Nokea
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.
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What is characteristic of an early (primary) PPH?
- A. occurs after 12 weeks postpartum
- B. is not an emergency
- C. often occurs due to uterine atony
- D. is diagnosed after the person is discharged
Correct Answer: C
Rationale: The correct answer is C because early (primary) postpartum hemorrhage (PPH) often occurs due to uterine atony, which is the inability of the uterus to contract effectively after childbirth. This leads to excessive bleeding within 24 hours of delivery. Choice A is incorrect because early PPH occurs within 24 hours postpartum, not after 12 weeks. Choice B is incorrect because early PPH is indeed an emergency due to the risk of rapid blood loss. Choice D is incorrect as early PPH is typically diagnosed before or shortly after discharge, not after.
What important assessment should the nurse perform on all postpartum persons?
- A. Screen for PPD with the EPDS.
- B. Screen for drug use with a urine drug screen.
- C. Screen for breast-feeding failure.
- D. Screen for contraception contraindications.
Correct Answer: A
Rationale: The correct answer is A because screening for Postpartum Depression (PPD) with the Edinburgh Postnatal Depression Scale (EPDS) is crucial for the well-being of postpartum individuals. PPD is a common and serious condition that can affect the mother's mental health and bonding with the baby. Early detection and intervention are key to ensuring proper support and treatment.
Choice B, screening for drug use, is not a routine assessment for all postpartum persons unless there are specific risk factors present. Choice C, screening for breast-feeding failure, is important but not the most critical assessment to perform on all postpartum individuals. Choice D, screening for contraception contraindications, is important for family planning but is not as immediate or essential as screening for PPD.
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider?
- A. White blood cells, 12,500 cells/mm3.
- B. Red blood cells, 4,500,000 cells/mm3.
- C. Hematocrit, 26%.
- D. Hemoglobin, 11 g/dL
Correct Answer: C
Rationale: A hematocrit of 26% indicates possible anemia, and it should be reported to the healthcare provider for further evaluation.
Which condition is considered a medical emergency that requires immediate treatment?
- A. Inversion of the uterus
- B. Hypotonic uterus
- C. ITP
- D. Uterine atony
Correct Answer: A
Rationale: The correct answer is A: Inversion of the uterus. This condition is a medical emergency as it involves the uterus turning inside out, which can lead to severe hemorrhage and shock. Immediate treatment is crucial to prevent further complications.
B: Hypotonic uterus, while concerning, does not pose an immediate life-threatening risk compared to uterine inversion.
C: ITP (Immune Thrombocytopenic Purpura) is a disorder affecting platelet levels, but it is not a medical emergency that requires immediate treatment like uterine inversion.
D: Uterine atony is a common postpartum complication, but it does not pose the same urgent threat as uterine inversion.
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, 'I don 't know what is wrong with me. I feel terrible. I should be happy, but I 'm not. ' Which of the following nursing diagnoses is appropriate for this client?
- A. Suicidal thoughts related to psychotic ideations.
- B. Post-trauma response related to traumatic delivery.
- C. Ineffective individual coping related to hormonal shifts.
- D. Spiritual distress related to immature belief systems.
Correct Answer: C
Rationale: The client 's symptoms suggest ineffective coping due to hormonal shifts commonly experienced during the postpartum period, possibly indicating postpartum blues.