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A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
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Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C because monitoring lochia flow is crucial post-vaginal delivery to assess for excessive bleeding, which could indicate postpartum hemorrhage. This goal takes precedence over other options as it pertains to the client's immediate health and well-being. A: Wearing a bra does not address any urgent postpartum concerns. B: Eating meals is important but does not take priority over assessing for hemorrhage. D: Ambulation is beneficial but not as critical as monitoring lochia flow for potential complications.
The nurse is providing education to a postpartum woman about exercises to strengthen the pelvis musculature. Which instruction should be included?
- A. "Ambulate three times a day."
- B. "Perform Kegel exercises."
- C. "Enroll in an aerobics class after discharge."
- D. "Do passive range-of-motion exercises while lying in bed."
Correct Answer: B
Rationale: The correct answer is B: "Perform Kegel exercises." Kegel exercises specifically target the pelvic floor muscles, which can help strengthen the pelvis musculature postpartum. This is important for improving pelvic floor support and preventing issues like urinary incontinence. Ambulating (A) is good for overall mobility but does not specifically target the pelvic muscles. Enrolling in an aerobics class (C) may be beneficial for overall fitness but does not address pelvic floor strengthening. Passive range-of-motion exercises (D) focus on joint flexibility rather than pelvic muscle strength.
The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D because presenting information on an age-appropriate level is crucial for effective teaching. Adolescents may have limited knowledge and experience, so tailoring the information to their level ensures understanding and compliance. Choice A focuses on grandparents' involvement, which is important but not the primary consideration. Choice B addresses parental expectations, which is relevant but not as critical as providing age-appropriate information. Choice C emphasizes the father's involvement, which is valuable but not the top priority compared to ensuring the information is understandable for the adolescent mother.
The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because how a mother physically recovers from labor and delivery is primarily influenced by biological and physiological factors rather than cultural influences. The mother's physical recovery is guided by medical interventions, individual health conditions, and postpartum care practices. On the other hand, choices A, B, and D are all influenced by cultural factors. Choice A pertains to cultural variations in rituals or customs related to the duration of each phase of becoming a mother. Choice B involves cultural beliefs around postpartum rest and support systems. Choice D addresses cultural norms regarding maternal autonomy and decision-making in the early stages of motherhood.
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: The correct answer is D: Prepare ice pack for application to perineal area. This intervention is crucial for managing pain and reducing swelling in the perineal area post third-degree tear. Ice packs help vasoconstriction, decreasing blood flow and minimizing inflammation. It also provides comfort to the patient.
A: Assess vital signs every 4 hours - This is important but not the priority in this situation. Monitoring vital signs is essential, but immediate comfort measures should be prioritized for the patient with a perineal tear.
B: Keep patient NPO for first 12 hours - There is no indication to keep the patient NPO for 12 hours. Adequate hydration and nutrition are important for postpartum recovery.
C: Catheterize patient prior to first ambulation - Catheterization may not be necessary unless there are specific indications. It is not a routine intervention for a perineal tear during the fourth stage of labor.