Nokea
A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, 'I 'm a failure. I couldn 't stand the pain and couldn 't even push my baby out by myself! ' Which of the following is the best response for the nurse to make?
- A. You 'll feel better later after you have had a chance to rest and to eat.
- B. Don 't say that. There are many women who would be ecstatic to have that baby.
- C. I am sure that you will have another baby. I bet that it will be a natural delivery.
- D. To have things work out differently than you had planned is disappointing.
Correct Answer: D
Rationale: The nurse should acknowledge the emotional distress and disappointment while offering validation and understanding about how things didn't go as expected.
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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 is a risk factor for uterine atony?
- A. small for gestational age
- B. primipara
- C. multiple gestation
- D. intrauterine growth restriction
Correct Answer: C
Rationale: Risk factors for uterine atony include multiple gestation and large infants.
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 in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform?
- A. Intermittently apply ice packs to her axillae and breasts.
- B. Apply lanolin to her breasts and nipples every 3 hours.
- C. Express milk from the breasts every 3 hours.
- D. Ask the primary health care provider to order a milk suppressant.
Correct Answer: A
Rationale: Ice packs can help reduce inflammation and pain associated with engorgement in women who choose to bottle-feed.
A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time?
- A. Provide the woman with a bedpan.
- B. Advise the woman that the feeling is likely related to the trauma of delivery.
- C. Remind the woman that she still has a catheter in place from the delivery.
- D. Assist the woman to the bathroom.
Correct Answer: D
Rationale: After delivery, if the woman feels the need to urinate, assisting her to the bathroom is appropriate to allow for normal voiding. A catheter should not still be in place unless indicated.