NR-327 Maternal-Child Nursing - Set 4 - Part 3

Correct Answer: Blood pressure and pulse before the dose

Nifedipine blocks calcium entry into smooth muscle everywhere, so hypotension and reflex tachycardia are the expected hazards. Pressure and pulse are checked before and after each dose, and the dose is held for hypotension. Option a is incorrect because reflex testing tracks magnesium sulfate, where absent reflexes signal rising serum levels. Calcium channel blockade does not depress neuromuscular transmission the way magnesium does, so reflexes stay intact. Option b is incorrect because hourly output belongs to the magnesium protocol, since that drug clears renally and accumulates when kidneys fall behind. Nifedipine carries no comparable renal hold parameter. Option c is incorrect because auscultating the chest matters most when pulmonary edema threatens, which happens with beta agonists, steroids, and generous fluids together. This oral agent does not carry that particular warning.

Correct Answer: "A dull backache with pelvic pressure means I should call you."

A new low backache together with pelvic pressure sits high on the list of preterm labor symptoms clients are told to report, because early preterm labor mimics ordinary pregnancy discomfort. Option b is incorrect because menstrual like cramping is itself a reportable symptom rather than a harmless one. Dismissing it delays the call, and treatment only helps when the client presents early. Option c is incorrect because any change in vaginal discharge counts, including an increase in amount or a shift to watery, mucousy, or bloody. Waiting for a frank gush misses the earlier warning. Option d is incorrect because contractions of preterm labor are often painless, and the teaching is to palpate the fundus and count tightening episodes. Pain is not the trigger for reporting.

Correct Answer: She believes the thoughts are instructions to follow

Intrusive thoughts that frighten a mother belong to postpartum anxiety, but a belief that they must be obeyed is delusional thinking. That shift means psychosis, so she needs constant supervision and immediate psychiatric referral. Option a is incorrect because embarrassment is nearly universal among women with intrusive thoughts and actually reflects intact insight. Shame makes disclosure harder, yet it does not signal that reality testing has slipped. Option b is incorrect because handing the infant to a trusted relative is a protective step, not a danger sign. Avoidance of this kind fits the anxious pattern already described and calls for treatment, not hospitalization. Option c is incorrect because trouble sleeping is common in the weeks after birth and accompanies anxiety, depression, and simple newborn care alike. On its own it separates none of those conditions from one another.

Correct Answer: Pink brown drainage that is slowly decreasing

Lochia serosa spans roughly days three through ten. Serous exudate, leukocytes, and older erythrocytes give it a pink brown serosanguineous look, and the amount tapers from small to moderate as healing advances. Option a is incorrect because heavy red flow with sizeable clots describes the first days, not the fifth. Persisting rubra past day four points to subinvolution or retained fragments and needs evaluation. Option c is incorrect because creamy yellowish drainage marks lochia alba, which typically starts near the tenth day and may linger for weeks. Arriving on day five it would be several days premature. Option d is incorrect because flow should be lighter each day, not heavier. Bleeding that brightens and increases after the first days suggests the placental site is reopening, and the provider must hear about it.

Correct Answer: A soft boggy fundus above the umbilicus

Atony means the myometrium fails to contract, so the uterus feels soft and boggy and rises above the umbilicus as blood collects. The open spiral arterioles stay uncompressed, which produces the heavy bleeding. Option b is incorrect because a firm midline fundus with scant lochia is the expected normal finding after birth. Contracted muscle already compresses the placental site vessels, so this client would not be losing blood heavily. Option c is incorrect because fundal tenderness paired with malodorous lochia signals endometritis, an infection that surfaces around the second to fifth postpartum day. Infection does not explain brisk bleeding within the first hour. Option d is incorrect because bright red bleeding that continues past a well contracted fundus points to a genital tract laceration. That is trauma rather than tone, and massaging the uterus will not slow it.

Correct Answer: "The delay lets the steroid injections mature your baby's lungs."

Tocolysis does not prevent preterm birth. It buys roughly forty eight hours to seven days, and that window lets a corticosteroid course reach full effect and allows transfer to appropriate newborn care. Option a is incorrect because no tocolytic holds a pregnancy to term, and the drugs are stopped after about forty eight hours. Promising a term birth sets her up for grief and mistrust. Option b is incorrect because the relationship runs the other way. Betamethasone remains the intervention that actually changes newborn outcomes, and delaying labor exists precisely so those two injections have time to work. Option d is incorrect because tocolytics often fail, especially once the cervix has dilated past four or five centimeters. Telling her the contractions will always settle overstates what these medications can deliver.

Correct Answer: The rising rate may precede a falling pressure

A young woman with expanded blood volume compensates well, so the heart speeds up long before pressure drops. A climbing pulse with a normal pressure is an early warning, and the nurse checks fundus and pad now. Option a is incorrect because the expected postpartum slowing runs between forty and eighty beats per minute for the first week. A rate traveling upward toward one hundred is the reverse of that pattern. Option c is incorrect because regional anesthesia tends to drop pressure through vasodilation rather than drive the rate up over hours. Its effects also fade as the block wears off instead of building steadily. Option d is incorrect because the volume returning from the placental bed raises stroke output and therefore lowers heart rate. If fluid shifting explained this, her pulse would be sitting comfortably in the fifties.

Correct Answer: Bilateral engorgement as milk comes in

Engorgement strikes both breasts around the third to fifth day when milk volume surges, producing firmness and tenderness without systemic illness. Softening the areola by hand expression lets the newborn latch again. Option b is incorrect because mastitis is one sided and brings fever, chills, and flu like aching with it. A woman whose temperature is normal and whose breasts match does not meet that description. Option c is incorrect because a blocked duct shows up as a discrete tender lump or wedge in one place. Widespread firmness across the whole of both breasts is a different mechanism altogether. Option d is incorrect because an abscess follows untreated mastitis and presents as a fluctuant, exquisitely painful mass with persistent fever. Nothing in this picture suggests a walled off pocket of pus.

Correct Answer: Bruising along the cheeks and jaw

Blades grip the sides of the head, so transient bruising and marks along the cheeks are expected. The nurse documents them, checks the symmetry of facial movement, and reassures the parents that they fade. Option a is incorrect because widespread petechiae suggest a clotting problem or infection rather than instrument pressure. Marks from forceps stay where the blades sat, along the sides of the face. Option b is incorrect because swelling that crosses sutures describes caput, the soft scalp edema seen after a vacuum or a long descent. Forceps leave their mark on the face instead. Option c is incorrect because jaundice visible at birth is always pathologic and points to hemolysis, not to a difficult delivery. Bilirubin staining takes at least a day to appear normally.

Correct Answer: Offer ibuprofen shortly before the next feeding

Suckling releases oxytocin, so cramping peaks during feeds, and a stretched multiparous uterus contracts in vigorous bursts rather than holding steady tone. Ibuprofen given ahead of the feed targets that prostaglandin driven pain. Option a is incorrect because stopping feeds removes the very oxytocin that firms the uterus and protects against bleeding. Afterpains signal effective involution, so the plan is to treat the pain and keep nursing. Option b is incorrect because retained fragments announce themselves through heavy bleeding, a boggy uterus, and lochia that turns red again. Cramping tied to nursing in a multipara fits ordinary involution instead. Option d is incorrect because ibuprofen and acetaminophen both pass into milk in amounts safe for the newborn. Denying relief leaves her exhausted and reluctant to feed, which undermines both lactation and uterine tone.