Nokea
The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it.What would the nurse expect to find on further assessment?
- A. A firm fundus the size of a grapefruit
- B. A full bladder
- C. Retained placental fragments
- D. Vital signs indicative of shock
- E. A soft, boggy fundus
Correct Answer: B,E
Rationale: Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.
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What does the nurse recognize as the possible cause of these signs and symptoms?
- A. Dehydration
- B. Hypovolemic shock
- C. Endometritis
- D. Cystitis
Correct Answer: C
Rationale: Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.
What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions?
- A. I will apply cold compresses to the painful areas.'
- B. I will take a warm shower before nursing the baby.'
- C. I will nurse first on the affected side.'
- D. I will empty the affected breast every 8 hours.'
Correct Answer: B
Rationale: Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
What does the nurse recognize these signs indicate?
- A. Uterine atony
- B. Uterine dystocia
- C. Uterine hypoplasia
- D. Uterine dysfunction
Correct Answer: A
Rationale: Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.
What is the first sign of hypovolemic shock from postpartum hemorrhage?
- A. Cold, clammy skin
- B. Tachycardia
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: Tachycardia is usually the first sign of inadequate blood volume.
What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
- A. Teach the patient how to massage the abdomen and then get help.
- B. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
- C. Begin massaging the fundus while another person notifies the physician.
- D. Ask the patient to void and reassess fundal tone and location.
Correct Answer: C
Rationale: When the uterus is boggy, the nurse should immediately massage it until it becomes firm.