Nokea
A woman who is 3 hours postpartum has had difficulty in urinating. She finally urinates 100 mL. The initial nursing action is to:
- A. Insert an indwelling catheter.
- B. Have her drink additional fluids.
- C. Assess the height of her fundus.
- D. Chart the urination amount.
Correct Answer: C
Rationale: Before taking further action, the nurse should assess the height of the fundus to determine if a full bladder may be contributing to urinary retention.
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What assessment finding would indicate a fluid volume deficit?
- A. skin tenting with testing of skin turgor
- B. hypertension
- C. bradycardia
- D. bounding pulse
Correct Answer: A
Rationale: Skin tenting is a classic sign of dehydration and fluid volume deficit due to reduced skin turgor.
The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
- A. maladaptive parenting
- B. psychosis
- C. postpartum depression
- D. bipolar disorder
Correct Answer: C
Rationale: Risk factors such as those listed increase the likelihood of postpartum depression which affects a person's emotional and mental well-being.
What important assessment should the nurse perform on all postpartum persons?
- A. Screen for PPD with the EPDS.
- B. Screen for drug use with a urine drug screen.
- C. Screen for breast-feeding failure.
- D. Screen for contraception contraindications.
Correct Answer: A
Rationale: Screening for PPD is essential during postpartum care.
The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects?
- A. Headache.
- B. Nausea.
- C. Cramping.
- D. Fatigue.
Correct Answer: A
Rationale: Methergine is used to prevent postpartum hemorrhage, but it can cause side effects such as headache, nausea, and cramping. The nurse should inform the client about these possible side effects to promote informed decision-making.
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed?
- A. Disseminated intravascular coagulation (DIC); asking for laboratory tests
- B. von Willebrand disease (vWD); noting whether bleeding times have been extended
- C. Thrombophlebitis; using real-time and color Doppler ultrasound
- D. Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis
Correct Answer: C
Rationale: The correct answer is C: Thrombophlebitis; using real-time and color Doppler ultrasound. Thrombophlebitis is the inflammation of a vein with the formation of a blood clot. In this scenario, the woman's symptoms of pain, tenderness, warmth, redness, and an enlarged, hardened area in her leg are indicative of thrombophlebitis. Using real-time and color Doppler ultrasound will confirm the diagnosis by visualizing the blood clot in the affected vein. This diagnostic method is effective in detecting thrombosis and determining the extent of the clot, guiding appropriate treatment.
Incorrect choices:
A: Disseminated intravascular coagulation (DIC) is a systemic process causing widespread clotting in small blood vessels, leading to bleeding. Asking for laboratory tests wouldn't be the appropriate way to confirm thrombophlebitis.
B: von Willebrand disease (vWD) is a genetic bleeding disorder, and checking