Nokea
A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?
- A. The client will breastfeed her baby every 2 hours.
- B. The client will consume a normal diet.
- C. The client will have a moderate lochial flow.
- D. The client will ambulate to the bathroom every 2 hours.
Correct Answer: C
Rationale: After delivery, the highest priority is ensuring the client has a normal lochial flow, which is a key indicator of the uterus returning to its non-pregnant state. Breastfeeding, diet, and ambulation are also important but secondary.
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A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time?
- A. Notify the doctor to get an order for acetaminophen.
- B. Request an infectious disease consult from the doctor.
- C. Provide the woman with cool compresses.
- D. Encourage intake of water and other fluids.
Correct Answer: D
Rationale: A slight increase in temperature is common in the first 24 hours after delivery due to hormonal changes and dehydration. Encouraging fluid intake is an appropriate intervention.
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 assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.
What is one difference between recovery from a cesarean birth versus a vaginal birth?
- A. Breast-feeding is discouraged after cesarean birth due to pain medications taken.
- B. Lochia will be heavier after a cesarean birth.
- C. Pain with movement is more intense after a cesarean birth.
- D. Gas pain is more intense after a vaginal birth.
Correct Answer: C
Rationale: The correct answer is C because pain with movement is typically more intense after a cesarean birth compared to a vaginal birth. This is due to the surgery involving abdominal muscles and tissues. Breastfeeding is not discouraged after a cesarean birth; in fact, it is encouraged. Lochia, postpartum bleeding, is not necessarily heavier after a cesarean birth. Gas pain is more commonly associated with cesarean births due to reduced mobility and effects of anesthesia. Therefore, choice C is the most fitting difference between the two types of birth recoveries.
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.