Correct Answer: A

Rationale: Bruising at the IV site with heparin suggests bleeding, requiring provider notification. Normal blood pressure, urine output, and heart rate are not urgent.

Correct Answer: D

Rationale: Monitoring potassium is critical for clients taking furosemide, a loop diuretic that increases potassium excretion, potentially causing hypokalemia, which can lead to arrhythmias.
Choice A is incorrect because, while furosemide can cause hyponatremia, potassium is the primary electrolyte of concern due to its cardiac implications.
Choice B is incorrect because hemoglobin is not directly affected by furosemide; it is monitored for other conditions like anemia.
Choice C is incorrect because calcium levels are not significantly impacted by furosemide compared to potassium.

Correct Answer: C

Rationale: Uterine contractions lasting 90 seconds indicate adequate contraction strength and duration, suggesting that the oxytocin infusion is effective, but the nurse should assess if the frequency and cervical progression support increasing the rate to achieve active labor (contractions every 2-3 minutes).
Choice A is wrong because contractions every 4 minutes may indicate early labor, and increasing the oxytocin rate may be premature without assessing cervical change or contraction strength.
Choice B is wrong because a fetal heart rate of 140/min with moderate variability is normal and does not directly indicate the need to adjust the oxytocin rate.
Choice D is wrong because a cervical dilation of 2 cm after 6 hours of labor suggests protracted labor, but increasing the oxytocin rate should be based on a comprehensive assessment, including contraction pattern and fetal status, not dilation alone.

Correct Answer: D

Rationale: Showering daily but avoiding soaking in a bathtub for 2 weeks is appropriate to prevent infection at the incision site, as prolonged soaking can soften the wound and increase the risk of bacterial entry.
Choice A is wrong because the weight limit for lifting is typically more restrictive; clients are advised to avoid lifting anything heavier than their newborn (about 10 pounds) for 6 weeks to prevent incisional strain or dehiscence.
Choice B is wrong because sexual intercourse is generally recommended to be delayed until 4-6 weeks post-cesarean to allow for healing of the incision and uterus.
Choice C is wrong because ibuprofen may be used for pain, but the nurse should emphasize consulting the provider for appropriate dosing and ensuring it is safe, especially if breastfeeding, rather than a blanket instruction to take it as needed.

Correct Answer: C

Rationale: Positioning the car seat at a 45-degree angle is correct to ensure the newborn's airway remains open and to reduce the risk of positional asphyxia, as recommended by car seat safety guidelines.
Choice A is wrong because the car seat should never be placed in the front passenger seat, even with the airbag off, due to the risk of injury from airbag deployment or other crash dynamics; the rear seat is safest.
Choice B is wrong because infants should remain in a rear-facing car seat until at least 2 years of age or until they exceed the car seat's height/weight limits, not forward-facing before 1 year.
Choice D is wrong because for rear-facing car seats, the harness straps should be at or below the infant's shoulders to provide proper support and prevent injury during a crash.