Nokea
A nurse is caring for a client, PP2, who is preparing to go home with her infant. The nurse notes that the client's blood type is O− (negative), the baby's type is A+ (positive), and the direct Coombs' test is negative. Which of the following actions by the nurse is appropriate?
- A. Advise the client to keep her physician appointment at the end of the week to receive her RhoGAM injection.
- B. Make sure that the client receives a RhoGAM injection before she is discharged from the hospital.
- C. Notify the client that because her baby's Coombs' test was negative she will not receive an injection of RhoGAM.
- D. Inform the client's physician that because the woman is being discharged on the second day, the RhoGAM could not be given.
Correct Answer: B
Rationale: RhoGAM is necessary to prevent sensitization.
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The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.
When assessing the A of the acronym REEDA, the nurse should evaluate the
- A. skin color.
- B. degree of edem
- C. edges of the episiotomy.
- D. episiotomy for discharg
Correct Answer: C
Rationale: The correct answer is C. When assessing the A of REEDA (Redness, Edema, Ecchymosis, Discharge, and Approximation) in wound assessment, nurses should evaluate the edges of the episiotomy. This is important to ensure proper healing and closure of the incision site. Evaluating skin color (A) is important for overall wound assessment but not specifically for the edges of the episiotomy. Edema (B) refers to swelling, which is important to monitor but not specific to the edges of the episiotomy. Checking the episiotomy for discharge (D) is relevant for the "D" component of REEDA but not for the "A" component, which specifically focuses on the edges of the incision.
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching?
- A. Always wipe the perineum from front to back.
- B. Remove any vernix caseosa from the labial folds.
- C. Put powder on the buttocks every time the baby stools.
- D. Weigh every diaper to assess hydration status.
Correct Answer: A
Rationale: Front-to-back wiping prevents urinary tract infections.
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: The correct answer is A: involvement of the partner during the prenatal period. This intervention increases the involvement of the adolescent partner postpartum by fostering a sense of responsibility, connection, and support early on in the pregnancy. By actively engaging the partner in prenatal care and decision-making processes, they are more likely to feel invested in the pregnancy and the well-being of the newborn. This involvement also promotes better communication and shared responsibilities between the partners, leading to a smoother transition into parenthood.
Summary of why other choices are incorrect:
B: Involvement of parents in decision making may be beneficial but does not directly address the involvement of the adolescent partner postpartum.
C: Restricting people in the labor room does not promote partner involvement postpartum and may hinder support networks.
D: Providing newborn care in the nursery may be helpful for short-term respite but does not enhance the involvement of the partner postpartum.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.