One-half hour after vaginal delivery of a term neonate, the nurse palp

RN NCLEX Maternal Neonatal Nursing

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Question 1 of 5.

One-half hour after vaginal delivery of a term neonate, the nurse palpates the fundus of a primigravid client, noting several large clots and a small trickle of bright red vaginal bleeding. The client's blood pressure is 136/92 mm Hg. Which of the following would the nurse do first?

A. Continue to monitor the client's fundus every 15 minutes.

B. Ask the physician for an order for methylergonovine (Methergine).

C. Immediately notify the physician of the client's symptoms.

D. Change the client's perineal pads every 15 minutes.

Explanation: Large clots and bright red bleeding post-delivery suggest possible uterine atony or retained placental fragments, requiring immediate physician notification for intervention. Monitoring, requesting medication, or changing pads are secondary actions.

Question 2 of 5.

After the nurse instructs a 20-year-old nulligravid client on how to perform a breast self-examination, which of the following client statements indicates that the teaching has been successful?

A. I should perform breast self-examination on the day my menstrual flow begins.

B. It's important that I perform breast self-examination on the same day each month.

C. If I notice that one of my breasts is much smaller than the other, I shouldn't worry.

D. If there is discharge from my nipples, I should call my health care provider.

Explanation: Breast self-examination should be performed about a week after the menstrual period begins, when breasts are least tender. Noticing nipple discharge is a concerning symptom that warrants contacting a healthcare provider, indicating successful teaching.

Question 3 of 5.

The nurse is teaching a group of women about fertility awareness methods of contraception. Which of the following would the nurse include as the most reliable indicator that ovulation has occurred?

A. A slight drop followed by a rise in basal body temperature.

B. A change in cervical mucus to thin, clear, and stretchy.

C. The onset of mittelschmerz, or midcycle pelvic pain.

D. The presence of a thick, cloudy cervical mucus.

Explanation: A slight drop followed by a rise in basal body temperature is the most reliable indicator of ovulation, as it reflects the hormonal shift post-ovulation. Cervical mucus changes and mittelschmerz are less precise, and thick mucus typically occurs post-ovulation.

Question 4 of 5.

A client asks about the side effects of oral contraceptives. Which of the following would the nurse include in the response?

A. Weight loss is a common side effect.

B. Nausea and breast tenderness may occur initially.

C. Hair loss is frequently reported.

D. Oral contraceptives decrease the risk of breast cancer.

Explanation: Nausea and breast tenderness are common initial side effects of oral contraceptives, which often subside. Weight gain, not loss, may occur, hair loss is not typical, and oral contraceptives do not significantly reduce breast cancer risk.

Question 5 of 5.

A nurse is discussing sterilization options with a male client. Which of the following statements by the client indicates a need for further teaching?

A. A vasectomy involves cutting the vas deferens to prevent sperm release.

B. I will need to use another contraceptive method until my sperm count is zero.

C. A vasectomy will decrease my testosterone levels.

D. A vasectomy is considered a permanent form of contraception.

Explanation: A vasectomy does not decrease testosterone levels, as the testes continue to produce hormones. The other statements are correct, indicating a need for further teaching about hormonal effects.

Related Questions

For the past 8 hours, a 20-year-old primigravid client in active labor with intact membranes has been experiencing regular contractions. The fetal heart rate is 136 bpm with good variability. After determining that the client is still in the latent phase of labor, the nurse should observe the client for:

A multigravid laboring client has an extensive documented history of drug addiction. Her last reported usage was 5 hours ago. She is 2 cm dilated with contractions every 3 minutes of moderate intensity. The physician orders nalbuphine (Nubain) 15 mg slow I.V. push for pain relief followed by an epidural when the client is 4 cm dilated. Within 10 minutes of receiving the nalbuphine, the client states she thinks she is going to have her baby now. Of the following drugs available at the time of the delivery, which should the nurse avoid using with this client in this situation?

A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to do which of the following?

A multigravid client in labor at 38 weeks' gestation has been diagnosed with Rh sensitization and probable fetal hydrops and anemia. When the nurse observes the fetal heart rate pattern on the monitor, which of the following patterns is most likely?

The physician who elects to perform a cesarean delivery on a primigravid client for fetal distress has informed the client of possible risks during the procedure. When the nurse asks the client to sign the consent form, the client's husband says, 'I'll sign it for her. She's too upset by what is happening to make this decision.' The nurse should: