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Which statement best describes the advantage of a labor, birth, recovery, and postpartum (LDRP) room?
- A. The family is in a familiar environment.
- B. They are less expensive than traditional hospital rooms.
- C. The infant is removed to the nursery to allow the mother to rest.
- D. The woman’s support system is encouraged to stay until discharge.
Correct Answer: A
Rationale: One of the advantages of a labor, birth, recovery, and postpartum (LDRP) room is that the family is in a familiar environment. LDRP rooms are designed to provide a comfortable setting where the mother, baby, and family can stay together throughout the entire childbirth process. This environment allows for better continuity of care, enhances bonding between the baby and the family, and helps reduce stress and anxiety often associated with being in an unfamiliar hospital setting. Being in a familiar environment can also promote a sense of security and control for the mother, which can positively impact her overall birthing experience.
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The telephone triage nurse receives a call from a patient who is 5 days postoperative total
abdominal hysterectomy. The patient states that her pain is not relieved with the medications and
that she has noticed blood in her urine. The nurse instructs the patient to report immediately to the
emergency department. What does the nurse suspect as the surgical complication?
- A. Possible complication related to the anesthesia
- B. Possible injury to the ureters or bladder
- C. Possible hemorrhage from the internal incision
- D. Possible peritoneal venous thromboembolism
Correct Answer: D
Rationale: In this situation where the patient is 5 days postoperative total abdominal hysterectomy and experiencing pain that is not relieved with medications, the nurse should suspect a possible hemorrhage from the internal incision. Although some pain is expected postoperatively, severe or worsening pain that is not relieved with medications can indicate a complication such as internal bleeding. Immediate medical attention is needed to assess and manage any potential hemorrhage to prevent further complications or adverse outcomes. Other signs of internal bleeding may include symptoms such as increasing abdominal distention, tachycardia, hypotension, and signs of shock.
The nurse is providing postoperative care to a patient who underwent a total abdominal hysterectomy 12 hours ago. Which of the following are appropriate nursing interventions? Select all that apply.
- A. Assist the patient with ambulation.
- B. Maintain the Foley catheter for 48 to 72 hours postoperatively.
- C. Monitor intake and output and characteristics of urin
- D. urinary tract infection
Correct Answer: A
Rationale: A. Assist the patient with ambulation: Encouraging early ambulation after surgery helps prevent complications such as blood clots, pneumonia, and pressure ulcers. It also promotes circulation and aids in the recovery process.
Which nursing diagnosis should the nurse identify as a priority for a patient in active labor?
- A. Risk for anxiety related to upcoming birth
- B. Risk for imbalanced nutrition related to NPO status
- C. Risk for altered family processes related to new addition to the family
- D. Risk for injury (maternal) related to altered sensations and positional or physical
changes
Correct Answer: D
Rationale: The priority nursing diagnosis for a patient in active labor should focus on ensuring the safety and well-being of the mother and the baby. "Risk for injury (maternal) related to altered sensations and positional or physical changes" is the most crucial diagnosis in this scenario as it directly addresses potential risks and complications that may occur during labor and delivery. This nursing diagnosis includes considerations for the physical changes the mother undergoes during labor, such as altered sensations and positioning, which can increase the risk of injury. By identifying and addressing this risk promptly, the nurse can help prevent potential harm to the mother and ensure a safe delivery process.
A nurse is caring for a patient who has HSV and is pregnant. The patient is concerned about the fetus. What medication is safest to take?
- A. valacyclovir
- B. none
- C. acyclovir
- D. famciclovir
Correct Answer: C
Rationale: Acyclovir is the antiviral medication of choice for treating HSV (Herpes Simplex Virus) infections during pregnancy due to its known safety profile. It is classified as Category B by the FDA, indicating that there is no evidence of risk to the fetus based on animal studies. Valacyclovir and famciclovir, on the other hand, are both classified as Category B (risk cannot be ruled out) and Category C (animal studies have shown adverse effects) by the FDA, respectively. It is generally recommended to avoid taking unnecessary medications during pregnancy, but if treatment for HSV is necessary, acyclovir is considered the safest option.
The nurse is formulating a nursing care plan for a postpartum patient. Which actions by the nurse indicate use of critical thinking skills when formulating the care plan? (Select all that apply.)
- A. Using a standardized postpartum care plan
- B. Determining priorities for each diagnosis written
- C. Writing interventions from a nursing diagnosis book
- D. Reflecting and suspending judgment when writing the care plan
Correct Answer: B
Rationale: B. Determining priorities for each diagnosis written: Prioritizing nursing diagnoses based on the patient's needs and condition requires critical thinking skills. The nurse must be able to identify the most urgent issues to address first in the care plan.