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A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D because general soreness is not a typical source of pain that postpartum patients experience. Uterine contractions, perineal trauma, and breast engorgement are common sources of pain in postpartum patients due to the physiological changes and processes associated with childbirth. General soreness is too vague and nonspecific to specifically assess for in this context. It is important for the nurse to focus on assessing and managing the more common sources of postpartum pain to provide effective care and support for the patient's recovery.
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The nurse is educating a new postpartum woman about peri-care. Which action by the client indicates understanding?
- A. The woman applied her peri-pad from back to front.
- B. The woman performed peri-care three times a day.
- C. The woman washed her hands before and after performing peri-care.
- D. The woman mixed tap water and hydrogen peroxide in her peri-bottle.
Correct Answer: C
Rationale: The correct answer is C because washing hands before and after peri-care is crucial to prevent the spread of infection. Before performing peri-care, clean hands reduce the risk of introducing harmful bacteria to the perineal area. After peri-care, hand hygiene prevents potential contamination from the perineum to other body parts or surfaces.
Explanation of why other choices are incorrect:
A: Applying the peri-pad from back to front can introduce bacteria from the rectal area to the urethra, increasing the risk of urinary tract infections.
B: While performing peri-care multiple times a day is important, it is not the best indicator of understanding peri-care principles.
D: Mixing tap water and hydrogen peroxide in the peri-bottle may be harmful and is not a standard practice for peri-care.
The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding/attachment. Which situations does the nurse NOT recognize as a cause for bonding/attachment problems?
- A. The mother experienced eclampsia in the third trimester of pregnancy.
- B. The neonate is being treated for meconium aspiration syndrome.
- C. The mother experienced dystocia in the second phase of labor.
- D. The father of the neonate is in the military and not yet home on leave.
Correct Answer: D
Rationale: The correct answer is D because the father being in the military and not yet home on leave does not directly impact bonding/attachment between the parents and the neonate. Bonding issues are typically related to factors such as maternal health conditions (choice A), neonatal health complications (choice B), or labor complications experienced by the mother (choice C). In contrast, the father's absence due to military service, while potentially challenging emotionally, does not inherently cause bonding/attachment problems as the mother and baby can still form a strong attachment bond. Choices A, B, and C are incorrect as they can directly affect the bonding/attachment process due to physical health issues of the mother and baby during pregnancy and labor.
The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?
- A. To prevent uterine prolapse.
- B. To prevent uterine movement
- C. To prevent uterine hemorrhage
- D. To prevent uterine inversion
Correct Answer: D
Rationale: The correct answer is D: To prevent uterine inversion. Placing a hand just above the symphysis pubis helps support the uterus and prevent it from turning inside out. This is crucial postpartum to avoid complications such as hemorrhage and shock. Choices A, B, and C are incorrect as palpating the uterus in this manner is specifically aimed at preventing uterine inversion, not prolapse, movement, or hemorrhage.
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B. A postpartum WBC level of 30,000/mm is expected due to the physiological response to labor and delivery, known as leukocytosis. This is a normal finding as the body increases white blood cell production to fight off potential infections postpartum.
A: Patient feeling cold related to blood loss is more indicative of hypovolemia, a result of excessive blood loss, not a normal cardiovascular response postpartum.
C: Risk for hemorrhage due to decrease in clotting factors is incorrect as postpartum women actually have an increase in circulating clotting factors to prevent excessive bleeding.
D: A normal postpartum hemoglobin level of less than 11 g/dL is incorrect because a hemoglobin level below 11 g/dL would indicate anemia, not a normal postpartum finding.
A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D: General soreness. Postpartum pain assessment typically focuses on specific sources such as uterine contractions, perineal trauma, and breast engorgement. General soreness is too vague and does not provide specific information for targeted intervention. By ruling out general soreness, the nurse can prioritize assessment and management of more specific sources of pain to provide appropriate care for the postpartum patient.