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A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant?
- A. Assess client 's fundal height.
- B. Teach client how to massage her fundus.
- C. Take the client 's vital signs.
- D. Document quantity of lochia in the chart.
Correct Answer: C
Rationale: The nursing care assistant can take vital signs, while the registered nurse is responsible for more complex assessments like fundal height and teaching skills such as massaging the fundus.
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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: Monitoring for signs of sepsis is important in postpartum endometritis as it can lead to severe complications if untreated.
The nurse educates the person with a newborn in the NICU. What guidance does the nurse provide?
- A. Breast milk is not good for a premature baby.
- B. Premature babies breast-feed easily.
- C. Skin-to-skin contact helps both baby and breast-feeding person.
- D. A bottle is recommended for all feedings.
Correct Answer: C
Rationale: Skin-to-skin contact is important for both mother and premature infant.
The nurse is developing a plan of care for the postpartum client during the 'taking in ' phase. Which of the following should the nurse include in the plan?
- A. Teach baby-care skills like diapering.
- B. Discuss the labor and birth with the mother.
- C. Discuss contraceptive choices with the mother.
- D. Teach breastfeeding skills like pumping.
Correct Answer: B
Rationale: During the 'taking in' phase, the mother is focused on her own recovery and reliving the birth experience. Discussing the labor and birth is appropriate at this time.
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate?
- A. You must wait to begin to perform exercises until after your six-week postpartum checkup.
- B. You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe.
- C. By next week you will be able to return to the exercise schedule you had during your prepregnancy.
- D. You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks.
Correct Answer: D
Rationale: Kegel exercises can be started early postpartum to help strengthen pelvic floor muscles. Other exercises can be gradually increased after approval from the healthcare provider.
The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate?
- A. Irrigate the incision twice daily.
- B. Monitor the incision for drainage.
- C. Apply steristrips to the incision line.
- D. Palpate the incision and assess for pain.
Correct Answer: B
Rationale: Monitoring the incision for drainage is key post-surgery to assess for signs of infection or complications. Irrigating the incision is not a routine practice unless instructed by a physician.