The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Hemoglobin and hematocrit

Abdominal contour and bowel sounds

Heart rate and blood pressure

Urinary output and IV fluid intake

Answer and Explanation

The Correct Answer is C

A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.

B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.

C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.

D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.

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Correct Answer is D

Explanation

A. Describe genetic testing protocols: While genetic testing may be part of prenatal care, it's not the primary concern for a pregnant woman addicted to heroin. The focus should be on managing the addiction and promoting a healthy pregnancy.

B. Discontinue the methadone right away: Abruptly stopping methadone, or any opioid replacement therapy, can lead to withdrawal symptoms, which can be harmful to both the mother and the fetus. It's crucial for pregnant individuals on methadone to work closely with their healthcare provider to manage the transition.

C. Sign up for group therapy sessions: Group therapy can be a supportive intervention for individuals dealing with addiction, but it should be part of a comprehensive treatment plan that includes medical management.

D. Start a prenatal care plan as soon as possible: This is the most appropriate choice. Prenatal care is crucial for monitoring the health of both the mother and the baby. Starting early allows healthcare providers to address any potential issues and provide necessary support. This includes managing the mother's opioid addiction through medications like methadone, which can be administered under close medical supervision during pregnancy.

A. Explain reasons consent for an infant autopsy is needed B. Determine if the mother desires a visit from her clergy C. Encourage the mother to hold and spend time with her baby D. Create a memory box of baby's footprints and photographs

Correct Answer is C

Explanation

Explain reasons consent for an infant autopsy is needed:
Autopsy might be necessary for understanding the cause of fetal demise, providing answers to the parents, and helping future pregnancies. However, it's not the most immediate or essential action in this scenario.

Determine if the mother desires a visit from her clergy:
Spiritual and emotional support is crucial during this distressing time. While clergy support is valuable, it's not the most urgent action needed immediately after delivery.

Encourage the mother to hold and spend time with her baby:
This is a crucial part of the grieving process and helps in acknowledging and creating memories with the baby. It's an essential step in providing emotional support to the mother.

Create a memory box of baby's footprints and photographs:
This is also a critical step in assisting the parents with the grieving process. It helps in cherishing the memories and creating keepsakes that may provide comfort in the future.

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Naxlex Comprehensive Predictor Exams

A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy? Which information should the nurse provide?

Correct Answer is D

Explanation

The nurse is caring for a client whose fetus died in utero at 32-weeks gestation. After the fetus is delivered vaginally, the nurse implements routine fetal demise protocol and identification procedures Which action is most important for the nurse to take?

Correct Answer is C

Explanation

A client who had her first baby three months ago and is breastfeeding her infant tells the nurse that she is currently using the same diaphragm that she used before becoming pregnant. Which information should the nurse provide this client?

The nurse is preparing to administer magnesium sulfate to a laboring client whose blood pressure has increased from 110/60 mmHg to 140/90 mmHg Which nursing protocol has the highest priority?

A primipara at 20-weeks gestation is scheduled for an ultrasound. In preparing the client for the procedure, the nurse should explain that the primary reason for conducting this diagnostic study is to obtain which information?

A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following the procedure the client calls the nurse to report a temperature of 99.8° F (37.67°C). Which action should the nurse implement?

After breast-feeding 10 minutes at each breast, a new mother calls the nurse to the postpartum room to help change the newborn's diaper. As the mother begins the diaper change, the newborn spits up the breast milk. What action should the nurse implement first?

A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. Which actions should the nurse plan to perform? (Select all that apply.)

Which physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?