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A post -cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, 'I have decided to make sure that I feel as little pain from this experience as possible. ' Which of the following should the nurse conclude in relation to this woman 's behavior?
- A. The woman needs a stronger narcotic order.
- B. The woman is high risk for severe constipation.
- C. The woman 's breast milk volume may drop while taking the medicine.
- D. The woman 's newborn may become addicted to the medication.
Correct Answer: C
Rationale: Frequent use of narcotic analgesics can affect breast milk production, potentially causing a decrease in supply.
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Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: Lack of attachment is often seen when the postpartum person is disinterested or avoids physical contact such as holding the newborn.
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
- A. Moderate serosanguinous drainage.
- B. Well-approximated edges.
- C. Ecchymotic area distal to the episiotomy.
- D. An area of redness adjacent to the incision.
Correct Answer: B
Rationale: A well-approximated episiotomy will have edges that are aligned and close together, indicating proper healing.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: A pale appearance with delayed capillary refill is indicative of shock and may require rapid intervention.
The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider?
- A. White blood cells, 12,500 cells/mm3.
- B. Red blood cells, 4,500,000 cells/mm3.
- C. Hematocrit, 26%.
- D. Hemoglobin, 11 g/dL
Correct Answer: C
Rationale: A hematocrit of 26% indicates possible anemia, and it should be reported to the healthcare provider for further evaluation.
What important assessment should the nurse perform on all postpartum persons?
- A. Screen for PPD with the EPDS.
- B. Screen for drug use with a urine drug screen.
- C. Screen for breast-feeding failure.
- D. Screen for contraception contraindications.
Correct Answer: A
Rationale: The correct answer is A because screening for Postpartum Depression (PPD) with the Edinburgh Postnatal Depression Scale (EPDS) is crucial for the well-being of postpartum individuals. PPD is a common and serious condition that can affect the mother's mental health and bonding with the baby. Early detection and intervention are key to ensuring proper support and treatment.
Choice B, screening for drug use, is not a routine assessment for all postpartum persons unless there are specific risk factors present. Choice C, screening for breast-feeding failure, is important but not the most critical assessment to perform on all postpartum individuals. Choice D, screening for contraception contraindications, is important for family planning but is not as immediate or essential as screening for PPD.