Nokea
A young mother is excited about her first baby. Choose the best teaching to help her obtain adequate rest after discharge.
- A. Plan to sleep or rest any time the infant sleeps.
- B. Do all housecleaning while the infant sleeps.
- C. Cook several meals at once and freeze for later use.
- D. Tell family and friends not to visit for the first month.
Correct Answer: A
Rationale: Encouraging the mother to rest when the baby sleeps is the best way to ensure adequate rest.
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A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with 'latch on ' and recommends that the mother do which of the following?
- A. Use a nipple shield at each breastfeeding.
- B. Cleanse the nipples with soap 3 times a day.
- C. Rotate the baby 's positions at each feed.
- D. Bottle feed for 2 days then resume breastfeeding.
Correct Answer: C
Rationale: Rotating positions during breastfeeding helps to prevent sore spots and promotes proper latch.
A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion?
- A. The father may become sad and weepy.
- B. Postpartum blues last about a week or two.
- C. Medications are available to relieve the symptoms.
- D. Very few women experience postpartum blues.
Correct Answer: B
Rationale: Postpartum blues are common and typically last 1-2 weeks. Medications are usually not needed unless symptoms persist or worsen.
The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states 'I don 't use those. I always use tampons. ' Which of the following actions by the nurse is appropriate at this time?
- A. Remove the peripad and insert a tampon into the woman 's vagina.
- B. Advise the client that for the first two days she will be bleeding too heavily for a tampon.
- C. State that it is unsafe to place anything into the vagina until involution is complete.
- D. Remind the client that a tampon would hurt until the soreness from the delivery resolves.
Correct Answer: B
Rationale: The nurse should explain that for the first two days after delivery, the bleeding is too heavy to use tampons, and this could increase the risk of infection.
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
- A. Moderate serosanguinous drainage.
- B. Well-approximated edges.
- C. Ecchymotic area distal to the episiotomy.
- D. An area of redness adjacent to the incision.
Correct Answer: B
Rationale: A well-approximated episiotomy will have edges that are aligned and close together, indicating proper healing.
The nurse is caring for a woman who is 6 hours postpartum after a vaginal delivery. She has a history of labial varicose veins and is reporting perineal pain of 8 on a 10-point scale. What interventions should the nurse include in the plan of care?
- A. Provide the patient with an inflatable donut ring to sit on and administer her oral pain medication.
- B. Explain that this is normal after a vaginal delivery and assist her to a side-lying position.
- C. Assess the perineum for a hematoma or inflamed varicosities, and administer oral pain medication.
- D. Administer oral stool softeners and encourage fluids.
Correct Answer: C
Rationale: The correct answer is C because it addresses the patient's specific issue of perineal pain related to her history of labial varicose veins. By assessing the perineum for a hematoma or inflamed varicosities, the nurse can identify the cause of the pain and provide appropriate treatment. Administering oral pain medication targets the source of discomfort.
Choice A is incorrect because providing an inflatable donut ring may offer temporary relief but does not address the underlying cause of the pain. Administering oral pain medication alone may not be sufficient without assessing the perineum.
Choice B is incorrect because dismissing the patient's pain as normal without further assessment can lead to overlooking potential complications. Assisting the patient to a side-lying position does not address the pain.
Choice D is incorrect because administering stool softeners and encouraging fluids may be beneficial for postpartum care but does not directly address the patient's perineal pain related to varicose veins.