Nokea
How does the nurse most likely feel and react to this finding?
- A. Concerned and reports a probable cervical laceration
- B. Attentive and massages the uterus to expel retained clots
- C. Distressed and reports a possible clotting disorder
- D. Satisfied with the normal early postpartum finding
Correct Answer: A
Rationale: The bright trickle of blood with a firm uterus suggests a cervical laceration.
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Where does the patient report that the pain is felt?
- A. Groin
- B. Achilles tendon
- C. Top of the foot
- D. Calf of the leg
Correct Answer: D
Rationale: A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans' sign, suggestive of deep vein thrombosis.
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.
A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
- A. Provision of IV fluids
- B. Placement of an indwelling Foley catheter
- C. Assessment of oxygen saturation
- D. Administration of anticoagulants
- E. Blood transfusion
Correct Answer: A,B,C,E
Rationale: Management of hypovolemic shock includes stopping blood loss, giving IV fluids, placing a Foley catheter, assessing oxygen saturation, and giving blood transfusions. Anticoagulants are not used.
What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions?
- A. I will apply cold compresses to the painful areas.'
- B. I will take a warm shower before nursing the baby.'
- C. I will nurse first on the affected side.'
- D. I will empty the affected breast every 8 hours.'
Correct Answer: B
Rationale: Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
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.