Nokea
A client is 10 minutes postpartum from a forceps delivery of a 4,500-gram neonate with a cleft lip. The physician performed a right mediolateral episiotomy during the delivery. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time?
- A. Ineffective breastfeeding.
- B. Fluid volume deficit.
- C. Infection.
- D. Pain.
Correct Answer: D
Rationale: Pain management is critical post-episiotomy.
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The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
- A. “I may not have a bowel movement until the 2nd postpartum day.”
- B. “If I breastfeed and supplemUenSt wiNth fTormula,O I won’t need any birth control.”
- C. “I know my normal pattern of bowel elimination won’t return until about 8 to 10 days.”
- D. “If I am not breastfeeding, I should use birth control when I resume sexual
Correct Answer: B
Rationale: The correct answer is B because the patient's statement about not needing birth control if breastfeeding and supplementing with formula is incorrect. Breastfeeding is not a reliable form of birth control and additional contraception is necessary to prevent unintended pregnancy.
Explanation:
1. Breastfeeding alone is not a foolproof method of contraception.
2. The combination of breastfeeding and formula feeding does not guarantee contraception.
3. Lactational amenorrhea method (LAM) is only effective if specific criteria are met.
4. The patient's misconception about not needing birth control while breastfeeding and supplementing with formula puts her at risk of unintended pregnancy.
Summary:
A: Correct statement about the timing of bowel movements postpartum.
C: Incorrect statement about the normal pattern of bowel elimination postpartum.
D: Correct statement about the need for birth control if not breastfeeding.
A nurse is doing a newborn assessment on a new admission to the nursery. Which of the following actions should the nurse make when evaluating the baby for developmental dysplasia of the hip (DDH)? Select one that doesn't apply
- A. Grasp the baby's legs with the thumbs on the inner thighs and forefingers on the outer thighs.
- B. Gently adduct and abduct the baby's thighs.
- C. Palpate the trochanter during hip rotation.
- D. Place the baby in a fetal position.
Correct Answer: D
Rationale: These maneuvers help detect instability or asymmetry in the hips indicative of DDH.
A nurse administered RhoGAM to a client whose blood type is A+ (positive). Which of the following responses would the nurse expect to see? Select all that apply.
- A. Fever.
- B. Flank pain.
- C. Dark-colored urine.
- D. Swelling at the injection site.
Correct Answer: D
Rationale: Localized swelling and dark urine may occur.
The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the client who had which of the following deliveries asks why she must receive a RhoGAM injection? Select one that doesn't apply
- A. Abortion at 10 weeks' gestation.
- B. Amniocentesis at 16 weeks' gestation.
- C. Fetal demise at 24 weeks' gestation.
- D. Birth of Rh-negative twins at 35 weeks' gestation.
Correct Answer: D
Rationale: RhoGAM is given in cases where there is potential exposure to Rh-positive blood.
The nurse educates the postpartum person on bowel discomfort. What instructions would they give?
- A. Limit water intake.
- B. Use laxatives daily.
- C. Ambulate often.
- D. Avoid stool softeners.
Correct Answer: C
Rationale: The correct answer is C: Ambulate often. After childbirth, ambulation helps stimulate bowel movements, preventing constipation. Walking helps promote peristalsis and improves overall bowel function.
Choice A: Limit water intake - Incorrect. Hydration is important for bowel function and limiting water intake can worsen constipation.
Choice B: Use laxatives daily - Incorrect. Daily use of laxatives can lead to dependence and disrupt natural bowel function.
Choice D: Avoid stool softeners - Incorrect. Stool softeners can be beneficial in preventing constipation and should not be avoided without medical advice.