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Which nursing intervention is most helpful in relieving postpartum
uterine contractions or "afterpains?"
a. Lying prone with a pillow on the abdomen
b. Using a breast pump
c. Massaging the abdomen
d. Giving oxytocic medications - CORRECT ANSWER ✔✔✔✔✔ a. Lying
prone with a pillow on the abdomen
Lying prone (A) keeps the fundus contracted and is especially useful
with multiparas, who commonly experience afterpains due to lack of
uterine tone.
A multigravida client arrives at the labor and delivery unit and tells the
nurse that her bag of water has broken. The nurse identifies the
presence of meconium fluid on the perineum and determines the fetal
heart rate is between 140 to 150 beats/minute. What action should the
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nurse implement next?
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,a. Ccmplete a sterile vaginal exam
b. Take maternal temperature every 2 hours
c. Prepare for an immediate cesarean birth
d. Obtain sterile suction equipment - CORRECT ANSWER ✔✔✔✔✔ a.
Complete a sterile vaginal exam
A vaginal exam (A) should be performed after the rupture of membranes
to determine the presence of a prolapsed cord.
When explaining "postpartum blues" to a client who is 1 day
postpartum, which symptoms should the nurse include in the teaching
plan? (Select all that apply.)
a. Mood swings
b. Panic attacks
c. Tearfulness
d. Decreased need for sleep
e. Disinterest in the infant - CORRECT ANSWER ✔✔✔✔✔ a. Mood
swings
c. Tearfulness
"Postpartum blues" is a common emotional response related to the
rapid decrease in placental hormones after delivery and include mood
swings (A), tearfulness (C), feeling low, emotional, and fatigued.
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A client at 30-weeks gestation, complaining of pressure over the pubic
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area, is admitted for observation. She is contracting irregularly and
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,demonstrates underlying uterine irritability. Vaginal examination reveals
that her cervix is closed, thick, and high. Based on these data, which
intervention should the nurse implement first?
a. Provide oral hydration
b. Have a complete blood count (CBC) drawn
c. Obtain a specimen for urine analysis
d. Place the client on strict bedrest - CORRECT ANSWER ✔✔✔✔✔ c.
Obtain a specimen for urine analysis
Obtaining a urine analysis (C) should be done first because preterm
clients with uterine irritability and contractions are often suffering from a
urinary tract infection, and this should be ruled out first.
A client in active labor complains of cramps in her leg. What intervention
should the nurse implement?
a. Ask the client if she takes a daily calcium tablet
b. Extend the leg and dorsiflex the foot
c. Lower the leg off the side of the bed
d. Elevate the leg above the heart - CORRECT ANSWER ✔✔✔✔✔ b.
Extend the leg and dorsiflex the foot
Dorsiflexing the foot by puching the sole of the foot forward or by
stnading (if the client is capable) (B), and putting the heel of the foot on
the floor is the best means of relieving leg cramps.
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, The nurse is caring for a woman with a previously diagnosed heart
disease who is in the second stage of labor. Which assessment findings
are of greatest concern?
a. edema, basilar rales, and an irregular pulse
b. Increased urinary output, and tachycardia
c. Shortness of breath, bradycardia, and hypertension
d. Regular heart rate, and hypertension - CORRECT ANSWER ✔✔✔✔✔
a. Edema, basilar rales, and an irregular pulse
Edema, basilar rales, and an irregular pulse (A) indicate cardiac
decompensation and require immediate intervention.
The nurse is teaching a woman how to use her basal body temperature
(BBT) pattern as a tool to assist her in conceiving a child. Which
temperature pattern indicates the occurrence of ovulation, and therefor,
the best time for intercourse to ensure conception?
a. Between the time the temperature falls and rises
b. Between 36 and 48 hours after the temperature rises
c. When the temperature falls and remains low for 36 hours
d. Within 72 hours before the temperature falls - CORRECT ANSWER
✔✔✔✔✔ a. Between the time the temperature falls and rises
In most women, the BBT drops slightly 24 to 36 hours before ovulation
and rises 24 to 72 hours after ovulation, when the corpus luteum of the
ruptured ovary produces progesterone. Therefore, intercourse between
the time of the temperature fall and rise (A) is the best time for
conception.
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