What is the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?

Assess the parents’ anxiety level and readiness to learn.

Gather literature for the parents.

Secure a quiet place for teaching

Discuss the plan with the nursing team

Answer and Explanation

The Correct Answer is A

Assess the parents’ anxiety level and readiness to learn. This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching.

The nurse should also consider the parent's learning style, cultural background, and literacy level.

Choice B is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.

Choice C is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.

Choice D is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.

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Correct Answer is C

Explanation

The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.

Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.

The nurse should stop the infusion immediately and notify the provider.

Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.

The nurse should act quickly to prevent further complications.

Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.

Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.

Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.

The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).

Hydralazine may cause hypotension and fetal distress.

A. Retained placental fragments. B. Unrepaired vaginal lacerations. C. Uterine atony D. Puerperal infection

Correct Answer is C

Explanation

Uterine atony.

This is when the uterus does not contract enough to stop the bleeding from the placental site after delivery. It is the most common cause of postpartum hemorrhage, accounting for up to 80% of cases. Uterine atony can be caused by factors such as prolonged or augmented labor, large baby, multiple pregnancies, infection, or retained placenta.

The woman in question has some risk factors for uterine atony, such as a large baby and augmentation of labor with Pitocin.

The other choices are wrong because:

A . Retained placental fragments: This is when parts of the placenta remain attached to the uterine wall and prevent it from contracting properly. It is the second most common cause of postpartum hemorrhage.

However, there is no indication in the question that the woman had any difficulty with the delivery of the placenta or that it was incomplete

B. Unrepaired vaginal lacerations: This is when there are tears or cuts in the vagina or cervix that cause bleeding. It is a less common cause of postpartum hemorrhage.

However, there is no indication in the question that the woman had any trauma during delivery or that she was examined for lacerations

D. Puerperal infection: This is when there is an infection in the uterus or other parts of the reproductive tract after delivery.

It can cause fever, pain, and bleeding. It is a rare cause of postpartum hemorrhage.

However, there is no indication in the question that the woman had any signs or symptoms of infection, such as fever, chills, or foul-smelling discharge.

Normal ranges for blood loss after delivery are less than 500 mL for vaginal birth and less than 1000 mL for C-section.

Any amount above these thresholds can be considered postpartum hemorrhage and requires prompt evaluation and treatment.

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What is the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of afterbirth hemorrhage in this woman is:

Correct Answer is C

Explanation

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:

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