Nokea
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, 'I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest. ' Which of the following actions should the nurse take at this time?
- A. Encourage the woman exclusively to breastfeed her baby.
- B. Have the woman massage her breasts hourly.
- C. Obtain an order to culture her expressed breast milk.
- D. Take the temperature and pulse rate of the woman.
Correct Answer: A
Rationale: Breastfeeding exclusively can help relieve engorgement, and frequent feedings prevent further complications.
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The nurse is admitting a 38-year-old patient to triage in early labor with ruptured membranes. Her history includes a previous vaginal delivery 4 years ago and the presence of a uterine fibroid. What interventions are appropriate based on the hemorrhage risk for this patient?
- A. The patient is a moderate hemorrhage risk, so a type and screen should be ordered.
- B. The patient is a high hemorrhage risk, so 4 units of packed red blood cells should be ordered.
- C. The patient is a low hemorrhage risk, so a hold tube should be drawn.
- D. The patient is a moderate hemorrhage risk, but blood is not drawn at this time.
Correct Answer: A
Rationale: Since the patient has a previous history of delivery and uterine fibroids, she is considered at moderate hemorrhage risk and a type and screen should be ordered.
What nursing intervention does the nurse include in the plan of care for a person with a wound infection?
- A. Reassure the postpartum person that infection will resolve without antibiotics.
- B. Assess for REEDA.
- C. Call health-care provider when temperature is 99.0° F.
- D. Scrub the incision vigorously with soap and water.
Correct Answer: B
Rationale: The correct answer is B: Assess for REEDA. REEDA stands for Redness, Edema, Ecchymosis, Drainage, and Approximation, which are key indicators of wound infection. By assessing for REEDA, the nurse can monitor and evaluate the progress of the infection. This intervention allows for early detection and prompt treatment of wound infections.
Choice A is incorrect because reassuring the postpartum person without antibiotics may lead to worsening infection. Choice C is incorrect as a temperature of 99.0° F is not necessarily indicative of a wound infection. Choice D is incorrect as scrubbing the incision vigorously with soap and water can introduce more bacteria and worsen the infection.
The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply.
- A. Foul-smelling lochia
- B. Hot, red, painful breasts
- C. Mild headache
- D. Not sleeping well
Correct Answer: A
Rationale: The correct answer is A: Foul-smelling lochia. This indicates a possible infection in the uterus, which requires medical attention to prevent complications. Hot, red, painful breasts (B) may indicate mastitis, which also requires medical intervention. Mild headache (C) and not sleeping well (D) are common postpartum issues but do not typically require immediate medical attention. In summary, choices B, C, and D are incorrect because they are common postpartum symptoms that do not necessarily warrant contacting the primary care provider, unlike foul-smelling lochia (A), which could indicate a serious issue.
Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers?
- A. Breastfeeding mothers usually involute completely by 3 weeks postpartum.
- B. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
- C. Breastfeeding mothers show higher levels of bone density after menopause.
- D. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.
Correct Answer: B
Rationale: Breastfeeding has long-term health benefits, including a decreased risk of developing type 2 diabetes later in life.
What postpartum infection can be transferred between the breast-feeding person and newborn if both are not treated appropriately?
- A. wound infection
- B. urinary tract infection
- C. thrush
- D. mastitis
Correct Answer: C
Rationale: Mastitis can be transferred between the breast-feeding person and the newborn if not treated.