A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective?

Correct Answer: B

Rationale: In this scenario, option B is the correct answer. The client's blood pressure dropping from 160/120 to 130/90 indicates that the hydralazine is effectively managing the hypertension associated with eclampsia. This is a crucial indicator of the medication's effectiveness as controlling blood pressure is a priority in postpartum care for clients with eclampsia to prevent complications like seizures and strokes. Option A is incorrect because the absence of seizures could be due to other factors, not necessarily the effectiveness of hydralazine. Option C is unrelated to the medication's effectiveness and may be attributed to factors like fluid loss after delivery. Option D is also incorrect as the resolution of a headache is not a direct indicator of hydralazine's effectiveness in managing hypertension. Educationally, understanding the rationale behind monitoring blood pressure in postpartum clients with eclampsia and interpreting the effectiveness of antihypertensive medications is crucial for providing safe and effective care to this vulnerable population. This question highlights the importance of assessing specific parameters to evaluate the effectiveness of pharmacological interventions in postpartum management.

Correct Answer: A

Rationale: In this question, the correct answer is A) 800 units of heparin per hour. To calculate this, we first need to determine the number of units of heparin in 1 mL of the IV solution. The 1/2 liter bag contains 25,000 units in 500 mL, so there are 50 units of heparin per milliliter (25,000 units ÷ 500 mL = 50 units/mL). The client is receiving the IV heparin at a rate of 16 mL/hr, so multiplying the units per mL by the flow rate gives us 800 units/hr (50 units/mL x 16 mL/hr = 800 units/hr). Option B, C, and D are marked as "NA" meaning not applicable or not relevant because they do not provide a numerical value for the units of heparin the client is receiving per hour. This question assesses the ability to calculate medication dosages accurately, which is crucial in nursing practice to ensure patient safety and effective treatment. Understanding how to calculate medication dosages correctly is essential for nurses working in various settings, including maternal health where postpartum hormonal changes can increase the risk of thrombotic events. Mastering dosage calculations is a fundamental skill that nurses must possess to provide safe and competent care to patients.

Correct Answer: A

Rationale: The correct answer is A) Postpartum clients are at high risk for thrombus formation. In the postpartum period, especially after a cesarean section, women are at an increased risk for thrombus formation due to hormonal changes, immobility, and vascular damage during delivery. Intermittent positive pressure boots help prevent blood clots by promoting circulation in the lower extremities through intermittent compression. Option B) Post-cesarean clients are at high risk for fluid volume deficit is incorrect because although fluid volume deficit can occur post-cesarean due to blood loss during surgery, it is not the primary concern addressed by intermittent positive pressure boots. Option C) Postpartum clients are at high risk for varicose vein development is incorrect as varicose veins are not typically a primary concern immediately postpartum, and the use of intermittent positive pressure boots does not directly prevent varicose veins. Option D) Post-cesarean clients are at high risk for poor milk ejection reflex is incorrect as milk ejection reflex is related to breastfeeding, not to the need for intermittent positive pressure boots post-cesarean. Educationally, understanding the rationale for using specific interventions postpartum is crucial for providing safe and effective care to women during this vulnerable period. Recognizing the risks and implementing appropriate interventions, like intermittent positive pressure boots, can significantly impact postpartum outcomes and prevent complications such as thrombus formation.

Correct Answer: C

Rationale: In the immediate postpartum period following a low forceps delivery, the nurse should assess the woman for heavy lochia. Lochia is the vaginal discharge after childbirth, consisting of blood, mucus, and uterine tissue. In the case of a low forceps delivery, there is an increased risk of trauma to the birth canal and uterus, leading to heavier bleeding. Monitoring the amount, color, and odor of lochia is crucial to assess for postpartum hemorrhage, a significant concern after instrumental deliveries. The other options are incorrect for several reasons: A) Infection: While infection is a concern in the postpartum period, it is not specifically associated with a low forceps delivery unless there are signs or symptoms present. B) Bloody urine: Hematuria is not a typical finding related to a low forceps delivery. It may indicate genitourinary issues but is not a direct result of this type of delivery. D) Rectal abrasions: This is not a common complication of a low forceps delivery. While perineal trauma is possible, rectal abrasions are not a primary concern in this scenario. Educationally, understanding the potential complications and assessments required after different types of deliveries is essential for nurses caring for postpartum women. Recognizing the specific risks associated with instrumental deliveries like low forceps can help nurses provide targeted and effective care to promote optimal recovery and prevent complications.

Correct Answer: B

Rationale: In this scenario, the nurse should question the order for magnesium sulfate (option B) for the postoperative cesarean client with severe preeclampsia. Magnesium sulfate is commonly used in the management of severe preeclampsia during labor and delivery to prevent seizures (eclampsia). However, once the patient has transitioned to the postpartum unit, magnesium sulfate is typically discontinued unless there are specific ongoing indications. Option A, Methergine, is a medication used to prevent or control postpartum hemorrhage by causing uterine contractions. This medication is commonly ordered post-cesarean to help the uterus contract and prevent excessive bleeding. Option C, Advil (ibuprofen), is a nonsteroidal anti-inflammatory drug that is often prescribed postoperatively for pain relief and inflammation control, which is appropriate for a postoperative patient. Option D, Morphine sulfate, is a potent opioid analgesic that may be ordered for pain management postoperatively, especially after a cesarean delivery. Educationally, it's crucial for nurses to understand the rationale behind medication orders and to be vigilant in assessing the appropriateness of each medication for the specific clinical situation of the patient. In this case, recognizing the transition from labor and delivery to the postpartum unit and understanding the indications for each medication is essential for safe and effective patient care.