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When assessing the A of the acronym REEDA, the nurse should evaluate the
- A. skin color.
- B. degree of edem
- C. edges of the episiotomy.
- D. episiotomy for discharg
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.
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What information about pain medication should postpartum discharge instructions include?
- A. Narcotic medications can cause constipation.
- B. Stop taking iron after birth.
- C. Do not take NSAIDs while breast-feeding.
- D. Acetaminophen should be avoided
Correct Answer: A
Rationale: The correct answer is A because narcotic medications commonly cause constipation, a common side effect that postpartum patients should be aware of. It is important to include this information in discharge instructions to ensure patient safety and comfort.
Choice B is incorrect because the discontinuation of iron supplements should be discussed with a healthcare provider, not automatically stopped after birth.
Choice C is incorrect because some NSAIDs are safe to take while breastfeeding, and this blanket statement may not apply to all medications in this category.
Choice D is incorrect because acetaminophen is generally considered safe for postpartum pain relief and should not be avoided without medical guidance.
A client is being discharged on Coumadin (warfarin) post-pulmonary embolism after a cesarean delivery. Which of the following should be included in the patient teaching?
- A. Take only ibuprofen for pain.
- B. Avoid overeating dark green, leafy vegetables.
- C. Drink grapefruit juice daily.
- D. Report any decrease in urinary output.
Correct Answer: B
Rationale: Leafy greens affect INR levels.
The pediatrician has ordered vitamin K 0.5 mg IM for a newborn. The medication is available as 2 mg/mL. How many milliliters (mL) should the nurse administer to the baby? Calculate to the nearest hundredth.
- A. 0.25 mL
- B. 0.50 mL
- C. 1.00 mL
- D. 2.00 mL
Correct Answer: A
Rationale: Calculation: 0.5 mg ÷ 2 mg/mL = 0.25 mL.
The person with a cesarean birth has additional nursing concerns beyond those of a person with a vaginal birth. What concern should the nurse anticipate for the cesarean birth?
- A. increased risk for DVT
- B. faster recovery
- C. less use of pain medication
- D. less risk for infection
Correct Answer: A
Rationale: The correct answer is A: increased risk for DVT. Cesarean birth increases the risk of Deep Vein Thrombosis (DVT) due to reduced mobility and potential blood clot formation. This is a critical concern as DVT can lead to serious complications like pulmonary embolism. Choices B and C are incorrect as cesarean birth typically results in longer recovery time and increased need for pain medication compared to vaginal birth. Choice D is incorrect as cesarean birth poses a higher risk of infection due to the surgical incision.
Which maternal event is abnormal in the early postpartal period?
- A. Diuresis and diaphoresis
- B. Flatulence and constipatiNon R I G
- C. Extreme hunger and thirst
- D. Lochial color changes from rubra to alba
Correct Answer: D
Rationale: The correct answer is D because the normal progression of lochia after childbirth is from rubra (red) to serosa (pinkish-brown) to alba (yellow-white). This signifies the normal healing process of the uterus. Choices A, B, and C are all normal postpartum events. Diuresis and diaphoresis help eliminate excess fluid from pregnancy, flatulence and constipation can occur due to hormonal changes and decreased muscle tone, and extreme hunger and thirst are common as the body recovers from childbirth.