Nokea
A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse 's best response?
- A. I know that it hurts but it is very important for you to cough.
- B. Let me check your lung fields to see if coughing is really necessary.
- C. If you take a few deep breaths in, that should be as good as coughing.
- D. If you support your incision with a pillow, coughing should hurt less.
Correct Answer: D
Rationale: Supporting the incision with a pillow while coughing reduces the strain on the surgical site, making it less painful.
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What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony?
- A. Establishing venous access
- B. Performing fundal massage
- C. Preparing the woman for surgical intervention
- D. Catheterizing the bladder
Correct Answer: B
Rationale: The correct answer is B: Performing fundal massage. Fundal massage helps to stimulate contractions of the uterus, which can help control bleeding in cases of uterine atony. This is a primary nursing responsibility to address the immediate cause of the hemorrhage. Establishing venous access (choice A) is important but not the primary responsibility in this situation. Preparing for surgical intervention (choice C) may be necessary if conservative measures fail, but it is not the initial step. Catheterizing the bladder (choice D) is not directly related to managing obstetric hemorrhage associated with uterine atony.
Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate?
- A. PPH is easy to recognize early; after all, the woman is bleeding.
- B. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH.
- C. If anything, nurses and physicians tend to overestimate the amount of blood loss.
- D. Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.
Correct Answer: B
Rationale: The correct answer is B because it accurately defines the criteria for postpartum hemorrhage (PPH). PPH is traditionally defined as losing more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth. This definition helps healthcare providers recognize and manage PPH effectively.
Now, let's analyze why the other choices are incorrect:
A: This statement is incorrect because PPH may not always be easy to recognize early based solely on visible bleeding. Other signs and symptoms, such as tachycardia and hypotension, also play a crucial role in identifying PPH.
C: This statement is incorrect because underestimating, rather than overestimating, the amount of blood loss in PPH can lead to delayed intervention and potentially worsen the patient's condition.
D: This statement is incorrect because PPH is not classified based on timing (early or late PPH), but rather on the amount of blood loss as defined in choice B.
A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks?
- A. Skim milk.
- B. Ginger ale.
- C. Orange juice.
- D. Chamomile tea.
Correct Answer: C
Rationale: Iron absorption is enhanced by vitamin C, and orange juice is rich in vitamin C, making it an appropriate drink to take with the supplement.
A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse 's first action should be to:
- A. Determine whether the bleeding slows to normal or remains as a large volume.
- B. Observe vital signs for signs of hypovolemic shock.
- C. Check to see what her previous lochia flow has been.
- D. Identify the type of pain relief that was given when she was in labor.
Correct Answer: A
Rationale: The nurse should first determine whether the bleeding slows or continues to be excessive, as it may be a normal occurrence post-ambulation or indicative of a complication.
A 2-day-postpartum breastfeeding woman states, 'I am sick of being fat. When can I go on a diet? ' Which of the following responses is appropriate?
- A. It is fine for you to start dieting right now as long as you drink plenty of milk. '
- B. Your breast milk will be low in vitamins if you start to diet while breastfeeding. '
- C. You must eat at least 3,000 calories per day in order to produce enough milk for your baby. '
- D. Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day. '
Correct Answer: D
Rationale: Breastfeeding can help with postpartum weight loss, as the body burns calories producing milk.