Nokea
During the immediate postpartum period the mother has a temperature of 100.2°F (37.8°C) pulse 52 respirations 18 BP 138/84. What should the nurse do?
- A. Report the temperature as abnormal.
- B. Continue to monitor every 15 minutes.
- C. Report the pulse as abnormal.
- D. Nothing as the vital signs are normal.
Correct Answer: D
Rationale: The vital signs are normal for a new postpartum patient.
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Within the first hour following a vaginal delivery the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurse's reaction to the assessment?
- A. This is a normal occurrence.
- B. This is abnormal and should be reported.
- C. The patient should be administered a blood thinner.
- D. The patient should be restricted to bed rest.
Correct Answer: A
Rationale: A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given.
What is the appropriate way to assess the fundus of the postpartum patient?
- A. Using the side of one hand moving down from the umbilicus
- B. Using one hand over the lower segment of the uterus
- C. Using one hand pushing upward from the lower uterus
- D. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
Correct Answer: D
Rationale: The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
After delivery of a 9-lb baby the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ___-degree laceration.
Correct Answer: second
Rationale: A second-degree laceration extends through the superficial tissues into the muscles of the perineum.
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
- A. Fatigue from labor
- B. Normal "taking in" response
- C. Abnormal "taking in" response
- D. Risk for altered maternal-infant bonding
Correct Answer: B
Rationale: Her primary focus will be on her own needs such as sleep ("taking in" stage).
A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother?
- A. Prewarm the crib sheets with a hot water bottle
- B. Swaddle the newborn tightly in a receiving blanket
- C. Place the baby in a larger crib or infant bed
- D. Offer a pacifier or allow the infant to suckle at the breast
- E. Take the infant for a ride in the car
Correct Answer: A,B,D,E
Rationale: Oftentimes, infants are comforted by warm sheets. Infants tend to like to be swaddled snugly. Many infants find comfort sucking a pacifier; breast-fed infants can suckle at the breast. Car rides are often soothing for infants. A large sleeping space is not soothing for infants. The opposite is true. A small sleeping space, such as a bassinette, tends to comfort a fussy baby.