Question

A nurse is caring for a client.

Answer 1

Correct Answers:

Perform a fundal massage

Rationale :

🩸Fundal massage is the immediate nursing intervention for a boggy uterus to promote uterine contraction and reduce bleeding.

🧠A boggy and deviated uterus suggests uterine atony, often related to bladder distention, and massage helps restore tone.

🩺Bleeding with clots, lightheadedness, and tachycardia are early signs of postpartum hemorrhage, which must be interrupted quickly.

⚕️While the provider will need to be notified eventually, direct nursing action is critical first to stabilize the client’s condition.

📌Core Message

Always initiate fundal massage immediately when signs of uterine atony and postpartum hemorrhage appear.

Answer 2

Correct Answers:

Fundus slightly boggy and displaced to the right
Heavy bleeding with large clots (-300 mL/hour)
BP decreased to 98/60 mmHg and HR increased to 108 bpm
Feeling lightheaded

Rationale :

🧻A boggy and deviated uterus indicates uterine atony, which is a leading cause of postpartum hemorrhage.

🩸A lochia flow of 300 mL/hour with large clots exceeds normal postpartum bleeding and signals active hemorrhage.

💓A drop in blood pressure with a rise in heart rate indicates the beginning of compensatory shock from blood loss.

😵The client’s lightheadedness reflects decreased cerebral perfusion due to hypovolemia from bleeding.

📌Core Message

Indicators like a boggy uterus, heavy bleeding, tachycardia, and lightheadedness signal postpartum hemorrhage.

Answer 3

Correct Answers:

Establish or maintain IV access with a large-bore catheter
Administer uterotonic medications per provider order (e.g., oxytocin)
Assess bladder for distention
Monitor vital signs every 5-10 minutes

Rationale :

💉Establishing or maintaining large-bore IV access ensures rapid fluid or blood product administration during hemorrhagic events.

🧪Uterotonics like oxytocin stimulate uterine contractions to control uterine atony and stop bleeding.

💁‍♂️A distended bladder can displace the uterus, contributing to ineffective uterine contraction, so assessment is critical.

📉Frequent vital sign monitoring (every 5–10 min) helps detect worsening hypovolemia and guides clinical decisions in PPH.

📌Core Message

After fundal massage, initiate IV access, give uterotonics, assess bladder, and monitor vitals frequently in PPH.

Answer 4

Correct Answers:

5 tablets

Rationale :

💊To give 1000 mcg using 200 mcg tablets, divide: 1000 ÷ 200 = 5 tablets.

🧮Dosage calculation must ensure the correct total dose is administered per provider order.

📏Rectal misoprostol is often used in postpartum hemorrhage due to its effective absorption and action.

📋Accurate calculation and double-checking the route and dose prevents medication errors in emergencies.

📌Core Message

Accurate medication dosage calculation ensures safe and effective delivery of uterotonic therapy in PPH.

Answer 5

Correct Answers:

Turn the patient on the left lateral position, apply O₂ per mask at 8-10L, turn off pitocin

Rationale :

📉Variable decelerations are commonly caused by cord compression, and maternal repositioning can relieve pressure.

💨Oxygen at 8–10 L/min improves fetal oxygenation, helping stabilize fetal heart rate patterns.

💊Turning off Pitocin reduces uterine contractions, decreasing stress on the fetus and uterine blood flow interruption.

📞These are initial independent nursing actions before contacting the provider, which is done if there is no resolution.

📌Core Message

When managing variable decelerations, prioritize repositioning, oxygen administration, and stopping Pitocin.

Answer 6

Correct Answers:

Effleurage is a light, circular massage applied to the abdomen to promote relaxation and distract from pain.

Rationale :

👐Effleurage is a nonpharmacologic comfort method that uses light fingertip strokes to distract from uterine contractions.

🧘It promotes relaxation and decreases pain perception by focusing attention away from the discomfort.

💆‍♀️This technique is especially effective in early labor, when the client can still focus and participate actively.

🌼Effleurage enhances the laboring person's sense of control and coping, aligning with holistic pain management.

📌Core Message

Effleurage is a gentle abdominal massage technique used to promote relaxation during early labor.

Answer 7

Correct Answers:

32103

Rationale :

💁‍♂️G (Gravida) is 4: twins, term infant, and one miscarriage.

👶T (Term births) is 1: the 39-week delivery.

👤P (Preterm births) is 1: twins born at 34 weeks.

🩸A (Abortions) is 1: 6-week miscarriage.

👨‍👩‍👧‍👦L (Living) is 3: twins and toddler son.

📌Core Message

Use the GTPAL method to accurately document a client’s obstetric history by analyzing each pregnancy outcome.

Answer 8

Correct Answers:

Cervical changes
Braxton Hicks Contractions
Leukorrhea
Increased energy level
Bloody Show
SROM (spontaneous rupture of membranes)
Lightening (the relief she can breathe again because the baby is descending)

Rationale :

🧷Cervical changes indicate that the body is preparing for effacement and dilation.

🩸Bloody show and increased vaginal discharge (leukorrhea) reflect cervical softening and capillary rupture.

📉Lightening occurs when the fetus descends into the pelvis, easing breathing but increasing pelvic pressure.

🔄Braxton Hicks contractions are false labor contractions that often precede true labor.

⚡A surge in energy level (“nesting”) is a recognized sign of impending labor.

💧Spontaneous rupture of membranes (SROM) marks the beginning of labor in some clients.

📌Core Message

Premonitory signs of labor include cervical changes, lightening, SROM, Braxton Hicks, and bloody show.

Answer 9

Correct Answers:

Moderate variability is a reassuring sign of fetal well-being.

Rationale :

📈Moderate variability (6–25 bpm) in FHR is a key indicator of intact neurologic function and adequate oxygenation.

🧠This pattern suggests a well-oxygenated fetal central nervous system, reassuring in labor progress.

🔄Variability reflects interaction between the sympathetic and parasympathetic systems and is continuously monitored.

🟢It is considered the most reliable sign of fetal well-being on continuous fetal heart rate monitoring.

📌Core Message

Moderate variability in fetal heart rate is a strong reassurance of fetal well-being.

Answer 10

Correct Answers:

Fetus lying on the cord
True knot in the cord
Fetus holding onto the umbilical cord
Cord around the fetus body or neck

Rationale :

💁‍♂️A true knot in the cord can compress blood flow, causing variable decelerations due to intermittent oxygen restriction.

🧸When a fetus lies on the cord or grabs the cord, mechanical compression can trigger abrupt FHR changes.

🔁A cord wrapped around the neck or body leads to repetitive compression, often resulting in variable decels on the strip.

⚠️These are all signs of umbilical cord compression, the primary cause of variable decelerations in labor.

📌Core Message

Variable decelerations are commonly caused by umbilical cord compression, including true knots and cord entanglement.

1 :
A nurse is caring for a client.

Answer Options

2 :
A nurse is caring for a 30-year-old female client.

Answer Options

3 :
A nurse is caring for client.

Answer Options

4 :
A client has just delivered and is experiencing bleeding.

Answer Options

5 :
What nursing action would the nurse take with the deceleration being depicted?

6 :
A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 :
What are the premonitory signs of labor? Select all that apply

9 :
A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 :
What are the causes of variable decels? Select all that apply

1 : A nurse is caring for a client.

Answer Options

2 : A nurse is caring for a 30-year-old female client.

Answer Options

3 : A nurse is caring for client.

Answer Options

4 : A client has just delivered and is experiencing bleeding.

Answer Options

5 : What nursing action would the nurse take with the deceleration being depicted?

6 : A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 : What are the premonitory signs of labor? Select all that apply

9 : A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 : What are the causes of variable decels? Select all that apply

1 :
A nurse is caring for a client.

2 :
A nurse is caring for a 30-year-old female client.

3 :
A nurse is caring for client.

4 :
A client has just delivered and is experiencing bleeding.

5 :
What nursing action would the nurse take with the deceleration being depicted?

6 :
A laboring patient is requesting comfort measures to help manage pain during the early stages of labor. The nurse suggests using effleurage. Which of the following statements best describes the purpose of effleurage during labor?

8 :
What are the premonitory signs of labor? Select all that apply

9 :
A nurse is assessing the fetal heart rate (FHR) of a laboring patient and notes moderate variability. What is the most appropriate interpretation of this finding?

10 :
What are the causes of variable decels? Select all that apply