The nurse is caring for four postpartum clients. Which client should b

Maternal NCLEX

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Question 1 of 5.

The nurse is caring for four postpartum clients. Which client should be the nurse's priority for monitoring for uterine atony?

A. Client who is 2 hours post-cesarean birth for a breech baby

B. Client who delivered a macrosomic baby after a 12-hour labor

C. Client who has a firm fundus after a vaginal delivery 4 hours ago

D. Client receiving oxytocin intravenously for past 2 hours

Explanation: Although the client postâ€”cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse's priority for monitoring for uterine atony. A macrosomic baby stretches the client's uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client's uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.

Question 2 of 5.

The nurse correctly explains that the bleeding is the result of sloughing of which structure?

A. Endometrium

B. Myometrium

C. Epimetrium

D. None of the above

Explanation: Menstrual bleeding occurs due to the sloughing of the endometrium, the inner lining of the uterus, when pregnancy does not occur.

Question 3 of 5.

On the basis of this finding, the nurse can assume that the client is at least how many months' pregnant?

A. 5 months

B. 6 months

C. 7 months

D. 8 months

Explanation: Ballottement, the rebound of the fetus when the cervix is tapped, is typically detectable around 4-5 months, indicating at least 5 months' gestation.

Question 4 of 5.

The nurse correctly assists the client into which position?

A. Lithotomy

B. Prone

C. Sims'

D. Trendelenburg's

Explanation: The lithotomy position, with legs elevated and apart, is standard for pelvic examinations to provide access to the pelvic area.

Question 5 of 5.

Which response by the nurse is most accurate?

A. Fluorescent treponemal antibody absorption (FTA-ABS) test can detect this defect.

B. Hepatitis B surface antigen (HBsAg) test can detect this defect.

C. Maternal serum alpha-fetoprotein (AFP) test can detect this defect.

D. Venereal Disease Research Laboratory (VDRL) test can detect this defect.

Explanation: The maternal serum alpha-fetoprotein (AFP) test screens for neural tube defects like spina bifida by measuring AFP levels.