A nurse is caring for a client who is postpartum and received methylergonovine. Which of the following findings indicates that the medication was effective?

Correct Answer: A

Rationale: Step 1: Methylergonovine is a uterotonic drug used to prevent or treat postpartum hemorrhage by causing uterine contractions. Step 2: Fundus firmness indicates effective contraction of the uterus, helping to control bleeding. Step 3: A firm fundus also suggests proper involution of the uterus, a crucial process in postpartum recovery. Step 4: Increase in blood pressure (B) is not a desired effect of methylergonovine and could indicate adverse reactions. Step 5: Increase in lochia (C) could suggest excessive bleeding or incomplete uterine contraction. Step 6: Absence of breast pain (D) is not directly related to the effectiveness of methylergonovine in controlling postpartum bleeding.

Correct Answer: A

Rationale: Correct Answer: A - Blot the perineal area dry after cleansing. Rationale: Blotting the perineal area dry after cleansing helps prevent moisture accumulation, reducing the risk of perineal infection. Moisture can create a favorable environment for bacterial growth and infection. This practice also helps maintain skin integrity and promotes healing post-vaginal delivery. Summary of other choices: B: Cleaning the perineal area from front to back is important to prevent introducing fecal bacteria to the urinary tract but is not directly related to reducing perineal infection. C: Performing hand hygiene before and after voiding is crucial for infection prevention but does not directly address reducing perineal infection. D: Washing the perineal area using a squeeze bottle of warm water after each voiding can be beneficial for cleanliness but does not specifically address reducing perineal infection like blotting dry after cleansing does.

Correct Answer: C

Rationale: The correct answer is C: Voids 6 or more times a day. Adequate breast milk intake is indicated by frequent urination (6 or more times/day) in infants. This shows the infant is hydrated and receiving enough milk. The other choices are incorrect because A) pacifier use doesn't indicate milk supply, B) hard stools can be a sign of dehydration or other issues, and D) feeding every 4 hours is a general guideline but not a definitive indicator of milk supply.

Correct Answer: A

Rationale: The correct answer is A: Check the fetal heart rate. This is the first action to assess the well-being of the fetus after the reported fluid gush, ensuring fetal safety. Checking fetal heart rate is crucial in determining fetal distress. Assessing for meconium staining (B) is important but comes after confirming fetal well-being. Performing a sterile vaginal examination (C) may introduce infection and should be avoided without proper indications. Notifying the healthcare provider (D) is necessary but should follow initial assessment of fetal status.

Correct Answer: B

Rationale: Rationale for Correct Answer (B): Limiting visitors and monitoring closely for signs of infection in a newborn in the NICU is crucial because newborns are highly vulnerable to infections. By restricting visitors, the risk of introducing pathogens is reduced. Close monitoring allows for early detection of any signs of infection, enabling prompt intervention to prevent complications. Summary of Other Choices: A: While maintaining strict hand hygiene is important, it alone is not sufficient to reduce the risk of infection in a newborn in the NICU. C: Proper sterilization of equipment is essential but may not directly address the risk of infection transmission from visitors or other sources. D: Administering prophylactic antibiotics is not recommended as a routine measure due to the potential for antibiotic resistance and adverse effects in newborns. Monitoring and prevention are preferred over indiscriminate antibiotic use.