Question 1

The nurse is caring for a client who had a cesarean section 4 hours ago.The client refuses to let the nurse complete the fundal assessment.Which statement is the best response to this problem?

Accepted Answer

Offering pain medication before the assessment can help alleviate discomfort, making the procedure more tolerable for the client. This approach addresses the client's likely concern about pain while ensuring the necessary assessment is completed.

Question 2

The nurse is caring for a client who delivered twins 2 days ago.During the morning assessment,the nurse notes that the fundus is firm and located midline and at the level of the umbilicus.Which should the nurse do in light of this information?

Accepted Answer

BTwo days postpartum, it is expected for the fundus to be firm, midline, and at the level of the umbilicus, especially after a twin delivery where the uterus was more greatly distended. Checking previous assessments (C) ensures the fundus is decreasing in size as expected, indicating normal involution. Asking the client to void and rechecking the fundus level (B) is also appropriate because a full bladder can displace the uterus and affect the fundus's position, potentially making it seem higher than it actually is.

Question 3

The nurse is precepting a graduate nurse who is caring for a client who received an insertion of misoprostol at 8 am.The client has not had any contractions since this was inserted.At 10 am,the graduate nurse prepares to hang the oxytocin.Which should the precepting nurse do at this time?

Accepted Answer

Misoprostol and oxytocin are both medications used to induce labor, but they must not be administered too closely together due to the risk of overstimulating the uterus, which can endanger both the mother and the baby. There should be at least a 4-hour window between the administration of misoprostol and the initiation of oxytocin to ensure the safety and well-being of both the patient and the fetus.

Question 4

The nurse is attending the birth of a premature neonate and prepares to do the 1-minute Apgar score of this infant.Assessment data shows the infant has a heart rate of 98,is not crying,has some flexion of the extremities,has a grimace when stimulated,and is very pale.Which will the nurse record as the Apgar score?

Accepted Answer

The Apgar score is calculated by assessing five criteria: heart rate (1 point for <100 bpm), respiratory effort (0 points for no crying), muscle tone (1 point for some flexion), reflex irritability (1 point for grimace), and color (0 points for very pale). The total score is 3.

Quiz 14: Reproduction

The nurse is caring for a client who had a cesarean section 4 hours ago.The client refuses to let the nurse complete the fundal assessment.Which statement is the best response to this problem?

The nurse is caring for a client who delivered twins 2 days ago.During the morning assessment,the nurse notes that the fundus is firm and located midline and at the level of the umbilicus.Which should the nurse do in light of this information?

The nurse is precepting a graduate nurse who is caring for a client who received an insertion of misoprostol at 8 am.The client has not had any contractions since this was inserted.At 10 am,the graduate nurse prepares to hang the oxytocin.Which should the precepting nurse do at this time?