Nokea
A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly?
- A. The nurse measures the fundal height using a paper centimeter tape.
- B. The nurse stabilizes the base of the uterus with his or her dependent hand.
- C. The nurse palpates the fundus with the tips of his or her fingers.
- D. The nurse precedes the assessment with a sterile vaginal exam.
Correct Answer: B
Rationale: To assess the fundus properly, the nurse should stabilize the base of the uterus with one hand and palpate the fundus with the other.
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What physiologic postpartum change occurs because the uterus shrinks in size, resulting in an increase in blood flow?
- A. Edema increases.
- B. Cardiac output increases.
- C. Temperature rises.
- D. Lochia increases.
Correct Answer: D
Rationale: As the uterus shrinks blood flow increases leading to the increased discharge of lochia.
Research has shown what intervention increases involvement of the adolescent partner postpartum?
- A. involvement of the partner during the prenatal period
- B. involvement of parents in decision making
- C. restricting people in the labor room
- D. providing newborn care in the nursery
Correct Answer: A
Rationale: Involving the partner early in the process increases their engagement and involvement postpartum.
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.
The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states 'I don 't use those. I always use tampons. ' Which of the following actions by the nurse is appropriate at this time?
- A. Remove the peripad and insert a tampon into the woman 's vagina.
- B. Advise the client that for the first two days she will be bleeding too heavily for a tampon.
- C. State that it is unsafe to place anything into the vagina until involution is complete.
- D. Remind the client that a tampon would hurt until the soreness from the delivery resolves.
Correct Answer: B
Rationale: The nurse should explain that for the first two days after delivery, the bleeding is too heavy to use tampons, and this could increase the risk of infection.
The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The primary care provider needs to be contacted about the assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed.