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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

Measure vital signs.

Obtain human chorionic gonadotropin levels.

Collect urine sample for urinalysis.

Recommend bed rest.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While measuring vital signs is important, it is not the most appropriate action based on the given symptoms.

Choice B rationale

Obtaining human chorionic gonadotropin levels is the most appropriate action. The symptoms described by the client could indicate a possible miscarriage or ectopic pregnancy, and hCG levels can help confirm this.

Choice C rationale

Collecting a urine sample for urinalysis is not the most appropriate action based on the given symptoms.

Choice D rationale

Recommending bed rest is not the most appropriate action based on the given symptoms.

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Correct Answer is C

Explanation

Choice A rationale

Initiating phototherapy for the newborn is a treatment for jaundice, not a diagnostic step. It would be premature to start this treatment without confirming the diagnosis and assessing the severity of jaundice.

Choice B rationale

Reviewing the mother’s medical records for blood type and Rh factor can be useful in cases where Rh incompatibility is suspected. However, this would not be the immediate next step when observing a yellow tint on the baby’s skin.

Choice C rationale

Measuring bilirubin levels using transcutaneous bilirubinometry is the appropriate next step when jaundice is suspected in a newborn. This non-invasive test can quickly and accurately

measure bilirubin levels, helping to determine the severity of jaundice and guide treatment decisions.

Choice D rationale

Evaluating the results of the cord blood Coomb’s test can help identify cases of immune- mediated hemolytic disease of the newborn, a potential cause of neonatal jaundice. However, this would not typically be the first step taken when jaundice is observed.

A. Return of lochia rubra. B. Engorged, painful breasts. C. Difficulty falling asleep. D. Decreased appetite. E. Feelings of sadness.

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

Explanation

Choice A rationale

Return of lochia rubra, or bright red bleeding, is not a sign of postpartum depression. It is a normal part of the postpartum period and can last for several weeks after childbirth.

Choice B rationale

Engorged, painful breasts can be a sign of breastfeeding complications, but they are not a sign of postpartum depression. They are a common experience for many women as their milk comes in after childbirth.

Choice C rationale

Difficulty falling asleep, even when the baby is sleeping, can be a sign of postpartum depression. Sleep disturbances are common among women with postpartum depression.

Choice D rationale

Decreased appetite can be a sign of postpartum depression. Changes in eating habits, such as eating too little or too much, are common symptoms of depression.

Choice E rationale

Feelings of sadness that last for more than two weeks after childbirth can be a sign of postpartum depression. While many women experience “baby blues” in the first few weeks after childbirth, prolonged feelings of sadness can indicate a more serious issue.

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

While conducting a daily assessment of a one-day-old newborn, the nurse notices a yellow tint on the baby’s forehead, sternum, and abdomen.What should be the nurse’s next course of action?

Correct Answer is C

Explanation

Which signs of postpartum depression require additional attention from the nurse? (Select all that apply.)

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

Explanation

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A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time. I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

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A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever.What instruction should the nurse give to this client?

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The nurse is caring for a client who is 10-weeks gestation and palpates the fundus at 2 fingerbreadths above the pubic symphysis.
The client reports nausea, vomiting, and scant dark brown vaginal discharge. Which action should the nurse take?