Extract:

The nurse should first address the client's blood pressure followed by the client's platelet count.

Question 1 of 5

Which of the following options correctly prioritizes these actions?

A. Blood pressure should be checked before platelet count.B. Platelet count is more important than blood pressure.C. Address both simultaneously.D. Ignore blood pressure.

Correct Answer: A

Rationale: Blood pressure should be checked first as it indicates immediate hemodynamic status, critical in acute settings, followed by platelet count for bleeding risk.

Extract:

A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.

Question 2 of 5

Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

A. Have the client ambulate as often as possible.B. Apply warm, moist packs to the client's lower legs.C. Apply elastic stockings before the client gets out of bed.D. Administer NSAIDs every 6 to 8 hours.

Correct Answer: A

Rationale: Early ambulation prevents blood stasis, a key measure to reduce thrombophlebitis risk post-cesarean.

Extract:

A nurse is reviewing the facility protocol about newborn identification and safety with a new parent.

Question 3 of 5

Which of the following information should the nurse include?

A. We will scan your baby's identification bracelet each time we check on him.B. You should check the identity of individuals who come to remove your baby from the room.C. We will match the bracelet on your baby with his footprint record each shift.D. Your baby will wear an electronic bracelet when he is out of your room.

Correct Answer: B

Rationale: Parents should verify the identity of anyone taking the baby from the room. This prevents unauthorized individuals from removing the baby, enhancing security and safety.

Extract:

Nurses' Notes 0830: The client is a gravida 2 para 1 at 30 weeks of gestation. Reports low back pain and abdominal cramping for the past two days. History includes cesarean birth for breech presentation. Reports smoking half a pack of cigarettes per day. BMI is greater than 30. The client is grimacing and has a positive report of fetal movement. External electronic fetal monitoring applied, showing fetal heart rate of 148/min. The abdomen is soft and nontender to palpation. 0845: Uterine contractions every 2â€“3 minutes, moderate in strength. Sterile vaginal examination reveals cervix dilated to 2 cm, 80% effaced, and -1 station. Mucous vaginal discharge and a small amount of bright red bleeding noted on the perineal pad. Vital Signs: Temperature: 36.8Â°C (98.2Â°F), Heart rate: 98/min, Respiratory rate: 18/min, Blood pressure: 112/68 mm Hg, Oxygen saturation: 98% on room air.

Question 4 of 5

For each finding, click to specify if the client finding is consistent with placenta previa, preterm labor, or abruptio placentae: A. Pain report, B. Uterine contractions, C. Perineal pad findings, D. Cervical dilation.

Findings	Placenta Previa	Preterm Labour	Abruptio Placentae
Pain report
Uterine contractions
Perineal pad findings
Cervical dilation

Correct Answer: A,B,C,D

Rationale: Pain and contractions suggest preterm labor/abruptio placentae; bleeding fits all three; dilation aligns with preterm labor/placenta previa.

Extract:

Nurses' Notes (Postpartum Assessment) 1200: The client successfully delivered a viable newborn via vaginal delivery. 1300: The client reports feeling tired and anxious. Assessment reveals the fundus is deviated to the left, boggy, and located 1 cm above the umbilicus. The perineal pad is saturated with lochia rubra, indicating excessive bleeding. The client reports an inability to ambulate to the bathroom due to residual numbness from the labor epidural. Pain is reported as 0 on a scale of 0 to 10. Fundal massage performed during assessment has yielded no improvement in uterine tone. A nurse is caring for a 36-year-old female client in the labor and delivery unit at 39 weeks of gestation admitted for evaluation of postpartum bleeding following a vaginal delivery.

Question 5 of 5

Select the 2 interventions the nurse should perform immediately.

A. Weigh the clientâ€™s perineal pad.B. Insert a straight catheter for the client.C. Administer methylergonovine 0.2 mg IM.D. Draw a complete blood count.E. Apply oxygen via nasal cannula.

Correct Answer: B,C

Rationale: Inserting a catheter empties the bladder, aiding uterine contraction; methylergonovine stimulates contractions to reduce bleeding from a boggy uterus.