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A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
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The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is displaying signs of uterine atony, a condition where the uterus fails to contract properly postpartum, leading to excessive bleeding. The soft and boggy fundus, displacement to the left, and moderate bleeding indicate a serious issue that requires immediate medical attention. By calling the healthcare provider, the nurse can ensure timely intervention and treatment to address the uterine atony and prevent further complications. The other options are not appropriate at this time: A may worsen the situation by increasing bleeding, B delays necessary action, and C may be needed but not as the first priority in this critical situation.
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B: The couple attends hospital classes addressing newborn and infant care. This is associated with intentional learning as it involves actively seeking out structured education on parenting skills. Attending classes allows the couple to acquire knowledge and skills related to newborn and infant care in a deliberate and purposeful manner.
Incorrect choices:
A: Observing other individuals who are mothers and fathers may provide some insights, but it is more passive and may not involve structured learning.
C: Discussing how they were parented is reflective but may not necessarily involve acquiring new parenting skills through intentional learning.
D: Watching media containing parenting roles is passive and may not provide the same level of structured education as attending classes specifically addressing newborn and infant care.
The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is the most important teaching for the nurse to provide because it is a potentially life-threatening complication that requires immediate medical attention. Secondary hemorrhage can occur after the initial postpartum period and can lead to severe bleeding. Understanding the signs and symptoms of secondary hemorrhage can help the patient seek prompt medical care if needed.
Choice A: The signs and symptoms of uterine infection are important to know, but they are usually treated with antibiotics and are not as immediately life-threatening as secondary hemorrhage.
Choice C: Postpartum depression is a serious concern but does not require immediate medical attention like secondary hemorrhage.
Choice D: A boggy uterus is a sign of uterine atony, which can lead to hemorrhage, but teaching about secondary hemorrhage takes precedence because it directly addresses a more severe form of bleeding that requires urgent intervention.
The nurse is providing education to a postpartum woman about exercises to strengthen the pelvis musculature. Which instruction should be included?
- A. "Ambulate three times a day."
- B. "Perform Kegel exercises."
- C. "Enroll in an aerobics class after discharge."
- D. "Do passive range-of-motion exercises while lying in bed."
Correct Answer: B
Rationale: The correct answer is B: "Perform Kegel exercises." Kegel exercises strengthen the pelvic floor muscles, which can help prevent urinary incontinence and improve pelvic organ support. Ambulating (choice A) is important for overall mobility but does not specifically target the pelvic muscles. Enrolling in an aerobics class (choice C) focuses on cardiovascular fitness and may not specifically strengthen the pelvis. Doing passive range-of-motion exercises (choice D) does not actively engage and strengthen the pelvic muscles. Kegel exercises are the most appropriate choice as they directly target the pelvic musculature to improve strength and function.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.