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The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: The correct answer is B: full bladder. A full bladder can cause the fundus to be boggy, elevated, and deviated to one side due to impeding the uterus from contracting properly. This can lead to postpartum hemorrhage. Uterine rupture (A) would present with severe abdominal pain and signs of shock. Perineal laceration (C) would not cause these fundus changes. Hematoma (D) would present with localized swelling and pain, not fundal changes.
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A client, who had no prenatal care, delivers a 10-lb 10-oz baby boy whose serum glucose result 1 hour after delivery was 20 mg/dL. Based on these data, which of the following tests should the mother have at her 6-week postpartum checkup?
- A. Glucose tolerance test.
- B. Indirect Coombs' test.
- C. Blood urea nitrogen (BUN).
- D. Complete blood count (CBC).
Correct Answer: A
Rationale: Glucose testing is indicated for gestational diabetes.
The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, he preceding nurse indicated that the patient’s lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient’s peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse’s priority action with this finding?
- A. Weigh the peripad.
- B. Replace the peripad.
- C. Contact the health care provider.
- D. Document the finding in the patient’s chart.
Correct Answer: C
Rationale: The correct answer is C: Contact the health care provider. This is the priority action because the sudden increase in lochia flow after breastfeeding could indicate postpartum hemorrhage, which is a serious complication that requires immediate medical attention. Contacting the healthcare provider will allow for prompt assessment and intervention.
A: Weigh the peripad - This is not the priority action as assessing the amount of blood loss is important, but contacting the healthcare provider for further assessment and intervention takes precedence.
B: Replace the peripad - While maintaining cleanliness and hygiene is important, addressing the potential postpartum hemorrhage is the priority.
D: Document the finding in the patient’s chart - Documentation is necessary but should come after the immediate concern of postpartum hemorrhage is addressed.
The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The
- A. Report the incident to the social services department.
- B. Advise the parents that the older son needs to be reprimande
- C. No action; this is a normal family adjusting to family change
- D. Report to oncoming staff that the mother is probably not a good disciplinarian.
Correct Answer: C
Rationale: Correct Answer: C - No action; this is a normal family adjusting to family change.
Rationale:
1. It is normal for new parents to have questions and concerns about newborn care.
2. The parents are actively engaged with the newborn and seeking information, indicating a positive adjustment.
3. The mother's behavior with the newborn does not raise any immediate concerns for intervention.
4. Reporting to social services or assuming parenting styles based on limited observation is unwarranted.
Summary:
A: Reporting to social services is unnecessary as there are no signs of neglect or abuse.
B: Reprimanding the older son is unrelated to the situation and inappropriate.
D: Assuming the mother's parenting style based on limited observation is unjustified and unprofessional.
A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? Select one that doesn't apply.
- A. Hyperthermia.
- B. Diarrhea.
- C. Hypotension.
- D. Palpitations.
Correct Answer: B
Rationale: Hemabate can cause hyperthermia, hypotension, and palpitations.
The postpartum person asks for only warm drinks and food. How can the nurse support this cultural tradition?
- A. Explain that nurses do not have control over the food.
- B. Tell the person that cold fluids are better for recovery.
- C. Instruct the person to call the nurse to warm up food or drink.
- D. Educate the person on culture in the United States.
Correct Answer: C
Rationale: Rationale for Correct Answer (C): Instructing the person to call the nurse to warm up food or drink is the best way to support the cultural tradition of consuming warm drinks and food. This option respects the individual's cultural preferences and provides a practical solution to meet their needs without imposing personal opinions. By offering assistance in warming up the food or drink, the nurse acknowledges and honors the person's cultural background, promoting a culturally sensitive and patient-centered approach.
Summary of Incorrect Choices:
A: Explaining that nurses do not have control over the food dismisses the person's request and does not address the cultural tradition.
B: Telling the person that cold fluids are better for recovery disregards the cultural preference for warm drinks and food.
D: Educating the person on culture in the United States is not relevant to supporting their specific cultural tradition of consuming warm drinks and food.