The nurse is caring for a postpartum client who is complaining of severe pain and a feeling of pressure in her perineum. Her fundus is firm and she has a moderate lochial flow. On inspection, the nurse finds that a perineal hematoma is beginning to form. Which assessment finding should the nurse obtain first?

Hemoglobin and hematocrit

Abdominal contour and bowel sounds

Heart rate and blood pressure

Urinary output and IV fluid intake

Answer and Explanation

The Correct Answer is C

A. Hemoglobin and hematocrit:
While monitoring hemoglobin and hematocrit levels is important for assessing blood loss, in the immediate situation of a developing perineal hematoma with severe pain and pressure, assessing vital signs takes precedence to identify any signs of circulatory compromise.

B. Abdominal contour and bowel sounds:
These assessments are not the first priority in this situation. The client's complaint of severe pain and pressure in the perineum indicates a localized issue that needs immediate attention.

C. Heart rate and blood pressure:
This is the correct answer. Assessing the client's heart rate and blood pressure is crucial to identify signs of shock or compromised circulation associated with the perineal hematoma.

D. Urinary output and IV fluid intake:
While monitoring urinary output and IV fluid intake is important for overall assessment, in the context of a perineal hematoma, assessing vital signs is more immediate to identify any signs of hemodynamic instability.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Request a return demonstration of a diaper change:While it's useful for parents to know how to change a diaper, feeding is more critical for the infant’s health and development in the early days.

B. Evaluate infant feeding techniques prior to discharge:Ensuring that the parents understand how to properly feed their newborn is crucial. Proper feeding techniques are essential for the infant's nutrition, growth, and development. Issues with feeding can lead to dehydration, weight loss, and other health problems. Therefore, this is the most important intervention.

C. Provide the results of the infant's hearing test to the parents:Sharing the results of the hearing test is important, but it is less immediate compared to ensuring that the infant is properly fed.

D. Ensure that they have the pediatric clinic's phone number:
While it is important for parents to have contact information for follow-up care, it is secondary to ensuring they can feed their baby properly.

A. Hemoglobin A1C. B. Postprandial blood glucose test C. Fasting blood glucose D. Oral glucose tolerance test

Correct Answer is C

Explanation

A. Hemoglobin A1C: Hemoglobin A1C is a test that reflects the average blood sugar levels over the past two to three months. It is not typically used for diagnosing gestational diabetes.

B. Postprandial blood glucose test: This test measures blood sugar levels after meals. While it can provide information about how the body processes glucose after eating, it's not the primary test for diagnosing gestational diabetes.

C. Fasting blood glucose: This test measures blood sugar levels after a period of fasting. It is a standard test used to diagnose gestational diabetes.

D. Oral glucose tolerance test (OGTT): This test involves fasting overnight and then drinking a glucose solution. Blood sugar levels are tested at intervals afterward. The OGTT is a common diagnostic test for gestational diabetes.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a young couple and their 24-hour-old infant for discharge from the hospital. In conducting discharge teaching, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is caring for a client who is 24-weeks gestation and reports increased thirst and urination. Which diagnostic test result should the nurse report to the healthcare provider?

Correct Answer is C

Explanation

A client who is 32 weeks gestation comes to the women's health clinic and reports nausea and vomiting. On examination, the nurse notes that the client has an elevated blood pressure. Which action should the nurse implement next?

The nurse is reviewing a woman's health care record during her first prenatal visit. The client has a history of chicken pox as a child and syphills as a teenager. Which action is most important for the nurse to take?

What instruction is most important for the nurse to provide a client in the first trimester of pregnancy who is experiencing nausea?

The nurse is caring for a client who delivered 6 hours ago. Assessment findings reveal a boggy uterus that is displaced above and to the right of the umbilicus. Which action should the nurse take?

The nurse examines a client who is admitted in active labor and determines the cervix is 3 cm dilated 50% effaced, and the presenting part is at 0 station. An hour later. she tells the nurse that she wants to go to the bathroom. Which action should the nurse implement first?

A client at 40-weeks gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. Which information is most important for the nurse to obtain?

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. The nurse would be correct in stating that the purpose for using the ointment is to

The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first?