Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is 5 hours postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?
A. Uterine atony
Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B. Thrombophlebitis
Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C. Puerperal infection
Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D. Retained placental fragments
Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this 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. Uterine atony is the most common cause of postpartum hemorrhage and is more likely to occur after a delivery of a large infant or in cases of rapid or prolonged labor.
B. Thrombophlebitis is a risk after childbirth, especially in clients who have undergone cesarean delivery or who have other risk factors such as prolonged immobility, but it is not directly related to the size of the newborn.
C. Puerperal infection is a risk following childbirth, but it is not directly related to the size of the newborn.
D. Retained placental fragments can lead to postpartum hemorrhage, but the size of the newborn is not a direct risk factor for this complication.
Similar Questions
A nurse is reviewing a newborn's laboratory results. Which of the following findings is the nurse's priority?
A. Platelets 200,000/mm3
A platelet count of 200,000/mm3 is within the normal range for a newborn and does not require immediate intervention.
B. Bilirubin 19 mg/dL
A bilirubin level of 19 mg/dL may indicate hyperbilirubinemia, which requires monitoring but is not an immediate priority unless significantly elevated.
C. Blood glucose 45 mg/dL
A blood glucose level of 45 mg/dL is below the normal range for a newborn and requires immediate attention as it may indicate hypoglycemia, which can lead to neurologicalcomplications if left untreated.
D. Hemoglobin 22 g/dL
A hemoglobin level of 22 g/dL is within the normal range for a newborn and does not require immediate intervention.
Full Explanation
- A) A platelet count of 200,000/mm3 is within the normal range for a newborn and does not require immediate intervention.
- B) A bilirubin level of 19 mg/dL is high and suggests the possibility of hyperbilirubinemia, which can lead to jaundice and, in severe cases, kernicterus, a form of brain damage. This is a critical value that requires immediate attention.
- C) A blood glucose level of 45 mg/dL is on the lower end of the normal range, but it is not as immediately concerning as the elevated bilirubin level. Monitoring and appropriate feeding should address this issue.
- D) A hemoglobin level of 22 g/dL is high, indicating polycythemia, which can be a risk factor for hyperviscosity syndrome. However, it is not as urgent as the bilirubin level of 19 mg/dL. Monitoring and partial exchange transfusion may be considered if symptoms develop.
A nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice?
A. Prepare for an exchange blood transfusion.
Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.
B. Initiate early feeding.
Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has notresponded to other measures.
C. Suction excess mucus with a bulb syringe.
Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Begin phototherapy.
Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.
Full Explanation
A. Initiating early feeding helps promote the passage of meconium, which contains bilirubin, out of the newborn's body, reducing the risk of jaundice.
B. Preparing for an exchange blood transfusion is not appropriate for preventing jaundice at this stage. Exchange transfusion is a treatment option for severe hyperbilirubinemia that has not
responded to other measures.
C. Suctioning excess mucus with a bulb syringe is important for maintaining a patent airway in the newborn but does not directly prevent jaundice.
D. Beginning phototherapy is a treatment for jaundice once it has occurred but is not a preventive measure.
A nurse is providing teaching about comfort measures for breast engorgement to a client who is postpartum and is breastfeeding. Which of the following statements by the client indicates a need for further teaching?
A. "I will apply ice packs to my breasts after feeding."
Applying ice packs to the breasts after feeding can help reduce swelling and discomfort associated with breast engorgement.
B. "I should apply hot packs to my breasts during feeding."
Applying hot packs to the breasts during feeding can increase blood flow and exacerbate engorgement. Heat can worsen inflammation and discomfort in the breasts.
C. "I should crush cabbage leaves and place them on my breasts."
Crushed cabbage leaves can be applied to the breasts between feedings to help reduce swelling and discomfort associated with engorgement.
D. "I will breastfeed every 2 hours."
Breastfeeding every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement.
Full Explanation
A. Applying ice packs to the breasts after feeding can help reduce swelling and discomfort associated with breast engorgement.
B. Applying hot packs to the breasts during feeding can increase blood flow and exacerbate engorgement. Heat can worsen inflammation and discomfort in the breasts.
C. Crushed cabbage leaves can be applied to the breasts between feedings to help reduce swelling and discomfort associated with engorgement.
D. Breastfeeding every 2 hours helps to ensure frequent emptying of the breasts, which can help alleviate engorgement.