Nokea
A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon?
- A. Fundus at the umbilicus.
- B. Nodular breasts.
- C. Pulse rate 60 bpm.
- D. Pad saturation every 30 minutes.
Correct Answer: D
Rationale: Excessive pad saturation every 30 minutes indicates possible postpartum hemorrhage and should be reported immediately to the surgeon.
You may also like to solve these questions
What is the most common reason for cracked, sore nipples?
- A. hungry infant
- B. pumping
- C. ineffective latch
- D. lack of supportive bra
Correct Answer: C
Rationale: Ineffective latch causes sore nipples in breastfeeding mothers.
The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: 'All I do is go to the bathroom. ' Which of the following is an appropriate nursing response?
- A. Catheterize the client per doctor 's orders.
- B. Measure the client 's next voiding.
- C. Inform the client that polyuria is normal.
- D. Check the specific gravity of the next voiding.
Correct Answer: C
Rationale: Polyuria, or frequent urination, is a normal phenomenon during the postpartum period as the body expels excess fluid.
What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of sepsis. Postpartum endometritis is a bacterial infection of the uterine lining that can lead to sepsis if not treated promptly. Monitoring for signs of sepsis is crucial for early detection and intervention to prevent serious complications. Option B is incorrect because breastfeeding is encouraged to promote bonding and provide nutrition. Option C is incorrect as fundal assessment is necessary to monitor uterine involution. Option D is incorrect as increasing family visiting hours is not directly related to managing postpartum endometritis.
A postpartum cesarean patient comes into the rural health clinic at 1 week postdelivery for an incision check by the nurse. The vital signs reveal a temperature of 100.5°F, and the patient reports moderate foul-smelling lochia. The nurse determines that the skin incision is healing normally, but when palpating the uterus, she discovers the patient to have uterine and pelvic tenderness. What are the most appropriate nursing actions?
- A. Explain to the patient that she may have an infection of her uterus, and blood will need to be drawn to determine if this is the cause of her pain and excess bleeding.
- B. Explain that the client should rest more to help the bleeding slow and that she should return to the clinic if she isn’t feeling better in a few days.
- C. Explain to the patient that she is experiencing normal postoperative pain and bleeding and to come back for her scheduled 6-week postpartum checkup.
- D. Explain to the patient that the incision appears to be healing nicely. Have her take Tylenol for the elevated temperature and continue with the ordered pain medication until her next visit.
Correct Answer: D
Rationale: Step 1: The nurse's assessment reveals signs of infection (fever, foul-smelling lochia, uterine, and pelvic tenderness).
Step 2: The nurse should address the immediate concerns - fever and pain. Tylenol helps reduce fever and pain.
Step 3: The incision healing well indicates no immediate surgical intervention required.
Step 4: Continuing pain medication ensures comfort until next visit.
Step 5: Blood tests for infection are not urgent; they can be done at the next visit if symptoms persist.
Summary:
A: Immediate blood draw is not necessary without a clear indication of sepsis.
B: Resting more won't address the infection; waiting a few days can worsen the condition.
C: Normal postoperative pain doesn't include fever and foul-smelling lochia; waiting for the 6-week checkup is risky.
Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum.
- A. Apply antibiotic cream to the area three times each day.
- B. Squirt warm water over the perineum after voiding or stooling.
- C. Maintain cold packs to the area at all times for the first 3 days.
- D. Check the leukocyte level daily and report changes.
Correct Answer: B
Rationale: Squatting warm water over the perineum after voiding or stooling helps to soothe and cleanse the area, promoting healing.