A nurse is collecting data from a client who is 18 hr postpartum.Which of the following findings require the nurse to intervene?

Fundus located to right of umbilicus.

Temperature 37.8° C (100° F).

Deep tendon reflexes 2+.

Moderate amount of lochia rubra.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.

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Correct Answer is C

Explanation

Choice A rationale

History of methicillin-resistant Staphylococcus aureus (MRSA) is not directly related to the use of a cervical cap. The main concern with a cervical cap is infection, but MRSA history alone doesn't make it a contraindication for this form of contraception.

Choice B rationale

History of thrombophlebitis is more of a concern with hormonal contraceptives due to the risk of blood clots. A cervical cap does not involve hormones, so this condition is not a direct contraindication.

Choice C rationale

History of toxic shock syndrome (TSS) is a contraindication for the use of a cervical cap because the cap can increase the risk of developing TSS again. TSS is associated with prolonged use of barrier contraceptives, which can create an environment that fosters the growth of bacteria responsible for TSS.

Choice D rationale

Type 1 diabetes mellitus is not a direct contraindication for the use of a cervical cap. The concern with diabetes is often related to blood glucose control and potential infections, but it doesn't specifically contraindicate the use of cervical caps.

A. Breech presentation B. Terbutaline administration C. FHR (Fetal Heart Rate) D. WBC count E. Lesions noted

Correct Answer is ["A","C","E"]

Explanation

Choice A rationale:

Breech presentation is a contraindication for dinoprostone as it increases the risk of complications during labor and delivery. Using dinoprostone to induce labor in a non-vertex presentation can lead to issues such as cord prolapse or obstructed labor, which necessitate a cesarean section for safe delivery.

Choice B rationale:

Terbutaline administration is used to manage preterm labor by relaxing the uterus. While it is relevant in labor management, it does not directly contraindicate the use of dinoprostone. Terbutaline and dinoprostone can be used in conjunction if properly managed.

Choice C rationale:

Fetal heart rate (FHR) monitoring showing abnormalities is a potential reason to withhold dinoprostone. Dinoprostone can increase uterine contractions, potentially stressing the fetus. A stable FHR with moderate variability indicates fetal well-being; however, if there were concerns, the provider might withhold dinoprostone.

Choice D rationale:

A WBC count of 9,500/mm³ is within the normal range and does not indicate an infection or condition that would contraindicate dinoprostone use. Elevated WBC count could raise concerns, but in this case, it is normal and not a contraindication.

Choice E rationale:

Lesions noted on the vaginal introitus and labia majora, likely caused by Herpes simplex virus, are a contraindication for dinoprostone. Active genital herpes lesions increase the risk of neonatal herpes transmission, making vaginal delivery risky. In such cases, cesarean delivery is often preferred to prevent transmission.

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A nurse is collecting data from a client who is 18 hr postpartum.Which of the following findings require the nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who inquires about a cervical cap for contraception.The nurse should identify that which of the following manifestations is a contraindication for the use of a cervical cap?

Correct Answer is C

Explanation

A nurse is assisting with the care of a 30-year-old female client who is scheduled to receive a dose of dinoprostone in the maternal newborn unit. Exhibits For which of the following findings should the nurse anticipate a provider's prescription to withhold the dinoprostone? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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