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A woman who is 18 hours postpartum says she is having 'hot flashes ' and 'sweats all the time. ' The appropriate nursing response is to:
- A. Report her signs and symptoms of hypovolemic shock.
- B. Tell her that her body is getting rid of unneeded fluid.
- C. Notify her nurse-midwife that she may have an infection.
- D. Limit her intake of caffeine-containing fluids.
Correct Answer: B
Rationale: Hot flashes and sweating are common during the postpartum period as the body gets rid of excess fluids. It is not an indicator of hypovolemic shock or infection.
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Which of the following is the priority nursing action during the immediate postpartum period?
- A. Palpate fundus.
- B. Check pain level.
- C. Perform pericare.
- D. Assess breasts.
Correct Answer: A
Rationale: Palpating the fundus is the priority to assess for uterine involution and prevent postpartum hemorrhage.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Respecting the patient's cultural preferences and providing support within nursing capabilities is important in providing individualized care.
The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time?
- A. Estrogen.
- B. Prolactin.
- C. Human placental lactogen.
- D. Human chorionic gonadotropin.
Correct Answer: B
Rationale: After delivery, prolactin levels rise to stimulate milk production, even if the mother has decided to bottle feed. Estrogen and other hormones also fluctuate, but prolactin will be the most significant in this case.
The nurse is developing a plan of care for the postpartum client during the 'taking hold ' phase. Which of the following should the nurse include in the plan?
- A. Provide the client with a nutritious meal.
- B. Encourage the client to take a nap.
- C. Assist the client with activities of daily living.
- D. Assure the client that she is an excellent mother.
Correct Answer: C
Rationale: During the 'taking hold' phase, the mother is more focused on newborn care and regaining control. Assisting with daily activities supports her autonomy.
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.