Nokea
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.
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The nurse and provider estimate the blood loss at delivery to be 400 mL in the measuring drape; now when doing the initial perineal care, the nurse finds a large amount of blood underneath the patient. What action reflects safe and accurate nursing care?
- A. Estimate the amount of blood loss from the sheet and client clothing, and notify the physician.
- B. Encourage the mother to report any additional bleeding or clots.
- C. Draw the ordered hematocrit and notify the provider if the result is less than 28.
- D. Weigh the blood-soaked linens and notify the provider of the additional blood loss.
Correct Answer: D
Rationale: The correct answer is D. Weighing the blood-soaked linens provides an accurate measurement of the additional blood loss, which is crucial for assessing the patient's condition accurately. Here's the rationale step-by-step:
1. Weighing the blood-soaked linens is an objective and precise method to quantify the additional blood loss.
2. This measurement helps to determine the total blood loss accurately, which is essential for assessing postpartum hemorrhage.
3. Providing this quantitative data to the provider enables them to make informed decisions about further interventions.
4. Estimating blood loss visually is subjective and can be inaccurate, leading to potential underestimation or overestimation.
5. Drawing hematocrit levels (choice C) may provide valuable information but does not directly address the immediate need to quantify the additional blood loss.
6. Encouraging the mother to report bleeding (choice B) is important for ongoing assessment but does not provide an objective measurement of the blood loss.
In summary
The nurse is developing a plan of care for the postpartum client during the 'taking in ' phase. Which of the following should the nurse include in the plan?
- A. Teach baby-care skills like diapering.
- B. Discuss the labor and birth with the mother.
- C. Discuss contraceptive choices with the mother.
- D. Teach breastfeeding skills like pumping.
Correct Answer: B
Rationale: During the 'taking in' phase, the mother is focused on her own recovery and reliving the birth experience. Discussing the labor and birth is appropriate at this time.
When referring to the 4 T’s of PPH, what does tissue refer to?
- A. Placental tissue or membranes are retained.
- B. Tissue of the perineum is torn.
- C. Tissue of the uterus is torn.
- D. Tissue is not perfused.
Correct Answer: A
Rationale: The correct answer is A because in the context of Postpartum Hemorrhage (PPH), the 4 T’s stand for Tone, Trauma, Tissue, and Thrombin. Tissue refers to placental tissue or membranes being retained, leading to excessive bleeding. This can be a common cause of PPH.
Option B is incorrect because it refers to perineal tears, which are related to trauma and not specifically related to tissue retention causing PPH. Option C is incorrect as it refers to uterine tissue tears, which is more related to trauma rather than retained tissue. Option D is incorrect because it refers to tissue not being perfused, which is not directly related to the concept of tissue retention causing PPH.
The nurse educates the person recovering from a cesarean birth on how to care for the incision. What education is discussed?
- A. Scrub the incision well twice daily.
- B. Remove the dressing the day after birth.
- C. Staples will be removed the day after birth.
- D. Vertical incisions heal faster with less pain.
Correct Answer: A
Rationale: The correct answer is A: Scrub the incision well twice daily. This is the correct answer because it emphasizes proper hygiene to prevent infection without causing harm to the incision site. Cleaning the incision twice daily helps to keep it clean and reduce the risk of infection.
B: Removing the dressing the day after birth is incorrect as it may disrupt the healing process and increase the risk of infection.
C: Staples being removed the day after birth is incorrect because staple removal timing varies depending on individual healing progress and is typically done by a healthcare provider.
D: Vertical incisions healing faster with less pain is incorrect as healing time and pain tolerance vary among individuals and are not solely determined by the incision type.
What is characteristic of an early (primary) PPH?
- A. occurs after 12 weeks postpartum
- B. is not an emergency
- C. often occurs due to uterine atony
- D. is diagnosed after the person is discharged
Correct Answer: C
Rationale: Early PPH is typically caused by uterine atony.