Nokea
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 the external os should appear symmetrically round. This indicates proper healing and restoration of the cervix to its pre-pregnancy state. Small lacerations (choice A) would not be expected at this point as healing should have occurred. A dilation of 3 cm (choice B) is not appropriate as the cervix should be closed postpartum. A firm and thick cervix (choice D) would not be expected as the cervix should have softened and returned to its normal consistency by this time.
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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 because attending hospital classes on newborn and infant care involves intentional learning by actively seeking out information and skills related to parenting. The couple is proactively engaging in a structured learning environment to acquire knowledge and techniques essential for parenting.
A: Observing other individuals who are parents may provide some insight, but it is more passive and not as structured as intentional learning.
C: Discussing how they were parented is reflective, but it does not necessarily involve seeking out new information or skills actively.
D: Watching media containing parenting roles can provide some information passively, but it may not be as reliable or comprehensive as attending formal classes.
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 goal because monitoring lochia flow post-vaginal delivery helps assess for excessive bleeding, which is crucial for preventing postpartum hemorrhage. Choice A is not a priority in the immediate postpartum period. Choice B is important but not as critical as monitoring lochia flow. Choice D is also important for preventing complications but not as urgent as assessing for postpartum bleeding.
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 reduces swelling and provides comfort to the perineal tear.
2. Ice packs help to decrease pain and promote healing in the perineal area.
3. Ice packs are a non-invasive and non-pharmacological method of pain relief.
4. Ice packs can be safely used without interfering with the wound healing process.
Summary of Incorrect Choices:
A: Assessing vital signs every 4 hours is important but not specific to managing perineal tear pain.
B: Keeping the patient NPO is not necessary for perineal tear management unless indicated for other reasons.
C: Catheterization prior to ambulation is not directly related to perineal tear care and may not be necessary during the fourth stage of labor.
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 are specifically designed to strengthen the pelvic floor muscles, which can help improve bladder control and support the pelvic organs postpartum. Ambulating and aerobics classes focus on overall body movement but not specifically on pelvic muscle strengthening. Passive range-of-motion exercises are beneficial for joint flexibility but do not target the pelvic muscles directly. Therefore, instructing the postpartum woman to perform Kegel exercises is the most appropriate recommendation to address her specific needs for pelvic muscle strengthening.
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 the most important teaching because postpartum hemorrhage can be life-threatening and requires immediate medical attention. The other choices, while important, are not as urgent as secondary hemorrhage. A: Uterine infection signs and symptoms can develop gradually and usually do not pose an immediate threat. C: Postpartum depression is a serious concern but does not require immediate medical intervention. D: A boggy uterus can be a sign of uterine atony but does not necessarily indicate an emergency situation like secondary hemorrhage.