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A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time?
- A. That is very concerning. I will request that your physician order an enema for you.
- B. Two days is not that bad. Some patients go four days or longer without a movement.
- C. You have been taking antibiotics through your intravenous. That is probably why you are constipated.
- D. Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid.
Correct Answer: B
Rationale: It is not uncommon for postpartum clients to experience delayed bowel movements due to the effects of anesthesia, immobility, and decreased peristalsis.
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A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because 'I am so tired right now. I just want to have something to eat and take a nap. ' Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following?
- A. Social deprivation.
- B. Child neglect.
- C. Normal postpartum behavior.
- D. Postpartum depression.
Correct Answer: C
Rationale: Requesting rest after feeding is typical postpartum behavior and does not indicate neglect or depression.
What postpartum infection is caused by STIs and chorioamnionitis?
- A. mastitis
- B. pneumonia
- C. cesarean wound infection
- D. postpartum endometritis
Correct Answer: D
Rationale: Postpartum endometritis can result from untreated STIs and chorioamnionitis and typically presents as fever and uterine tenderness.
What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of sepsis. Postpartum endometritis is a bacterial infection of the uterine lining that can lead to sepsis if not treated promptly. Monitoring for signs of sepsis is crucial for early detection and intervention to prevent serious complications. Option B is incorrect because breastfeeding is encouraged to promote bonding and provide nutrition. Option C is incorrect as fundal assessment is necessary to monitor uterine involution. Option D is incorrect as increasing family visiting hours is not directly related to managing postpartum endometritis.
The nurse is collecting information during a follow-up OB appointment with a patient who delivered 3 months ago. The patient reports her partner has become cynical, irritable, and verbally abusive. The nurse will screen for which risks related to paternal postnatal depression (PPND)? Select all that apply.
- A. The father exhibited depression during the pregnancy
- B. The birth of this fourth child was unexpected and unplanned
- C. The father expresses feeling bored and underappreciated in his job
- D. The father is recently estranged from his parents and siblings
Correct Answer: B
Rationale: The correct answer is B. The birth of a fourth child being unexpected and unplanned can be a risk factor for paternal postnatal depression (PPND) due to increased stress and pressure. Choice A is incorrect because past depression during pregnancy doesn't directly correlate with PPND. Choice C is incorrect as feeling bored and underappreciated at work is not a direct risk factor for PPND. Choice D is incorrect as being recently estranged from family members doesn't directly relate to PPND.
Which client is at greatest risk for early PPH?
- A. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
- B. Woman with severe preeclampsia on magnesium sulfate whose labor is being
- C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
- D. Primigravida in spontaneous labor with preterm twins
Correct Answer: B
Rationale: The correct answer is B because a woman with severe preeclampsia on magnesium sulfate is at the greatest risk for early postpartum hemorrhage (PPH) due to the increased risk of placental abruption, coagulopathy, and uterine atony associated with preeclampsia and magnesium sulfate use. Preeclampsia can lead to poor placental perfusion, increasing the risk of hemorrhage during and after delivery. Magnesium sulfate can also affect blood clotting mechanisms, further increasing the risk of excessive bleeding. The other choices are less likely to be at greatest risk for early PPH. Choice A involves a primiparous woman with cesarean delivery, which may have controlled bleeding. Choice C is a multiparous woman with a relatively short labor duration, which is not a significant risk factor for early PPH. Choice D is a primigravida with preterm twins, which does not inherently increase the risk of early PPH