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A postpartum patient comes to the clinic for her 6-week postpartum checkup. When assessing the patient's cervix, how should the nurse expect the cervix to appear?
- A. Noticeable small lacerations
- B. Approximately 3 cm dilated
- C. Symmetrically round external os
- D. Firm and thick
Correct Answer: C
Rationale: The correct answer is C: Symmetrically round external os. At 6 weeks postpartum, the cervix should have healed and returned to its pre-pregnancy state. The external os should appear symmetrically round, indicating proper healing and involution. A: Noticeable small lacerations would indicate incomplete healing. B: Approximately 3 cm dilated is not expected in a postpartum patient. D: Firm and thick would not be typical findings at 6 weeks postpartum.
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The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is crucial because it can be life-threatening and requires immediate medical attention. Secondary hemorrhage is excessive bleeding that occurs after the first 24 hours postpartum. It is important for the nurse to educate the patient on recognizing the signs such as increased bleeding, lightheadedness, dizziness, and low blood pressure. Choices A, C, and D are important topics for patient education but do not pose the same level of urgency and immediate risk as secondary hemorrhage.
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.
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.
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.