Nokea
Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate?
- A. Provide the woman with warm blankets.
- B. Put the woman in the Trendelenburg position.
- C. Notify the primary health care provider.
- D. Increase the intravenous infusion.
Correct Answer: A
Rationale: Shaking or chills immediately after delivery is common due to the drop in body temperature. Providing warm blankets helps alleviate this discomfort.
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What nursing intervention does the nurse include in the plan of care for a person with mastitis?
- A. Provide antipyretic.
- B. Stop antibiotics when redness is resolved.
- C. Encourage the person to stop breast-feeding.
- D. Start an IV and prepare for signs of sepsis.
Correct Answer: A
Rationale: Antipyretics help manage the symptoms of mastitis.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
- A. Apply antibiotic ointment to the perineum daily.
- B. Change the peripad at each voiding.
- C. Void at least every two hours.
- D. Spray the perineum with povidone-iodine after toileting.
Correct Answer: B
Rationale: Changing peripads frequently helps prevent the growth of bacteria and reduces the risk of infection.
On admission to the labor and delivery unit, a client 's hemoglobin (Hgb) was assessed at 11.0 g/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery?
- A. Hgb 12.5 g/dL; Hct 37%.
- B. Hgb 11.0 g/dL; Hct 33%.
- C. Hgb 10.5 g/dL; Hct 31%.
- D. Hgb 9.0 g/dL; Hct 27%.
Correct Answer: C
Rationale: Postpartum blood loss can lead to a decrease in Hgb and Hct. A decrease to 10.5 g/dL for hemoglobin and 31% for hematocrit is expected due to normal blood loss during delivery.
Which medications are used to manage PPH? (Select all that apply.)
- A. Oxytocin
- B. Methergine
- C. Terbutaline
- D. Hemabate
Correct Answer: A
Rationale: The correct answer is A: Oxytocin. Oxytocin is the first-line medication for managing postpartum hemorrhage (PPH) as it helps in the contraction of the uterus to control bleeding. Methergine (B) is used for uterine atony but is not the first-line choice. Terbutaline (C) is a tocolytic agent and not indicated for PPH. Hemabate (D) is used as a second-line medication for PPH after oxytocin.