Nokea
A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make?
- A. Place the client flat in bed.
- B. Assess for dependent edema.
- C. Auscultate lung fields.
- D. Check patellar reflexes.
Correct Answer: C
Rationale: General anesthesia can impair lung function, necessitating lung auscultation.
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To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
- A. Have the patient drink carbonated beverages to promote urinary excretion.
- B. Tell the patient that because of postpartum diuresis there is less risk to develop dehydration.
- C. Limit fluid intake to prevent polyuri
- D. Teach the patient to perform pelvic floor exercises to combat potential stress
Correct Answer: D
Rationale: The correct answer is D, teaching the patient to perform pelvic floor exercises to combat potential stress incontinence. This intervention strengthens pelvic floor muscles, aiding in bladder control postpartum. Choice A is incorrect as carbonated beverages can irritate the bladder. Choice B is incorrect as postpartum diuresis increases fluid loss, increasing the risk of dehydration. Choice C is incorrect as limiting fluid intake can lead to dehydration and hinder urinary elimination.
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4–6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: Rationale for Correct Answer (A):
- A: Correct because postpartum women should avoid placing anything in the vagina to prevent infection and allow healing.
- B: Incorrect because ovulation can occur before the first postpartum period.
- C: Incorrect because resuming sexual intercourse should be based on individual healing and comfort, not just discharge.
- D: Incorrect because sexual intimacy is a normal part of relationships and should be discussed postpartum for emotional well-being.
A mother, 1 day postpartum from a 3-hour labor and a spontaneous vaginal delivery, questions the nurse because her baby's face is"purple." Upon examination, the nurse notes petechiae over the scalp, forehead, and cheeks of the baby. The nurse's response should be based on which of the following?
- A. Petechiae are indicative of severe bacterial infections.
- B. Rapid deliveries can injure the neonatal presenting part.
- C. Petechiae are characteristic of the normal newborn rash.
- D. The injuries are a sign that the child has been abused.
Correct Answer: B
Rationale: Petechiae can result from pressure changes during rapid delivery, particularly affecting the presenting part.
A 40-week-gestation neonate is in the first period of reactivity. Which of the following actions should the nurse take at this time?
- A. Encourage the parents to bond with their baby.
- B. Notify the neonatologist of the finding.
- C. Perform the gestational age assessment.
- D. Place the baby under the overhead warmer.
Correct Answer: A
Rationale: Bonding is encouraged during periods of reactivity.
The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which of the following actions should be included?
- A. Clean the eyes from outer canthus to inner canthus.
- B. Cleanse the ear canals with a cotton swab.
- C. Assemble all supplies before beginning the bath.
- D. Check the temperature of the bath water with the fingertips.
Correct Answer: C
Rationale: Preparing supplies ensures efficiency and safety during bathing.