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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.
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The nurse evaluates a postpartum couplet for parent-infant attachment. What finding would be concerning?
- A. The postpartum person is sleepy.
- B. Parents are both caring for the infant.
- C. The parent is disinterested in the infant.
- D. The family is involved.
Correct Answer: C
Rationale: A lack of interest or emotional engagement with the infant is a concerning sign that may indicate attachment issues.
Which classification of placental separation is not recognized as an abnormal adherence pattern?
- A. Placenta accreta
- B. Placenta increta
- C. Placenta percreta
- D. Placenta abruptio
Correct Answer: D
Rationale: Placenta abruptio, also known as abruptio placentae, is the premature separation of the placenta from the uterine wall before delivery. It is not classified as an abnormal adherence pattern like placenta accreta, increta, and percreta. Placenta accreta occurs when the placenta attaches too deeply into the uterine wall. Placenta increta is when the placenta invades the myometrium, and placenta percreta is when it penetrates through the myometrium and reaches the serosa. These abnormal adherence patterns are associated with risks and complications during pregnancy and delivery, while placenta abruptio is a separate condition related to premature placental separation.
When teaching the postpartum woman about peripads, the nurse should tell her that:
- A. She can change to tampons when the initial perineal soreness goes away.
- B. Pads having cold packs within them usually hold more lochia than regular pads.
- C. Blood-soaked pads must be returned in a plastic bag to the hospital after discharge.
- D. The pads should be applied and removed in a front to back direction.
Correct Answer: D
Rationale: The pads should be applied and removed in a front-to-back direction to reduce the risk of infection.
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine?
- A. The woman should not become pregnant for at least 4 weeks.
- B. The woman should pump and dump her breast milk for 1 week.
- C. Surgical masks must be worn by the mother when she holds the baby.
- D. Antibodies transported through the breast milk will protect the baby.
Correct Answer: A
Rationale: The rubella vaccine is a live vaccine, and it is contraindicated during pregnancy. Women should avoid pregnancy for at least 4 weeks after receiving the vaccine to ensure no risk to the developing fetus.
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.