Nokea
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days postdelivery. What should the nurse do in response to these results?
- A. Document the laboratory report findings
- B. Assess the client for increased lochia
- C. Assess the client’s temperature orally
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution. Assessing the client’s lochia is unnecessary with these results. Assessing the client’s temperature is unnecessary with these results. Notifying the HCP is unnecessary with these results.
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Which item should the client include in her hospital bag?
- A. Comfortable loose clothing
- B. High-heeled shoes
- C. Heavy perfumes
- D. Large meals
Correct Answer: A
Rationale: Comfortable loose clothing is practical for labor and postpartum, ensuring ease and comfort.
The nurse assesses the 34-week pregnant client (G2P1). Place the assessment findings in the sequence that they should be addressed by the nurse from the most significant to the least significant.
- A. Pedal edema at +3
- B. BP 144/94 mm Hg
- C. Positive group beta streptococcus vaginal culture
- D. Fundal height increase of 4.5 cm in 1 week
Correct Answer: B,D,A,C
Rationale: BP 144/94 mm Hg warrants immediate evaluation. It could indicate preeclampsia, a condition that can progress to serious complications. Fundal height increase of 4.5 cm in 1 week is abnormal and requires further follow-up. Normal fundal height increase is 1 to 2 cm per week. An increase in fundal size can be related to gestational diabetes, large-for-gestational-age fetus, fetal anomalies, or polyhydramnios. Pedal edema at +3 may be a normal physiological process if it is an isolated finding. Pedal edema warrants further assessment because it can be a symptom of preeclampsia. Positive group beta streptococcus vaginal culture warrants antibiotic treatment in labor but does not warrant intervention during the pregnancy.
Before hospitalization, an adolescent client had decided to give up her newborn for adoption. The client had an uncomplicated vaginal delivery and is still committed to her decision. Which intervention should the nurse exclude?
- A. Offer to the client a transfer to a different unit within the hospital.
- B. Talk to the client about having possible feelings of ambivalence.
- C. Initiate a case management or social work consult for the client.
- D. Notify her family to ensure that support is available upon her discharge.
Correct Answer: D
Rationale: Offering to transfer the client is appropriate and would not be excluded. The postpartum unit may be filled with sounds and sights that may distress the client. It would be appropriate for the nurse to discuss possible ambivalence with the client, as she may have increased feelings of attachment, love, and grief after delivery. Having those feelings does not necessarily mean that the client has made the wrong decision. Initiating a case management or social work consult is appropriate and would not be excluded. The client may not have support systems available because she may not have disclosed her pregnancy to others. The adolescent may not have disclosed the pregnancy to family. Although it would be appropriate for the nurse to explore the client’s support system with the client, the nurse should not contact the client’s family.
When up to the bathroom for the first time after a vaginal delivery, the client states, “A friend told me that I’m going to have trouble with urinary incontinence now that I have had a baby.” Which is the best response by the nurse?
- A. “That’s not true. You won’t need to worry about this until menopause.”
- B. “I will teach you how to do Kegel exercises to strengthen your muscles.”
- C. “Wearing a pad similar to a sanitary pad will help contain the incontinence.”
- D. “If this occurs, notify your HCP to have surgery to correct urinary incontinence.”
Correct Answer: B
Rationale: Women of any life stage can experience urinary incontinence. Kegel exercises strengthen muscles surrounding the vagina and urinary meatus, preventing urinary incontinence for many women. To perform Kegel exercise, contract the muscles around the vagina and hold for 10 seconds, then rest for 10 seconds. This should be repeated 30 or more times each day. The nurse should educate the client about ways in which to prevent urinary incontinence, not just offer information about how to manage the condition if it should occur. Surgical repair only occurs in the most extreme circumstances, after less invasive interventions have been unsuccessful.
The client at 31 weeks’ gestation is diagnosed with mild preeclampsia and placed on home management. What information should the nurse include when providing home management instructions? Select all that apply.
- A. “Plan for hospitalization when nearing 36 weeks’ gestation.”
- B. “Weigh daily and inform the HCP of a sudden increase in weight.”
- C. “Home care will be consulted to take your blood pressure (BP) daily.”
- D. “Perform stretching and range-of-motion exercises twice daily.”
- E. “Rest as much as possible, especially in the lateral recumbent position.”
Correct Answer: B,D,E
Rationale: A sudden weight gain could indicate that the mild preeclampsia is uncontrolled and the client is retaining fluid. The HCP should be consulted. Stretching and ROM exercises can help prevent thrombophlebitis and venous stasis. The lateral recumbent position improves uteroplacental blood flow, reduces maternal BP, and promotes diuresis. A diagnosis of mild preeclampsia does not require hospitalization during the antepartum period unless home management fails to reduce the client’s BP, or other complications occur. BP monitoring every 4 to 6 hours is recommended for the client with mild preeclampsia, but the BP can be taken by the client and does not require a consult with home care.