a multiparous client at 36 hours postpartum reports increased bleeding and cramping on examination the nurse finds the uterine fundus 2 centimeters ab
Logo

Nursing Elites

HESI LPN

HESI Focus on Maternity Exam

1. A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first?

Correct answer: C

Rationale: Encouraging the client to void is the priority action in this scenario. A distended bladder can prevent the uterus from contracting properly, leading to increased bleeding and a high uterine fundus. By encouraging the client to void, the nurse can help the uterus contract effectively, reducing bleeding. Increasing intravenous fluids or administering ibuprofen would not address the immediate concern of a distended bladder affecting uterine contraction. While it may be necessary to involve the healthcare provider, addressing the bladder distention promptly is crucial to prevent further complications.

2. Which of the following statements is a symptom of cystic fibrosis in children?

Correct answer: B

Rationale: The correct answer is B. Cystic fibrosis is a genetic disorder that causes the body to produce thick, sticky mucus. This mucus can clog the airways in the lungs and obstruct the pancreas, leading to severe respiratory and digestive problems. Choice A is incorrect because uncontrollable muscle movements and personality changes are not typical symptoms of cystic fibrosis. Choice C is incorrect because cystic fibrosis does not directly cause red blood cells to clump together and obstruct small blood vessels. Choice D is incorrect because cystic fibrosis primarily affects the respiratory and digestive systems, not the central nervous system.

3. A nurse on the postpartum unit is caring for four clients. For which of the following clients should the nurse notify the provider?

Correct answer: C

Rationale: The correct answer is C because in a client receiving magnesium sulfate, absent deep tendon reflexes can indicate magnesium toxicity, which requires immediate intervention to prevent serious complications. Choices A, B, and D are common postpartum occurrences that do not typically warrant immediate provider notification. A urinary output of 300 ml in 8 hours, abdominal cramping during breastfeeding, and frequent changing of perineal pads due to lochia rubra are within the expected range of postpartum recovery and do not indicate an urgent need for provider notification.

4. Which procedure is used to detect neural tube defects such as spina bifida and certain chromosomal abnormalities?

Correct answer: D

Rationale: The correct answer is the Alpha-fetoprotein (AFP) assay. This blood test measures the level of AFP in a pregnant woman's blood, aiding in the detection of neural tube defects and certain chromosomal abnormalities in the fetus. Choice A, artificial insemination, is a method used to facilitate fertilization and is not related to detecting fetal abnormalities. Choice B, amniocentesis, involves collecting amniotic fluid for genetic testing, not directly measuring AFP levels. Choice C, endometriosis, is a medical condition involving abnormal tissue growth and is not a procedure for detecting fetal abnormalities. Therefore, the Alpha-fetoprotein (AFP) assay is the most appropriate option for detecting neural tube defects such as spina bifida and certain chromosomal abnormalities.

5. A client is preparing to administer methylergonovine 0.2 mg orally to a client who is 2 hr postpartum and has a boggy uterus. For which of the following assessment findings should the nurse withhold the medication?

Correct answer: A

Rationale: The correct answer is A. Methylergonovine can increase blood pressure, so it should be withheld if the client has hypertension. A blood pressure reading of 142/92 mm Hg indicates hypertension and is a contraindication for administering methylergonovine. Choices B, C, and D are within normal limits and not contraindications for administering this medication. Urine output, pulse rate, and respiratory rate are not factors that determine the appropriateness of administering methylergonovine in this situation.

Similar Questions

A client has bacterial vaginosis. Which of the following medications should the nurse expect to administer?
When discussing risk factors for gestational diabetes mellitus (GDM) with a group of pregnant clients, which ethnicity should the nurse identify as having the lowest incidence of GDM?
According to a study in the year 2013 by Fellman, if a woman is a twin, if her mother was a twin, or if she has previously borne twins, then:
When should the low-risk patient, who is 16 weeks pregnant, be advised to return to the prenatal clinic?
The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse document in the medical record?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses