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A client G2 P1102 is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client 's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform?
- A. Assess her feet and ankles for pitting edema.
- B. Lower both of her legs at the same time.
- C. Advise the client to stop feeding her baby while her blood pressure is assessed.
- D. Measure the length of the episiotomy and document the findings in the chart.
Correct Answer: A
Rationale: The nurse should assess for signs of deep vein thrombosis (DVT) or pitting edema in the postpartum period, especially after stirrup use during delivery.
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A patient who has been on prolonged bedrest for bleeding associated with placenta previa was taken to the operating room for an emergency cesarean delivery. Sixteen hours postoperatively, the patient complains that her left leg is hurting. The nurse finds that the entire left leg is swollen and has pitting edema, while the right leg appears to be normal. Which order does the nurse anticipate when paging the health care provider to the room?
- A. White blood cell count (WBC)
- B. Ultrasound of the leg
- C. X-ray of the leg
- D. Serum creatinine
Correct Answer: B
Rationale: The swollen and painful leg may indicate a deep vein thrombosis (DVT), and an ultrasound is the appropriate diagnostic test.
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.
Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate?
- A. PPH is easy to recognize early; after all, the woman is bleeding.
- B. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH.
- C. If anything, nurses and physicians tend to overestimate the amount of blood loss.
- D. Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.
Correct Answer: B
Rationale: The correct answer is B because it accurately defines the criteria for postpartum hemorrhage (PPH). PPH is traditionally defined as losing more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth. This definition helps healthcare providers recognize and manage PPH effectively.
Now, let's analyze why the other choices are incorrect:
A: This statement is incorrect because PPH may not always be easy to recognize early based solely on visible bleeding. Other signs and symptoms, such as tachycardia and hypotension, also play a crucial role in identifying PPH.
C: This statement is incorrect because underestimating, rather than overestimating, the amount of blood loss in PPH can lead to delayed intervention and potentially worsen the patient's condition.
D: This statement is incorrect because PPH is not classified based on timing (early or late PPH), but rather on the amount of blood loss as defined in choice B.
What is characteristic of an early (primary) PPH?
- A. occurs after 12 weeks postpartum
- B. is not an emergency
- C. often occurs due to uterine atony
- D. is diagnosed after the person is discharged
Correct Answer: C
Rationale: Early (primary) postpartum hemorrhage is usually due to uterine atony and requires immediate medical intervention.
The nurse develops a plan to increase a patient 's milk supply. What is an intervention they can implement?
- A. Pump between nursing sessions.
- B. Nurse every 6 hours.
- C. Keep newborn in bassinet between sessions.
- D. Offer a pacifier when newborn cries.
Correct Answer: A
Rationale: Pumping between breastfeeding sessions can help stimulate milk production by increasing demand.