Nokea
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse 's response?
- A. The client 's obstetric status is optimal for receiving the vaccine.
- B. The client 's immune system is highly responsive during the postpartum period.
- C. The client 's baby will be high risk for acquiring rubella if the woman does not receive the vaccine.
- D. The client 's insurance company will pay for the shot if it is given during the immediate postpartum period.
Correct Answer: B
Rationale: The postpartum period offers a good opportunity for immunization because the immune system is more responsive. Administering the vaccine before discharge ensures the woman is protected in the future.
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What is a risk factor for PPD?
- A. vaginal birth
- B. family support
- C. traumatic birth
- D. breast-feeding
Correct Answer: C
Rationale: A traumatic birth experience including complications or high-stress events increases the risk of postpartum depression (PPD).
The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful?
- A. The woman swallows the tablets whole.
- B. The woman takes the pills between meals.
- C. The woman calls the doctor if she develops a headache.
- D. The woman understands that her urine may turn orange.
Correct Answer: D
Rationale: Colace (docusate sodium) is a stool softener that can turn the urine orange. This is a common side effect and should be discussed with the patient during teaching to avoid unnecessary concern.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time?
- A. Do nothing. This is a normal finding.
- B. Massage the woman 's fundus.
- C. Take the woman to the bathroom to void.
- D. Notify the woman 's primary health care provider.
Correct Answer: A
Rationale: A firm fundus at the umbilicus and heavy lochia rubra is normal during the first few hours after delivery.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: Hemorrhagic shock is characterized by inadequate tissue perfusion due to severe blood loss, leading to decreased circulating volume. The body's compensatory mechanisms kick in to maintain blood pressure, causing the peripheral blood vessels to constrict. This constriction can lead to cool, clammy, and pale skin as the body shunts blood away from the skin's surface to the vital organs. The skin may also feel cool to the touch due to reduced perfusion. This observation is significant in indicating hemorrhagic shock because it signifies the body's response to the insufficient circulating volume and the need to prioritize perfusion to essential organs.
What is a risk factor for PPD?
- A. vaginal birth
- B. family support
- C. traumatic birth
- D. breast-feeding
Correct Answer: C
Rationale: The correct answer is C: traumatic birth. Traumatic birth can lead to postpartum depression (PPD) due to the physical and emotional stress experienced during labor and delivery. This can trigger feelings of anxiety, helplessness, and trauma that contribute to the development of PPD. Vaginal birth (choice A) and breast-feeding (choice D) are not inherently risk factors for PPD. Family support (choice B) is typically considered a protective factor against PPD, providing emotional and practical assistance for new mothers.