A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours.At 6 hours post-partum, the client is anxious and restless.
On further assessment, a large perineal hematoma is seen.
She is unable to urinate.
After notifying the physician, the nurse should plan to:

Insert a Foley catheter.

Instruct the client on using a Sitz Bath when she voids.

Monitor the fundal height.

Apply a heating pad to the area.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Inserting a Foley catheter can relieve the bladder and provide an opportunity to monitor urinary output, which is essential for assessing the patient's condition with a perineal hematoma.

Choice B rationale

A Sitz bath may help with pain relief and hygiene but does not address the immediate concern of urinary retention and assessment for injury.

Choice C rationale

Monitoring the fundal height is important but does not address the urgent need to relieve the patient's inability to urinate.

Choice D rationale

Applying a heating pad to the area may help with pain, but it does not address the immediate problem of urinary retention due to the hematoma.

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Correct Answer is ["0.8"]

Explanation

Step 1 is 0.2 mg × 4 doses = 0.8 mg

The total amount the patient will receive in a 24-hour period is 0.8 mg.

A. Place the newborn in a radiant warmer. B. Monitor the newborn's blood pressure. C. Initiate phototherapy. D. Obtain blood glucose by heel stick.

Correct Answer is D

Explanation

Choice A rationale

Placing the newborn in a radiant warmer is appropriate for managing hypothermia but does not directly address the signs of diaphoresis, jitteriness, and lethargy, which are indicative of hypoglycemia.

Choice B rationale

Monitoring the newborn's blood pressure is not the primary action needed for signs of hypoglycemia. The immediate need is to check blood glucose levels and address any hypoglycemia.

Choice C rationale

Initiating phototherapy is a treatment for hyperbilirubinemia (jaundice) and is not related to the signs of diaphoresis, jitteriness, and lethargy seen in hypoglycemia.

Choice D rationale

Obtaining blood glucose by heel stick is the correct action as the signs of diaphoresis, jitteriness, and lethargy are indicative of hypoglycemia. Checking blood glucose levels will help in diagnosing and managing the condition.

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Naxlex Comprehensive Predictor Exams

The client has a physician's order for Methylergonovine (Methergine) 0.2 mg by mouth every 6 hours for 24 hours. The RN knows the reason for this order is to assist in controlling postpartum bleeding. What is the total amount the patient will receive in mg in a 24-hour period?

Correct Answer is ["0.8"]

Explanation

A nurse is caring for a newborn who exhibits signs of diaphoresis, jitteriness, and lethargy.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

The nurse develops a teaching plan for a 24-hour vaginal postpartum client with a firm fundus, scant lochia, and a 4th degree laceration.Her hemoglobin level is 10.0 gm/dl, and hematocrit is 30%. The mother is breastfeeding.Which medication would the nurse expect to be contraindicated?

The nurse is providing discharge teaching about the possibility of mastitis to a mother who is breastfeeding.Which statement by the client indicates a need for MORE teaching?

The nurse is reviewing discharge instructions with the postpartum client who had a cesarean section 4 days ago and will include which of the following warning signs to report once she is home?

A nurse is caring for a mother who delivered vaginally 2 hr ago.Heart rate 106/min.Axillary temperature 36.6° C (98.0° F). Respiratory rate 22 /min.Oxygen saturation 94%. Select the 4 findings the nurse should report to the provider.

The nurse is teaching the patient about breastfeeding.The nurse knows the following: 1. The hormone responsible for the let-down reflex is:

The nurse calculates the 1-minute Apgar score of a neonate with the following characteristics to be: Heart rate 60; weak cry, partial flexion of extremities; weak suck; gray color.