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A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time?
- A. Notify the doctor to get an order for acetaminophen.
- B. Request an infectious disease consult from the doctor.
- C. Provide the woman with cool compresses.
- D. Encourage intake of water and other fluids.
Correct Answer: D
Rationale: A slight increase in temperature is common in the first 24 hours after delivery due to hormonal changes and dehydration. Encouraging fluid intake is an appropriate intervention.
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A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time?
- A. Provide the woman with a bedpan.
- B. Advise the woman that the feeling is likely related to the trauma of delivery.
- C. Remind the woman that she still has a catheter in place from the delivery.
- D. Assist the woman to the bathroom.
Correct Answer: D
Rationale: After delivery, if the woman feels the need to urinate, assisting her to the bathroom is appropriate to allow for normal voiding. A catheter should not still be in place unless indicated.
A postpartum cesarean patient comes into the rural health clinic at 1 week postdelivery for an incision check by the nurse. The vital signs reveal a temperature of 100.5°F, and the patient reports moderate foul-smelling lochia. The nurse determines that the skin incision is healing normally, but when palpating the uterus, she discovers the patient to have uterine and pelvic tenderness. What are the most appropriate nursing actions?
- A. Explain to the patient that she may have an infection of her uterus, and blood will need to be drawn to determine if this is the cause of her pain and excess bleeding.
- B. Explain that the client should rest more to help the bleeding slow and that she should return to the clinic if she isn’t feeling better in a few days.
- C. Explain to the patient that she is experiencing normal postoperative pain and bleeding and to come back for her scheduled 6-week postpartum checkup.
- D. Explain to the patient that the incision appears to be healing nicely. Have her take Tylenol for the elevated temperature and continue with the ordered pain medication until her next visit.
Correct Answer: D
Rationale: The foul-smelling lochia, fever, and uterine tenderness point toward a uterine infection, requiring further investigation.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.
A client G2 P1102 is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client 's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform?
- A. Assess her feet and ankles for pitting edema.
- B. Lower both of her legs at the same time.
- C. Advise the client to stop feeding her baby while her blood pressure is assessed.
- D. Measure the length of the episiotomy and document the findings in the chart.
Correct Answer: A
Rationale: The nurse should assess for signs of deep vein thrombosis (DVT) or pitting edema in the postpartum period, especially after stirrup use during delivery.
The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management?
- A. Application of hot packs to the perineal area
- B. Information applicable to medication therapy
- C. Instructions to improve circulation by ambulating
- D. Medicating for pain above level 4 on a 0 to 10 scale
Correct Answer: B
Rationale: The nurse will need to provide applicable discharge teaching for both antibiotic and analgesic therapy. Antibiotics need to be taken as ordered and until they are gone.