Nokea
A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
- A. Provision of IV fluids
- B. Placement of an indwelling Foley catheter
- C. Assessment of oxygen saturation
- D. Administration of anticoagulants
- E. Blood transfusion
Correct Answer: A,B,C,E
Rationale: Management of hypovolemic shock includes stopping blood loss, giving IV fluids, placing a Foley catheter, assessing oxygen saturation, and giving blood transfusions. Anticoagulants are not used.
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What nursing action is the most appropriate to prevent thrombus formation?
- A. Have the woman sit in a chair for meals.
- B. Monitor vital signs every 4 hours and report any changes.
- C. Tell the woman to remain in bed with her legs elevated.
- D. Assist the woman with ambulation for short periods of time.
Correct Answer: D
Rationale: Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.
What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
- A. Teach the patient how to massage the abdomen and then get help.
- B. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
- C. Begin massaging the fundus while another person notifies the physician.
- D. Ask the patient to void and reassess fundal tone and location.
Correct Answer: C
Rationale: When the uterus is boggy, the nurse should immediately massage it until it becomes firm.
The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of __ mL.
Correct Answer: 15
Rationale: The weight of 1 g in a perineal pad is equal to 1 mL of blood loss.
Which statement indicates to the nurse that the patient understands the signs of late postpartum hemorrhage?
- A. My discharge would change to red after it has been pink or white.'
- B. If I have a postpartum hemorrhage, I will have severe abdominal pain.'
- C. I should be alert for an increase in bright red blood.'
- D. I would pass a large clot that was retained from the placenta.'
Correct Answer: A
Rationale: A return to red bleeding after lochia has changed to pink or white may indicate a late postpartum hemorrhage.
What is the best response to a postpartum woman who tells the nurse she feels 'tired and sick all of the time since I had the baby 3 months ago'?
- A. This is a normal response for the body after pregnancy. Try to get more rest.'
- B. I'll bet you will snap out of this funk real soon.'
- C. Why don't you arrange for a babysitter so you and your husband can have a night out?'
- D. Let's talk about this further. I am concerned about how you are feeling.'
Correct Answer: D
Rationale: If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.