A nurse is caring for a client who is 2 hours postpartum. The nurse notes that the client soaked a perineal pad in 10 minutes, the client's skin color is ashen, and she states she feels weak and lightheaded. After applying oxygen via nonrebreather face mask at 10 L/min, which of the following actions should the nurse take next?

Insert an indwelling urinary catheter.

Administer oxytocin by continuous IV infusion.

Massage the client's fundus to promote contractions.

Tilt the client onto her right side with her legs elevated to at least 30 degrees.

Answer and Explanation

The Correct Answer is C

Choice A reason:
Inserting an indwelling urinary catheter can be helpful in measuring urine output and reducing bladder distention, which may impede uterine contractions. However, it is not the immediate next step in managing postpartum hemorrhage.

Choice B reason:
Administering oxytocin by continuous IV infusion is a standard intervention to promote uterine contractions after delivery, which helps to control bleeding. However, before starting an oxytocin infusion, it is important to ensure that there are no retained placental fragments and that the uterus is not already well-contracted.

Choice C reason:
Massaging the client's fundus is the priority action because it can stimulate uterine contractions, which are essential for controlling postpartum bleeding. A firm, contracted uterus helps to compress the blood vessels and prevent excessive bleeding.

Choice D reason:
Tilting the client onto her right side with her legs elevated can help improve venous return and may be part of the management for shock. However, the immediate concern in a postpartum client with excessive bleeding is to manage the bleeding by promoting uterine contractions.

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Correct Answer is D

Explanation

Choice A reason:
A soft, edematous area on the scalp, often referred to as a cephalohematoma, is a common finding after vacuum-assisted deliveries. This is due to the suction applied during delivery and usually resolves without intervention. However, it should be monitored for any signs of increased swelling or jaundice as it can sometimes lead to hyperbilirubinemia.

Choice B reason:
The blue coloring of the hands and feet, known as acrocyanosis, is a normal finding in the first few days of life. It occurs due to the immature circulation in the newborn and typically resolves as the baby's circulation adapts to life outside the womb.

Choice C reason:
Facial edema can be present in newborns following a vacuum-assisted delivery due to the pressure applied during the procedure. It is usually transient and resolves within a few days. However, persistent or severe edema may warrant further evaluation.

Choice D reason:
Poor sucking is a significant finding that should be reported to the provider. Effective sucking is crucial for adequate nutrition and hydration in the newborn. Poor sucking can be a sign of neurological compromise or other issues that require immediate attention to ensure the baby can feed properly and thrive.

A. "I will tip the nipple so air is present as my baby sucks." B. "I will keep my baby's head elevated while he is feeding." C. "I will allow my baby to burp several times during each feeding." D. "My baby will have soft, formed yellow stools." E. An increase in lochia, or postpartum vaginal discharge, is not an indicator of methylergonovine's effectiveness. Lochia will naturally change and decrease as the postpartum period progresses and is not directly affected by the medication.

Correct Answer is A

Explanation

Choice A reason:
Tipping the nipple to allow air as the baby sucks can lead to the baby ingesting air, which may cause discomfort and increase the risk of colic. Proper bottle feeding technique involves tilting the bottle to fill the nipple with milk, thus preventing the baby from swallowing air.

Choice B reason:
Keeping the baby's head elevated during feeding is recommended to prevent milk from flowing too fast and to reduce the risk of ear infections and choking. It also aids in proper digestion and helps prevent reflux.

Choice C reason:
Allowing the baby to burp several times during each feeding is important to release any air swallowed during feeding. This can help prevent discomfort, gas, and spit-up. Burping can be done by gently patting the baby's back in different positions such as over the shoulder, sitting up, or lying across the lap.

Choice D reason:
Expecting soft, formed yellow stools is appropriate for a newborn, especially if breastfed, as their stools tend to be soft and a mustard yellow color. The frequency and consistency of stools can vary, but they generally reflect the baby's diet and are an indicator of good health.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a newborn following a vacuum-assisted delivery. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is teaching the parent of a newborn about bottle feeding. Which of the following statements by the parent indicates a need for further instruction?

Correct Answer is A

Explanation

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?

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes. The nurse suspects placenta previa. Which of the following is an appropriate nursing action?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?

A nurse is instructing a female client on how to check her basal body temperature to determine if she is ovulating. The nurse should instruct the client to check her temperature at which of the following times?

A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery. Which of the following findings should the nurse expect?

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions?

A nurse is preparing to administer liquid mycostatin 600,000 units PO TID. Available is mycostatin 100,000 units/mL. How many m. should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)