A client is being cared for 2 hours after a spontaneous vaginal birth and has saturated two perineal pads with blood in a 30-minute period. Which of the following is the priority nursing intervention at this time?

Correct Answer: A

Rationale: The correct answer is A: Palpate the client's uterine fundus. Palpating the uterine fundus is crucial to assess for uterine atony, a common cause of postpartum hemorrhage. If the fundus is boggy or deviated, it indicates uterine atony and immediate interventions are needed. B: Assisting the client to a bedpan to urinate is important, but addressing the potential cause of excessive bleeding takes precedence. C: Administering oxytocic medication may be necessary to help stimulate uterine contractions, but assessing the fundus comes first to determine the underlying cause of bleeding. D: Increasing fluid intake is not the priority in this situation. Palpating the fundus and addressing potential hemorrhage are the immediate concerns.

Correct Answer: B

Rationale: The correct answer is B (15 to 25 pounds) because this recommendation aligns with the guidelines for weight gain during pregnancy for a client with a BMI of 26.5. The Institute of Medicine recommends this weight gain range for individuals in the overweight category. It is important to strike a balance between gaining enough weight to support the health of the fetus and not gaining excess weight that may lead to complications. Choice A (11 to 20 pounds) may not provide enough weight gain for optimal pregnancy outcomes, while choice C (25 to 35 pounds) may lead to excessive weight gain. Choice D (1 pound per week) is too specific and does not account for individual variations in weight gain patterns during pregnancy. It is crucial to tailor weight gain recommendations based on the client's BMI to ensure a healthy pregnancy.

Correct Answer: B

Rationale: The correct answer is B: Cullen's sign. Cullen's sign is the presence of periumbilical ecchymosis, indicating blood in the peritoneum due to internal bleeding from a ruptured ectopic pregnancy. Chvostek's sign (choice A) is related to facial muscle spasm due to hypocalcemia. Chadwick's sign (choice C) is bluish discoloration of the cervix indicating pregnancy. Goodell's sign (choice D) is softening of the cervix in early pregnancy. These signs are not indicative of blood in the peritoneum like Cullen's sign is.

Correct Answer: B

Rationale: The correct answer is B because implantation actually occurs around 6-10 days after fertilization, not after conception. This is a critical distinction as conception refers to the union of sperm and egg to form a zygote, while fertilization specifically refers to the fusion of the genetic material. Therefore, the statement by the newly licensed nurse is inaccurate and requires intervention. A: Fertilization typically occurs in the outer third of the fallopian tube, making this statement correct. C: Sperm can indeed remain viable in the woman's reproductive tract for 2 to 3 days, indicating this statement is accurate. D: Bleeding or spotting can indeed accompany implantation, making this statement correct. In summary, choice B is incorrect because implantation occurs around 6-10 days after fertilization, not conception. Choices A, C, and D are all correct statements related to conception and fertilization.

Correct Answer: A

Rationale: Rationale: Contractions lasting longer than 90 seconds can indicate uterine hyperstimulation, which can lead to decreased oxygenation of the fetus. This finding should be reported to the provider for further assessment and intervention. Contractions occurring every 3 to 5 minutes (choice B) are normal in the active phase of labor. Strong contractions (choice C) are also expected during this phase. Feeling contractions in the lower back (choice D) is common and not typically a cause for concern. Reporting contractions lasting longer than 90 seconds is crucial to ensure the safety of both the mother and the baby.

Correct Answer: A

Rationale: The correct answer is A: Vastus lateralis. This muscle is the preferred site for IM injections in newborns due to its large muscle mass and minimal risk of damage to nerves and blood vessels. Administering vitamin K in the vastus lateralis ensures proper absorption and distribution of the medication. Ventrogluteal and dorsogluteal sites are not recommended for newborns due to the risk of sciatic nerve damage and limited muscle mass. The deltoid muscle is typically used for older children and adults, not newborns.

Correct Answer: C

Rationale: The correct answer is C because the indirect Coombs test is used to detect Rh-positive antibodies in the mother's blood. In this scenario, the mother is Rh-negative, so if she has been sensitized to Rh-positive blood during childbirth, her immune system may produce antibodies that could potentially harm future Rh-positive pregnancies. This test helps identify the presence of these antibodies early on so appropriate interventions can be initiated to prevent hemolytic disease of the newborn. Choices A, B, and D are incorrect: A: This test does not determine if kernicterus will occur in the newborn. Kernicterus is a severe complication of jaundice, which may result from hemolytic disease of the newborn if untreated. B: The indirect Coombs test does not detect Rh-negative antibodies in the newborn's blood. It specifically looks for Rh-positive antibodies in the mother's blood. D: The test does not determine the presence of maternal antibodies in the newborn's blood. It focuses on detecting antibodies in

Correct Answer: A

Rationale: The correct answer is A: Painless red vaginal bleeding. This finding supports the diagnosis of placenta previa due to the characteristic symptom of painless bleeding in the third trimester. Placenta previa occurs when the placenta partially or completely covers the cervix, leading to bleeding as the cervix begins to dilate. The other choices are incorrect because increasing abdominal pain with a non-relaxed uterus (B) may indicate placental abruption, abdominal pain with scant red vaginal bleeding (C) is not typical of placenta previa, and intermittent abdominal pain following the passage of bloody mucus (D) is more suggestive of preterm labor or bloody show.

Correct Answer: B

Rationale: The correct answer is B: Document this as an expected finding. A heart rate of 130/min in a newborn is within the normal range (120-160/min). The nurse should document this as an expected finding because it indicates a healthy heart rate for a newborn. There is no immediate need for intervention or further assessment as the heart rate falls within the normal range for a newborn. Asking another nurse to verify the heart rate (choice A) is unnecessary as it is within the normal range. Calling the provider to further assess the newborn (choice C) is not needed since the heart rate is normal. Preparing the newborn for transport to the NICU (choice D) is not indicated as the heart rate is within the normal range.