Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?
A. Request the provider perform a vaginal examination.
This is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.
B. Check the client's fundus.
Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.
C. Measure the client's vital signs.
This is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.
D. Feel for a full bladder.
This is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.
This question is an excerpt from Nurse Dive's nursing test bank - Postpartum AMD Newborn Care Proctored Exam. Take the full exam now
Full Explanation
Check the client's fundus. Lochia rubra is the normal vaginal bleeding and discharge that occurs after childbirth. It consists of blood, mucus, and tissue from the placenta and the uterus lining. It is usually bright red and may have some clots, but these clots should not be big or difficult to pass. If the client has a large amount of lochia rubra with several clots, it may indicate that the uterus is not contracting well and needs to be massaged to expel any retained tissue or blood. Checking the client's fundus is the first action the nurse should take to assess the uterine tone and location.
Choice A is incorrect because requesting the provider perform a vaginal examination is not the first action the nurse should take. A vaginal examination may be necessary if the fundal massage does not reduce the bleeding or if there is a suspicion of lacerations or hematoma, but it is not a priority intervention.
Choice C is incorrect because measuring the client's vital signs is not the first action the nurse should take. Vital signs can help monitor the client's hemodynamic status and identify signs of shock, such as tachycardia, hypotension, and pallor, but they are not as important as checking the fundus in this situation.
Choice D is incorrect because feeling for a full bladder is not the first action the nurse should take. A full bladder can displace the uterus and interfere with its contraction, leading to increased bleeding. However, it is not as likely as uterine atony to cause a large amount of lochia rubra with several clots.
Similar Questions
The first sign of hypovolemic shock from postpartum hemorrhage is likely to be:
A. Hypotension
Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.
B. Cold, clammy skin
Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.
C. Tachycardia
Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.
D. Decreased urinary output
Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.
Full Explanation
Tachycardia. Tachycardia is a sign of hypovolemic shock from postpartum hemorrhage, which occurs when the blood volume is reduced and the heart rate increases to compensate for the low cardiac output and tissue perfusion. Tachycardia is usually the first sign of hypovolemic shock, as it can occur even before a significant drop in blood pressure or other symptoms.
Choice A. Hypotension is incorrect because it is a late sign of hypovolemic shock, which occurs when the compensatory mechanisms fail to maintain adequate blood pressure and organ perfusion.
Choice B. Cold, clammy skin is incorrect because it is a sign of peripheral vasoconstriction, which occurs as a compensatory mechanism to divert blood flow to the vital organs. However, it is not specific to hypovolemic shock and can occur in other types of shock as well.
Choice D. Decreased urinary output is incorrect because it is a sign of renal impairment, which occurs as a result of reduced blood flow to the kidneys. However, it is not specific to hypovolemic shock and can occur in other types of shock or renal disorders as well.
A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. The neonatal reflex that the nurse would teach the mother to elicit, in order to facilitate breastfeeding is:
A. Sucking
Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.
B. Grasp
Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.
C. Tonic neck
Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.
D. Rooting
The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. When the corner of the baby's mouth is stroked or touched, the baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This reflex lasts about 4 months.
Full Explanation
Rooting. The rooting reflex is a primitive neonatal reflex that helps the baby find the breast or bottle to start feeding. When the corner of the baby's mouth is stroked or touched, the baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This reflex lasts about 4 months.
Choice A. Sucking is not the correct answer because it is a different reflex that starts when the roof of the baby's mouth is touched, and it does not help the baby find the breast or bottle.
Choice B. Grasp is not the correct answer because it is a reflex that causes the baby to close his or her fingers in a grasp when the palm of the hand is stroked, and it has nothing to do with breastfeeding.
Choice C. Tonic neck is not the correct answer because it is a reflex that causes the baby to assume a "fencing" position when the head is turned to one side, and it also has nothing to do with breastfeeding.
Parents express concern about the milia on the face and nose of their baby. The nurse's most helpful response would be to instruct the parents to:
A. Squeeze out the white material after cleansing the face.
This is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.
B. Contact a pediatric dermatologist for topical medication
This is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.
C. Leave the milia alone: it will disappear spontaneously. No treatment is needed.
Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.
D. Wash the baby's face with a mild astringent several times a day.
Thisis incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.
Full Explanation
Leave the milia alone: it will disappear spontaneously. No treatment is needed. Milia are small, white cysts that form on the skin, usually on the face, nose, or cheeks of newborns. They are harmless and very common, affecting about half of all healthy infants. They are caused by dead skin cells trapped in pockets of the skin or mouth. They are not a type of acne and are not related to breastfeeding or formula feeding. They usually go away on their own within a few weeks or months without any intervention.
Choice A is incorrect because squeezing out the white material can damage the skin and cause infection or scarring.
Choice B is incorrect because contacting a pediatric dermatologist is unnecessary and expensive for a benign condition that resolves by itself.
Choice D is incorrect because washing the baby's face with a mild astringent can irritate the skin and make the milia worse.