Nokea
The nurse is assessing a patient who is 12 hours postpartum. The uterus is firm to palpation, at midline, and is 1 cm below the umbilicus with continuous heavy vaginal bleeding. What is the nurse’s first action?
- A. Massage the uterus and resume the IV Pitocin drip.
- B. Change the peri-pad and reassess the bleeding.
- C. Call the provider to check for a cervical laceration.
- D. Administer the ordered iron supplement and ibuprofen.
Correct Answer: A
Rationale: The correct answer is A: Massage the uterus and resume the IV Pitocin drip. The patient is showing signs of uterine atony with heavy vaginal bleeding. Massaging the uterus helps stimulate contractions, controlling bleeding. Resuming IV Pitocin enhances uterine contractions further. Choices B, C, and D are incorrect. Changing the peri-pad does not address the underlying cause of bleeding. Checking for a cervical laceration may be needed later but is not the immediate priority. Administering iron supplement and ibuprofen does not address the acute issue of uterine atony and bleeding.
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The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple:
- A. On admission to the labor room.
- B. In the client room after the delivery.
- C. When the client put the baby to the breast for the first time.
- D. The day before the client and baby are to leave the hospital.
Correct Answer: D
Rationale: Teaching about the need for an infant car seat should occur before discharge to ensure the parents have time to arrange for one, typically the day before discharge.
The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management?
- A. Application of hot packs to the perineal area
- B. Information applicable to medication therapy
- C. Instructions to improve circulation by ambulating
- D. Medicating for pain above level 4 on a 0 to 10 scale
Correct Answer: B
Rationale: The correct answer is B: Information applicable to medication therapy. The rationale is that proper pain management is crucial for patient comfort and healing. The nurse should educate the patient on the importance of taking the prescribed pain medication as directed to manage pain effectively. This includes information on dosage, frequency, and potential side effects. Hot packs (Choice A) may not be recommended for an infected episiotomy as heat can exacerbate the infection. Ambulation (Choice C) is important for circulation, but it may not directly address pain management. Medicating for pain above level 4 (Choice D) is vague and does not provide specific guidance on when to take pain medication.
The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately?
- A. The uterus is displaced.
- B. The uterine fundus is boggy.
- C. Small clots are expressed with massage.
- D. Peripad weighs 100 g within 15 minutes.
Correct Answer: D
Rationale: The nurse will monitor the amount and characteristics of each patient’s lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss.
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a normal diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate to the bathroom every 2 hours.
Correct Answer: C
Rationale: After delivery, the highest priority is ensuring the client has a normal lochial flow, which is a key indicator of the uterus returning to its non-pregnant state. Breastfeeding, diet, and ambulation are also important but secondary.
The nurse develops a plan to increase a patient’s milk supply. What is an intervention they can implement?
- A. Pump between nursing sessions.
- B. Nurse every 6 hours.
- C. Keep newborn in bassinet between sessions.
- D. Offer a pacifier when newborn cries.
Correct Answer: A
Rationale: Pumping between nursing sessions can increase milk supply.