Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
A. Fundal height below the umbilicus
Fundal height below the umbilicus:In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B. Decreased urge to void
Decreased urge to void:A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C. Increased urine output
Increased urine output: Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D. Displaced fundus from the midline
Displaced fundus from the midline:A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Ati Med Surg Quiz Proctored Examquiz. Take the full exam now
Full Explanation
A) Fundal height below the umbilicus:
In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B) Decreased urge to void:
A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C) Increased urine output:
Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D) Displaced fundus from the midline:
A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
Similar Questions
A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention?
A. Fundal height below the umbilicus
Fundal height below the umbilicus:In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B. Decreased urge to void
Decreased urge to void:A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C. Increased urine output
Increased urine output: Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D. Displaced fundus from the midline
Displaced fundus from the midline:A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
Full Explanation
A) Fundal height below the umbilicus:
In the immediate postpartum period, the fundus typically descends at a predictable rate. A fundal height below the umbilicus on the first day postpartum is expected. It is not a cause for immediate intervention unless accompanied by other signs of postpartum hemorrhage.
B) Decreased urge to void:
A decreased urge to void is common in the immediate postpartum period due to perineal swelling, episiotomy or lacerations, and the effects of regional anesthesia. However, it is not an immediate concern as long as the client is voiding adequate amounts of urine.
C) Increased urine output:
Increased urine output in the postpartum period is expected due to the diuretic effect of the body eliminating excess fluid retained during pregnancy. It is not a cause for immediate intervention as long as the client is not exhibiting signs of dehydration.
D) Displaced fundus from the midline:
A displaced fundus from the midline is concerning as it may indicate uterine atony, which is the most common cause of postpartum hemorrhage. Immediate intervention is necessary to prevent further complications such as excessive bleeding.
A nurse is teaching a client who is postpartum and has a new prescription for an injection of Rh, (D) Immunoglobulin. Which of the following should be included in the teaching?
A. It destroys Rh antibodies in mothers who are Rh negative.
It destroys Rh antibodies in mothers who are Rh negative:This statement is incorrect. Rh(D) Immunoglobulin, commonly known as RhoGAM, does not destroy Rh antibodies in mothers who are Rh negative. Instead, it prevents the mother's immune system from producing Rh antibodies against Rh-positive fetal blood cells.
B. It destroys Rh antibodies in newborns who are Rh positive.
It destroys Rh antibodies in newborns who are Rh positive:This statement is incorrect. Rh(D) Immunoglobulin does not destroy Rh antibodies in newborns. Its purpose is to prevent the formation of Rh antibodies in Rh-negative mothers, thus protecting future pregnancies from hemolytic disease of the newborn (HDN).
C. It prevents the formation of Rh antibodies in newborns who are Rh positive.
It prevents the formation of Rh antibodies in newborns who are Rh positive: This statement is incorrect. Rh(D) Immunoglobulin does not prevent the formation of Rh antibodies in newborns. It acts by suppressing the mother's immune response to Rh-positive fetal blood cells, thereby preventing the production of Rh antibodies that could harm future pregnancies.
D. It prevents the formation of Rh antibodies in mothers who are Rh negative.
It prevents the formation of Rh antibodies in mothers who are Rh negative:This statement is correct. Rh(D) Immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies in response to exposure to Rh-positive fetal blood cells during pregnancy or childbirth. By neutralizing fetal Rh-positive red blood cells in the maternal circulation, it prevents sensitization of the mother's immune system and protects future pregnancies from HDN.
Full Explanation
A) It destroys Rh antibodies in mothers who are Rh negative:
This statement is incorrect. Rh(D) Immunoglobulin, commonly known as RhoGAM, does not destroy Rh antibodies in mothers who are Rh negative. Instead, it prevents the mother's immune system from producing Rh antibodies against Rh-positive fetal blood cells.
B) It destroys Rh antibodies in newborns who are Rh positive:
This statement is incorrect. Rh(D) Immunoglobulin does not destroy Rh antibodies in newborns. Its purpose is to prevent the formation of Rh antibodies in Rh-negative mothers, thus protecting future pregnancies from hemolytic disease of the newborn (HDN).
C) It prevents the formation of Rh antibodies in newborns who are Rh positive:
This statement is incorrect. Rh(D) Immunoglobulin does not prevent the formation of Rh antibodies in newborns. It acts by suppressing the mother's immune response to Rh-positive fetal blood cells, thereby preventing the production of Rh antibodies that could harm future pregnancies.
D) It prevents the formation of Rh antibodies in mothers who are Rh negative:
This statement is correct. Rh(D) Immunoglobulin is administered to Rh-negative mothers to prevent the formation of Rh antibodies in response to exposure to Rh-positive fetal blood cells during pregnancy or childbirth. By neutralizing fetal Rh-positive red blood cells in the maternal circulation, it prevents sensitization of the mother's immune system and protects future pregnancies from HDN.
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?
A. Wash the cord daily with mild soap and water.
Wash the cord daily with mild soap and water:This instruction is incorrect. Washing the umbilical cord stump daily with soap and water can increase the risk of infection and delay the drying process. It is recommended to keep the cord stump clean and dry without using soap or other cleansing agents.
B. Give a sponge bath until the cord stump falls off.
Give a sponge bath until the cord stump falls off:This instruction is correct. Until the umbilical cord stump falls off, it is advisable to give the newborn sponge baths rather than immersing them in a tub of water. Sponge baths help keep the cord stump dry and reduce the risk of infection until it naturally separates from the baby's body.
C. Cover the cord with the diaper.
Cover the cord with the diaper: This instruction is incorrect. Covering the umbilical cord stump with a diaper can create a moist environment, which may increase the risk of infection. It is recommended to fold down the top edge of the diaper to expose the cord stump to air and aid in drying.
D. Apply petroleum jelly to the cord stump.
Apply petroleum jelly to the cord stump:This instruction is not recommended. Applying petroleum jelly or any other substance to the umbilical cord stump can interfere with the drying process and increase the risk of infection. It is best to allow the cord stump to air dry naturally without the use of additional products.
Full Explanation
A) Wash the cord daily with mild soap and water:
This instruction is incorrect. Washing the umbilical cord stump daily with soap and water can increase the risk of infection and delay the drying process. It is recommended to keep the cord stump clean and dry without using soap or other cleansing agents.
B) Give a sponge bath until the cord stump falls off:
This instruction is correct. Until the umbilical cord stump falls off, it is advisable to give the newborn sponge baths rather than immersing them in a tub of water. Sponge baths help keep the cord stump dry and reduce the risk of infection until it naturally separates from the baby's body.
C) Cover the cord with the diaper:
This instruction is incorrect. Covering the umbilical cord stump with a diaper can create a moist environment, which may increase the risk of infection. It is recommended to fold down the top edge of the diaper to expose the cord stump to air and aid in drying.
D) Apply petroleum jelly to the cord stump:
This instruction is not recommended. Applying petroleum jelly or any other substance to the umbilical cord stump can interfere with the drying process and increase the risk of infection. It is best to allow the cord stump to air dry naturally without the use of additional products.