Nokea
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
- A. Respiratory rate 8 rpm.
- B. Complaint of thirst.
- C. Urinary output of 250 mL/hr.
- D. Numbness of feet and ankles.
Correct Answer: A
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, which must be reported immediately as a potential complication of narcotic use.
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What nursing intervention does the nurse include in the plan of care for a person with a perineal laceration infection?
- A. Demonstrate the use of a urinary catheter.
- B. Provide an abdominal binder.
- C. Encourage use of the peri-bottle for cleaning front to back.
- D. Discourage use of pain medications.
Correct Answer: C
Rationale: The correct answer is C because using a peri-bottle for cleaning front to back helps prevent introducing more bacteria into the infected perineal laceration. This method maintains proper hygiene, reduces the risk of further infection, and promotes healing. A urinary catheter (A) is not typically indicated for a perineal laceration infection. An abdominal binder (B) may provide support but does not directly address the infection. Discouraging pain medications (D) is not appropriate as pain management is important for patient comfort and healing.
What is characteristic of a late (secondary) PPH?
- A. occurs within the first 24 hours
- B. is caused by subinvolution of the uterus
- C. does not occur after cesarean births
- D. cannot be treated with Methergine
Correct Answer: B
Rationale: Late (secondary) postpartum hemorrhage is typically caused by subinvolution of the uterus and may occur after the first 24 hours.
The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected?
- A. If your nipples are cracked, you will need to stop breastfeeding.
- B. Pump your milk and throw it away until the infection is gone.
- C. The baby gave you an infection and needs to be on antibiotics.
- D. Continuing to breastfeed will help clear up the condition.
Correct Answer: D
Rationale: The correct answer is D: Continuing to breastfeed will help clear up the condition.
Rationale:
1. Continuing to breastfeed helps to empty the breast and prevent milk stasis, which can worsen mastitis.
2. Breastfeeding helps maintain milk production and prevents engorgement, which can exacerbate the infection.
3. Breast milk has antibacterial properties that can help fight the infection.
4. Stopping breastfeeding abruptly can lead to more serious complications like abscess formation.
Summary:
A: Incorrect. Stopping breastfeeding abruptly can lead to complications and does not address the underlying infection.
B: Incorrect. Pumping and throwing away milk does not address the underlying infection and can lead to decreased milk supply.
C: Incorrect. Mastitis is not caused by the baby, and antibiotics are not always necessary if managed promptly with breastfeeding and self-care.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time?
- A. Do nothing. This is a normal finding.
- B. Massage the woman 's fundus.
- C. Take the woman to the bathroom to void.
- D. Notify the woman 's primary health care provider.
Correct Answer: A
Rationale: A firm fundus at the umbilicus and heavy lochia rubra is normal during the first few hours after delivery.
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate?
- A. Take the woman 's temperature.
- B. Advise the woman to decrease her fluid intake.
- C. Reassure the woman that this is normal.
- D. Notify the neonate 's pediatrician.
Correct Answer: C
Rationale: Profuse diaphoresis is a common and normal occurrence in the first 24 hours postpartum as the body works to eliminate excess fluid accumulated during pregnancy.