaching?

3 : A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

4 : A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

5 : A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet?

6 : A nurse is providing discharge instructions to a client who is 24 hours postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?

8 : A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

9 : A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

10 : A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?

1 :
After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

2 :
A nurse is discussing risk factors of postpartum hemorrhage with a newly licensed nurse. Which of the following conditions is a risk factor for postpartum hemorrhage that the nurse should include in the teaching?

3 :
A nurse is planning care for a client who is pregnant and has HIV. Which of the following actions should the nurse include in the plan of care?

4 :
A nurse is teaching a client and her partner about the technique of counterpressure during labor. Which of the following statements by the nurse is appropriate?

5 :
A nurse is providing dietary teaching to a client who is at 32 weeks of gestation and has cholelithiasis. Which of the following foods should the nurse recommend for the client to include in her diet?

6 :
A nurse is providing discharge instructions to a client who is 24 hours postpartum and has decided not to breastfeed. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is performing a heel stick on a newborn. Which of the following actions should the nurse take?

8 :
A nurse is assessing a full-term newborn upon admission to the nursery. Which of the following clinical findings should the nurse report to the provider?

9 :
A nurse is caring for a client who is at 30 weeks of gestation and is receiving magnesium sulfate for preeclampsia. The nurse should recognize which of the following manifestations as an adverse reaction to the medication?

10 :
A nurse is caring for a client who has a placenta previa. Which of the following findings should the nurse expect?