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The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: 'All I do is go to the bathroom. ' Which of the following is an appropriate nursing response?
- A. Catheterize the client per doctor 's orders.
- B. Measure the client 's next voiding.
- C. Inform the client that polyuria is normal.
- D. Check the specific gravity of the next voiding.
Correct Answer: C
Rationale: Polyuria, or frequent urination, is a normal phenomenon during the postpartum period as the body expels excess fluid.
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Lacerations of the cervix, vagina, or perineum are also causes of PPH. Which factors influence the causes and incidence of obstetric lacerations of the lower genital tract? (Select all that apply.)
- A. Operative and precipitate births
- B. Adherent retained placenta
- C. Abnormal presentation of the fetus
- D. Congenital abnormalities of the maternal soft tissue
Correct Answer: A
Rationale: A. Operative and precipitate births: Obstetric lacerations of the lower genital tract are more likely to occur during operative deliveries (such as forceps or vacuum-assisted deliveries) and precipitate births (very rapid deliveries) due to the increased forces and speed involved during these types of deliveries.
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform?
- A. Intermittently apply ice packs to her axillae and breasts.
- B. Apply lanolin to her breasts and nipples every 3 hours.
- C. Express milk from the breasts every 3 hours.
- D. Ask the primary health care provider to order a milk suppressant.
Correct Answer: A
Rationale: Ice packs can help reduce inflammation and pain associated with engorgement in women who choose to bottle-feed.
Which of the following laboratory values would the nurse expect to see in a normal postpartum woman?
- A. Hematocrit, 39%.
- B. White blood cell count, 16,000 cells/mm3.
- C. Red blood cell count, 5 million cells/mm3.
- D. Hemoglobin, 15 grams/dL.
Correct Answer: B
Rationale: A slightly elevated white blood cell count is common postpartum due to the physiological stress of delivery and recovery.
The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus?
- A. Scant amount of odorless lochia
- B. Presence of headache, malaise, and chills
- C. Pain or discomfort in the midline lower abdomen
- D. Elevated temperature greater than 100.4°F (38°C)
Correct Answer: D
Rationale: The correct answer is D, an elevated temperature greater than 100.4°F. Endometritis, an infection of the uterine lining, commonly caused by beta-hemolytic streptococcus, often presents with a fever. This is a key sign of infection, indicating the presence of an inflammatory process. The other choices are incorrect because:
A: Scant amount of odorless lochia is indicative of normal postpartum discharge, not necessarily endometritis.
B: Headache, malaise, and chills are non-specific symptoms that could be present in various conditions, not specific to endometritis.
C: Pain or discomfort in the midline lower abdomen could be related to postpartum uterine contractions or other causes, but it is not a specific finding for endometritis.
The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient?
- A. Prescriptions for antidepressant/antipsychotic drugs
- B. Discharge to home with 24-hour observation in place
- C. Immediate hospitalization in a psychiatric unit
- D. Prescribed neonate visits during in-patient treatment
Correct Answer: C
Rationale: The nurse expects the health care provider to immediately hospitalize the patient in a psychiatric unit. Maintaining the patient in the postpartum unit delays necessary psychiatric treatment.