Nokea
The postpartum client is being discharged to home with a streptococcal puerperal infection. The client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse?
- A. “No precautions are necessary since you are taking antibiotics.”
- B. “You should always wear a mask when caring for your newborn and toddler.”
- C. “Wash your hands before caring for your children and after toileting and perineal care.”
- D. “Your husband should provide all cares for both children until your infection is gone.”
Correct Answer: C
Rationale: The course of an endometrial infection is approximately 7 to 10 days, and thus standard precautions should be in place for that period of time even if the client has started antibiotics. Puerperal infections are not spread by droplets, and thus a mask is not necessary. Other than hand hygiene, no additional precautions need to be taken by the client in her home. The client is able to provide cares for her children, but hand washing is required before cares.
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Which statement made by a participant regarding remedies of heartburn and nausea indicates that teaching has been effective?
- A. I should eat frequent, small meals.
- B. I should take an antacid after eating.
- C. I should eat my largest meal in the evening.
- D. I should drink extra water with my meals.
Correct Answer: A
Rationale: Frequent, small meals reduce stomach acid and nausea, unlike large meals or extra water, which may worsen symptoms.
The laboring multigravida client’s last vaginal examination was 8/90/+1. The client now states feeling rectal pressure. Which action should the nurse perform first?
- A. Encourage the client to push.
- B. Notify the obstetrician or midwife.
- C. Help the client to the bathroom.
- D. Complete another vaginal exam.
Correct Answer: D
Rationale: The nurse should first evaluate labor progress by performing another vaginal exam. Previously the client was almost fully effaced (90%), and fetal station was 1 cm below the ischial spines (+1). Rectal pressure is often due to pressure exerted during descent of the fetal presenting part. The client needs to be fully dilated (10 cm, not 8 cm) and fully effaced (100%, not 90%) before being encouraged to push. Pushing too early may cause cervical edema and lacerations and may slow the labor process. Rectal pressure may indicate that the client has progressed since the last vaginal exam. Another vaginal exam should be performed before contacting the obstetrician or midwife. During labor, rectal pressure is usually not due to the need for a bowel movement because intestinal motility decreases.
The nurse is caring for the Muslim client in labor. What should the nurse be most aware of as a possible belief of the client?
- A. Male health care providers should enter the room after receiving permission from her husband.
- B. The client may prefer to eat only “hot” foods and to drink only special tea and warm water.
- C. Fathers, rather than female relatives, are usually present to provide support during the labor.
- D. She will be more likely to moan, scream, or cry out in pain during each labor contraction.
Correct Answer: A
Rationale: Some Muslim women are not comfortable with male HCPs and may prefer to have their husband in the room if a male is involved in care. Eating “hot” foods and drinking special tea and warm water are preferences of Hmong women from Laos and not those of Muslim women. The Muslim client may choose to have her husband, a male relative, or a female friend or relative provide support during childbirth, rather than her father. Muslim women are more likely to be silent and stoic during labor contractions, and not cry out in pain.
On the basis of the health history data, how should the nurse record the client's pregnancy status on the prenatal records?
- A. Multipara
- B. Primipara
- C. Primigravida
- D. Multigravida
Correct Answer: C
Rationale: A primigravida is a woman pregnant for the first time, which matches the client's status of being possibly 2 months pregnant with no prior pregnancies.
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? Select all that apply.
- A. “You should change your peripad at least twice each day.”
- B. “Once home, use a warm sitz bath to sooth your perineum.”
- C. “Keep your perineum warm and dry until stitches are removed.”
- D. “Use your peri-bottle to apply water to the perineum after each void.”
- E. “Wash your perineum with mild soap at least once each 24 hours.”
- F. “Check your perineum for foul odor or increased redness, heat, or pain.”
Correct Answer: B,D,E,F
Rationale: The peripad should be changed more frequently to reduce the risk of infection. Lochia amount should never exceed a moderate amount (less than a 6-inch stain on a perineal pad). A warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce the incidence of infection. Perineal lacerations are repaired with sutures that dissolve. Clients do not need to have perineal sutures removed. Cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection. Washing with mild soap and rinsing with water each 24 hours reduces the risk of infection. Teaching the client to watch for signs and symptoms of infection is important and allows the client to be an active participant in her care.