Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 12 hours postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?
A. Urine output of 3,000 mL in 12 hours
Urine output of 3,000 mL in 12 hours is within the expected range for a postpartum client and does not necessarily indicate a complication.
B. Fundus palpable at the umbilicus
The fundus palpable at the umbilicus is a normal finding in a client who is 12 hours postpartum, as the fundus typically descends approximately 1 cm per day.
C. Orthostatic hypotension
Orthostatic hypotension is a potential sign of postpartum hemorrhage or other complications.It occurs when there is a significant drop in blood pressure upon assuming an upright position. This finding warrants further assessment and intervention.
D. Heart rate 110/min
A heart rate of 110/min may be within the expected range for a postpartum client and does not necessarily indicate a complication.
This question is an excerpt from Nurse Dive's nursing test bank - Ati N230 Exam 3 With Ngn Maternal Newborn Proctored Exam. Take the full exam now
Full Explanation
A) A urine output of 3,000 mL in 12 hours postpartum is typically not concerning. Postpartum diuresis is a normal physiological response as the body eliminates excess fluid accumulated during pregnancy.
B) The fundus palpable at the umbilicus is an expected finding 12 hours postpartum as the uterus begins to contract and return to its pre-pregnancy size.
C) Orthostatic hypotension can occur postpartum as a result of the cardiovascular system adjusting after delivery, but it is not typically a sign of a serious complication.
D) A heart rate of 110/min could indicate a postpartum complication such as hemorrhage or infection and should be investigated further. It is higher than the normal range and could be a sign of an underlying issue that needs immediate attention.
Similar Questions
A nurse is planning care for a newborn who has spina bifida. Which of the following actions should be included in the plan of care?
A. Apply snug, clean diapers.
Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtain rectal temperatures.
Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Place the newborn in the prone position.
Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Cover the lesion with a dry dressing.
Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.
Full Explanation
A. Applying snug diapers is not recommended as it can put pressure on the sacral lesion, potentially causing damage or infection.
B. Obtaining rectal temperatures is contraindicated due to the risk of bowel and nerve damage.
C. Placing the newborn in the prone position is the correct action, as it prevents pressure on the lesion and reduces the risk of trauma or infection.
D. Covering the lesion with a dry dressing is incorrect. The lesion should be covered with a moist, sterile, non-adherent dressing to prevent drying out and minimize infection risk.
A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy. Which of the following actions should the nurse take?
A. Monitor the newborn's blood pressure.
Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtain blood glucose by heel stick.
Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Place the newborn in a radiant warmer.
Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiate phototherapy.
Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.
Full Explanation
A. Monitoring the newborn's blood pressure may be indicated in some situations but is not the priority in this case, as the symptoms described suggest hypoglycemia rather than hypertension.
B. Obtaining blood glucose by heel stick is the priority action. The symptoms of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia in newborns, and obtaining a blood glucose level will confirm the diagnosis and guide appropriate treatment.
C. Placing the newborn in a radiant warmer may help to prevent heat loss but does not address the underlying issue of hypoglycemia.
D. Initiating phototherapy is not indicated for the symptoms described, which suggest hypoglycemia rather than hyperbilirubinemia.
A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?
A. Encourage the client to move to the left lateral position.
Encouraging the client to move to the left lateral position helps to promote uterinecontractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assist the client to the bathroom to void.
Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Ask the client to rate her pain.
Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encourage the client to perform Kegel exercises.
Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.
Full Explanation
A. Encouraging the client to move to the left lateral position helps to promote uterine
contractions and reposition the uterus to its midline position, which can help to alleviate uterine atony.
B. Assisting the client to the bathroom to void may be appropriate to relieve bladder distention, but it does not directly address the issue of uterine atony.
C. Asking the client to rate her pain is not relevant to the assessment findings of a slightly boggy and displaced fundus.
D. Encouraging the client to perform Kegel exercises is not indicated for the management of uterine atony.