Nokea
A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication?
- A. Apical pulse.
- B. Lochia flow.
- C. Blood pressure.
- D. Episiotomy.
Correct Answer: C
Rationale: Methergine can raise blood pressure, so it is important to assess the patient's blood pressure before administering each dose.
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A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse 's response?
- A. The client 's obstetric status is optimal for receiving the vaccine.
- B. The client 's immune system is highly responsive during the postpartum period.
- C. The client 's baby will be high risk for acquiring rubella if the woman does not receive the vaccine.
- D. The client 's insurance company will pay for the shot if it is given during the immediate postpartum period.
Correct Answer: B
Rationale: The postpartum period offers a good opportunity for immunization because the immune system is more responsive. Administering the vaccine before discharge ensures the woman is protected in the future.
A post -cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, 'I have decided to make sure that I feel as little pain from this experience as possible. ' Which of the following should the nurse conclude in relation to this woman 's behavior?
- A. The woman needs a stronger narcotic order.
- B. The woman is high risk for severe constipation.
- C. The woman 's breast milk volume may drop while taking the medicine.
- D. The woman 's newborn may become addicted to the medication.
Correct Answer: C
Rationale: Frequent use of narcotic analgesics can affect breast milk production, potentially causing a decrease in supply.
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.
The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, “I think that my baby is deformed inside and we have to fix him.” Which risk factor is most strongly related to possible postpartum psychosis (PPP)?
- A. Separation from the baby’s father
- B. Personal history of bipolar disorder
- C. Prolonged labor resulting in cesarean
- D. Loss of first child from a heart defect
Correct Answer: B
Rationale: The correct answer is B, personal history of bipolar disorder. Postpartum psychosis is a severe mental health condition that can occur in women with a history of bipolar disorder. Bipolar disorder is a major risk factor for developing postpartum psychosis due to the hormonal changes and stress of childbirth. The extreme agitation, depressed mood, and delusional thoughts exhibited by the patient in the scenario are indicative of postpartum psychosis.
Choice A, separation from the baby’s father, is not a strong risk factor for postpartum psychosis. Choice C, prolonged labor resulting in cesarean, is associated with physical complications but not necessarily with postpartum psychosis. Choice D, loss of the first child from a heart defect, is a traumatic event but is not directly linked to the development of postpartum psychosis.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.