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A nurse is preparing to perform a fundal assessment on a postpartum client who delivered 12 hours ago. What should the nurse do first?
- A. Lower the head of the bed
- B. Locate the level of the fundus
- C. Assist the woman to the bathroom to empty her bladder
- D. Massage the fundus
Correct Answer: C
Rationale: The correct answer is C because assisting the woman to the bathroom to empty her bladder is the first step in a fundal assessment. A full bladder can displace the uterus and affect fundal height accuracy. Lowering the head of the bed (A) is not necessary for this assessment. Locating the level of the fundus (B) should come after ensuring the bladder is empty. Massaging the fundus (D) is not the initial step and could be harmful if the bladder is full.
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A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence?
- A. An increase in oxytocin release related to the newborn suckling
- B. The presence of intense afterbirth pains related to multiparity
- C. An expected response to the daily administration of oxytocin
- D. The efforts of the uterus to return to a prepregnancy condition
Correct Answer: A
Rationale: Rationale for correct answer A:
1. Breastfeeding stimulates the release of oxytocin.
2. Oxytocin causes uterine contractions.
3. Uterine contractions help the uterus return to its pre-pregnancy size.
4. Severe uterine cramps post-delivery are likely due to increased oxytocin release from breastfeeding.
Summary of why other choices are incorrect:
B: Afterbirth pains are typically crampy, but the scenario specifies severe pain on the first day after delivery, which is more likely due to breastfeeding.
C: Daily administration of oxytocin would not lead to sudden severe cramps on the first day post-delivery.
D: Uterus shrinking back to prepregnancy size causes cramping, but the timing and severity described in the scenario point more towards oxytocin release from breastfeeding.
The nurse is educating a postpartum woman on how to prevent engorgement. Which action of the patient indicates effective learning?
- A. Breastfeeding the infant every 2 to 3 hours
- B. Avoiding using soap on the breast when bathing
- C. Drinking 8 to 10 glasses of water during the day
- D. Binding the breast with a towel or stretch bandage
Correct Answer: A
Rationale: The correct answer is A because breastfeeding the infant every 2 to 3 hours helps to establish a proper milk supply, prevent engorgement, and ensure adequate milk removal. This frequent nursing schedule stimulates milk production and prevents the breasts from becoming overly full. Choice B is incorrect because avoiding soap on the breast does not directly prevent engorgement. Choice C is incorrect as hydration is important but not the primary method to prevent engorgement. Choice D is incorrect because binding the breast with a towel or stretch bandage can constrict milk flow and lead to engorgement.
The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient?
- A. Run warm water over breasts while in the shower.
- B. Wear a supportive bra for 24 hours a day.
- C. Express milk by a breast pump or manually.
- D. Take analgesics for breast pain management.
Correct Answer: C
Rationale: The correct answer is C because expressing milk by a breast pump or manually helps in relieving engorgement, preventing mastitis, and maintaining milk supply. This action also allows for proper milk removal and promotes breastfeeding success.
A: Running warm water over breasts can provide temporary relief but does not address the underlying issue of engorgement or milk expression.
B: Wearing a supportive bra is important, but doing so 24 hours a day can lead to discomfort and potential issues with milk supply and breast health.
D: Taking analgesics may provide pain relief but does not address the root cause of the issue and may mask potential problems.
The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema (swelling), Ecchymosis (bruising), Discharge, and Approximation (suture line). Pain description is not specifically covered by REEDA, as it focuses on the physical aspects of the perineal assessment. Describing pain would fall under a separate assessment category such as pain scale assessment. Choices A, B, and C are incorrect because they are all aspects that are included in the REEDA assessment for the perineum.
The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments isn't covered by REEDA?
- A. Perineal coloration
- B. Suture line appearance
- C. Amount of swelling
- D. Description of pain
Correct Answer: D
Rationale: The correct answer is D, Description of pain. The REEDA acronym stands for Redness, Edema, Ecchymosis, Discharge, and Approximation. These components focus on physical aspects like inflammation, bruising, wound healing, and discharge. Pain assessment is important but not part of the REEDA acronym, which specifically addresses visible signs of perineal healing postpartum. A thorough assessment should include pain evaluation separately. Choices A, B, and C are incorrect because they are covered by the REEDA acronym, focusing on perineal coloration, suture line appearance, and amount of swelling, respectively.