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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: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.
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 physical recovery from labor and delivery is a biological process rather than a cultural influence. The nurse assesses cultural influences, such as beliefs and practices, which shape the mother's experience of motherhood. Choices A, B, and D are influenced by cultural factors, such as time spent in each phase, expectations related to rest, and involvement in decision-making, respectively. These aspects reflect how cultural norms, values, and traditions impact the transition to motherhood.
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: Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process, not solely influenced by culture. Other choices (A, B, D) relate to cultural factors affecting the mother's transition to motherhood, such as rituals, beliefs, and social expectations. Cultural influence can affect the time spent in each phase, expectations related to rest, and decision-making processes. It is crucial for the nurse to assess these cultural influences to provide culturally competent care.
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B: The couple attends hospital classes addressing newborn and infant care. This is associated with intentional learning as it involves actively seeking out structured education on parenting skills. Attending classes allows the couple to acquire knowledge and skills related to newborn and infant care in a deliberate and purposeful manner.
Incorrect choices:
A: Observing other individuals who are mothers and fathers may provide some insights, but it is more passive and may not involve structured learning.
C: Discussing how they were parented is reflective but may not necessarily involve acquiring new parenting skills through intentional learning.
D: Watching media containing parenting roles is passive and may not provide the same level of structured education as attending classes specifically addressing newborn and infant care.
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.