The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects?

Correct Answer: A

Rationale: In the context of pharmacology, Methergine (ergonovine) is commonly used to prevent or control postpartum hemorrhage by causing uterine contractions. The correct side effect to warn a client about when receiving Methergine is a headache. This is because Methergine can cause vasoconstriction, which may lead to increased blood pressure and subsequent headaches. Regarding the incorrect options: - Nausea is a common side effect of Methergine but it is not the primary side effect that the client should be warned about. - Cramping is expected with the use of Methergine as it causes uterine contractions to prevent hemorrhage. - Fatigue is not typically associated with Methergine use and is not a significant side effect to warn the client about in this scenario. Educationally, it is important for nurses to understand the specific side effects of medications to effectively educate clients on what to expect and how to manage them. By providing accurate information, nurses can enhance patient safety and promote better adherence to treatment regimens.

Correct Answer: C

Rationale: In this scenario, the correct task to delegate to the nursing care assistant is taking the client's vital signs (Option C). This is appropriate because measuring vital signs is a routine and non-invasive task that does not require specialized nursing knowledge or assessment skills. Nursing care assistants are trained to perform basic tasks like measuring blood pressure, pulse, temperature, and respiratory rate under the supervision of a registered nurse. Option A, assessing the client's fundal height, requires a higher level of assessment and interpretation of findings, which is more appropriate for a registered nurse. Option B, teaching the client how to massage her fundus, involves patient education and requires knowledge of proper technique and patient-specific considerations, making it a task better suited for a nurse. Option D, documenting the quantity of lochia in the chart, involves recording and interpreting clinical data, which falls within the scope of a registered nurse's responsibilities. This question provides a valuable teaching opportunity by highlighting the importance of appropriate delegation based on the complexity and skill level required for each task. Understanding delegation principles is crucial for efficient and safe patient care delivery in healthcare settings.

Correct Answer: B

Rationale: In the immediate postpartum period, the correct answer is B) Excess blood volume from pregnancy is circulating in the woman's periphery. During pregnancy, a woman's blood volume increases significantly to support the needs of the developing fetus. After delivery, this excess blood volume is suddenly no longer needed, leading to a rapid shift of blood from the uterus to the maternal circulation. This sudden increase in circulating blood volume can overwhelm the cardiovascular system, potentially leading to cardiovascular compromise. Option A is incorrect because the weight of the uterine body being reduced does not directly impact cardiovascular compromise. Option C is incorrect as the dilation of the cervix and the flow of lochia are related to the stages of labor and not specifically to cardiovascular compromise post-delivery. Option D is incorrect as maternal blood pressure typically drops after the baby is delivered due to the sudden decrease in intra-abdominal pressure, not when the baby's head emerges. Understanding the physiological changes that occur in the postpartum period is crucial for maternity nurses to provide appropriate care and anticipate potential complications. By recognizing the risk of cardiovascular compromise due to the sudden shift in blood volume, nurses can closely monitor vital signs and intervene promptly if needed to ensure the well-being of the mother.

Correct Answer: B

Rationale: In the postpartum period, it is crucial for the nurse to provide accurate and evidence-based information to support the client's recovery and well-being. Option B, advising the client that for the first two days she will be bleeding too heavily for a tampon, is the correct answer. This is because immediately after childbirth, the woman will experience lochia, which is a postpartum vaginal discharge containing blood, mucus, and placental tissue. Using tampons during this time can increase the risk of infection and hinder the natural healing process. Option A is incorrect as inserting a tampon immediately after childbirth can introduce bacteria into the vagina, leading to infections. Option C is incorrect because it is not necessarily unsafe to place anything into the vagina until involution is complete, but rather tampons specifically should be avoided in the immediate postpartum period. Option D is incorrect as the discomfort from using a tampon is not the primary concern; the risk of infection and interference with healing are more significant issues to address. Educationally, this scenario highlights the importance of providing appropriate postpartum care and education to women. Nurses must be knowledgeable about the physiological changes that occur after childbirth and be able to communicate effectively with clients to promote their health and well-being. By choosing the correct action, the nurse can help prevent complications and support the client in her recovery process.

Correct Answer: B

Rationale: In this scenario, option B, "Monitor the incision for drainage," is the most appropriate action for the nurse to take after the surgeon has removed the cesarean section dressing from a post-op day 1 client. This is the correct answer because monitoring the incision for drainage is essential in assessing for signs of infection, which is a common complication postpartum. Drainage from the incision site could indicate infection, and early detection is crucial for prompt intervention and prevention of further complications. Option A, "Irrigate the incision twice daily," is incorrect because irrigating the incision without proper assessment and orders from the healthcare provider can introduce pathogens and disrupt the healing process. Option C, "Apply steristrips to the incision line," is incorrect because applying steristrips is not within the nurse's scope of practice without specific orders from the healthcare provider. Steristrips are typically applied during the initial closure of the incision by the surgeon. Option D, "Palpate the incision and assess for pain," is incorrect because palpating the incision can introduce pathogens and increase the risk of infection. Assessing for pain is important, but monitoring for drainage is a more immediate concern in this situation. In an educational context, understanding proper postoperative wound care is crucial for nursing practice. Nurses need to know how to assess incisions for signs of complications, such as infection, and follow evidence-based guidelines to provide safe and effective care to postpartum clients. Monitoring for drainage is a fundamental aspect of wound care assessment and plays a vital role in early detection and management of complications.