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A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because 'I am so tired right now. I just want to have something to eat and take a nap. ' Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following?
- A. Social deprivation.
- B. Child neglect.
- C. Normal postpartum behavior.
- D. Postpartum depression.
Correct Answer: C
Rationale: Requesting rest after feeding is typical postpartum behavior and does not indicate neglect or depression.
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A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, 'I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest. ' Which of the following actions should the nurse take at this time?
- A. Encourage the woman exclusively to breastfeed her baby.
- B. Have the woman massage her breasts hourly.
- C. Obtain an order to culture her expressed breast milk.
- D. Take the temperature and pulse rate of the woman.
Correct Answer: A
Rationale: Breastfeeding exclusively can help relieve engorgement, and frequent feedings prevent further complications.
What is the term for the separation found in the midline of the abdomen after birth?
- A. uterine subinvolution
- B. umbilical hernia
- C. striae
- D. diastasis recti abdominus
Correct Answer: D
Rationale: Diastasis recti abdominus refers to the separation of the rectus muscles along the midline of the abdomen after birth.
The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management?
- A. Application of hot packs to the perineal area
- B. Information applicable to medication therapy
- C. Instructions to improve circulation by ambulating
- D. Medicating for pain above level 4 on a 0 to 10 scale
Correct Answer: B
Rationale: The correct answer is B: Information applicable to medication therapy. The rationale is that proper pain management is crucial for patient comfort and healing. The nurse should educate the patient on the importance of taking the prescribed pain medication as directed to manage pain effectively. This includes information on dosage, frequency, and potential side effects. Hot packs (Choice A) may not be recommended for an infected episiotomy as heat can exacerbate the infection. Ambulation (Choice C) is important for circulation, but it may not directly address pain management. Medicating for pain above level 4 (Choice D) is vague and does not provide specific guidance on when to take pain medication.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
- A. assessment of partner changing a diaper
- B. assessment of vaginal bleeding
- C. assessment of social support
- D. assessment of family dynamics
Correct Answer: B
Rationale: Monitoring vaginal bleeding in the first 8 hours postpartum helps detect any potential complications such as postpartum hemorrhage.