Nokea
A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking 'my baby sister ' home. Which of the following is an appropriate response by the nurse?
- A. It 's always nice when siblings are excited to have the babies go home.
- B. Your daughter is very advanced for her age. She must speak very well.
- C. Your daughter is likely to become very jealous of the new baby.
- D. Older sisters can be very helpful. They love to play mother.
Correct Answer: C
Rationale: It is common for older siblings to feel jealousy when a new baby arrives. Preparing the child for the changes can help manage these feelings.
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What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: Precipitous labor increases the risk of postpartum infection.
The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus?
- A. Scant amount of odorless lochia
- B. Presence of headache, malaise, and chills
- C. Pain or discomfort in the midline lower abdomen
- D. Elevated temperature greater than 100.4°F (38°C)
Correct Answer: D
Rationale: The correct answer is D, an elevated temperature greater than 100.4°F. Endometritis, an infection of the uterine lining, commonly caused by beta-hemolytic streptococcus, often presents with a fever. This is a key sign of infection, indicating the presence of an inflammatory process. The other choices are incorrect because:
A: Scant amount of odorless lochia is indicative of normal postpartum discharge, not necessarily endometritis.
B: Headache, malaise, and chills are non-specific symptoms that could be present in various conditions, not specific to endometritis.
C: Pain or discomfort in the midline lower abdomen could be related to postpartum uterine contractions or other causes, but it is not a specific finding for endometritis.
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.
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 correct answer is D. A peripad weighing 100 g within 15 minutes indicates excessive postpartum bleeding, requiring immediate intervention to prevent hypovolemic shock. A displaced uterus (choice A) and small clots with massage (choice C) are expected findings after delivery and can be managed with appropriate interventions. A boggy uterine fundus (choice B) may indicate uterine atony but does not necessarily require immediate notification unless accompanied by excessive bleeding.
The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance, the day before. The baby 's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate?
- A. Sometimes babies just don 't deliver the way we expect them to.
- B. With all of your preparations, it must have been disappointing for you to have had a cesarean.
- C. I know you had to have surgery, but you are very lucky that your baby was born healthy.
- D. At least your husband was able to be with you when the baby was born.
Correct Answer: B
Rationale: The nurse should acknowledge the emotional impact of an unplanned cesarean section while validating the mother's feelings.