Nokea
Based on this finding, what does the nurse explain the probable treatment will involve?
- A. Anticoagulants for 6 weeks
- B. Application of ice to the affected leg
- C. Gentle massage of the affected leg
- D. Passive leg exercises twice a day
Correct Answer: A
Rationale: Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism.
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Which statement indicates to the nurse that the patient understands the signs of late postpartum hemorrhage?
- A. My discharge would change to red after it has been pink or white.'
- B. If I have a postpartum hemorrhage, I will have severe abdominal pain.'
- C. I should be alert for an increase in bright red blood.'
- D. I would pass a large clot that was retained from the placenta.'
Correct Answer: A
Rationale: A return to red bleeding after lochia has changed to pink or white may indicate a late postpartum hemorrhage.
What action should the nurse implement?
- A. Notify the charge nurse of a possible infection.
- B. Prepare to put the patient in isolation.
- C. Have the infant removed from the room and returned to the nursery.
- D. Assess the patient further.
Correct Answer: D
Rationale: A white blood cell count of 20,000 to 30,000 cells/dL is normal in the early postpartum period, so the patient should be assessed further for other signs of infection.
What will the nurse teach a nursing mother to do to reduce the risk of mastitis?
- A. Limit fluid intake to 1 liter per day.
- B. Empty both breasts with each feeding.
- C. Take warm showers.
- D. Wear a supportive bra.
- E. Pump breasts to ensure emptying.
Correct Answer: B,C,D,E
Rationale: Nursing mothers should take in about 3 liters of fluid a day. Emptying both breasts, taking warm showers, wearing a supportive bra, and pumping breasts reduce the risk of mastitis.
The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it.What would the nurse expect to find on further assessment?
- A. A firm fundus the size of a grapefruit
- B. A full bladder
- C. Retained placental fragments
- D. Vital signs indicative of shock
- E. A soft, boggy fundus
Correct Answer: B,E
Rationale: Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.
What does the nurse suspect from these symptoms?
- A. Phlebitis
- B. Puerperal infection
- C. Late postpartum hemorrhage
- D. Mastitis
Correct Answer: A
Rationale: The complaints related to the leg, such as redness and pain, are indicative of phlebitis. The other signs are normal in the postpartum patient.