A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F),
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A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3 C (99.2 F), and pulse rate 52/min. Which of the following actions should the nurse take?
Report the vital signs to the provider.
Massage the fundus.
Ask the client when she last voided.
Administer an oxytocic agent.
Ask the client when she last voided
Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication?
IV narcotics administered to the mother during labor
Maternal drug use
Hyaline membrane disease
Meconium aspiration
IV narcotics administered to the mother during labor
The nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make?
"An epidural given too early during labor can cause maternal hypertension."
"An epidural given too early during labor will not be effective in active labor."
"An epidural given too early can cause fetal depression."
"An epidural given too early can prolong labor."
An epidural given too early can prolong labor
Clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.
A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client?
"You should eat some crackers before rising from bed in the morning."
"You should eat foods served at warm temperatures."
"You should sip whole milk with breakfast."
"You should brush your teeth immediately after meals."
You should eat some crackers before rising from bed in the morning
Morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.
A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh(D) Immune Globulin?
While the client is in labor
Following an episode of influenza during pregnancy
Prior to a blood transfusion
At 28 weeks of gestation
At 28 weeks of gestion
The nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.
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