Nokea
The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol?
- A. Increased patient restlessness.
- B. Manifestations of severe pain.
- C. Development of abnormal vital signs.
- D. Patient requests water for extreme thirst.
Correct Answer: C
Rationale: The correct answer is C: Development of abnormal vital signs. Stage 3 hemorrhage protocol is initiated when vital signs such as tachycardia, hypotension, and tachypnea are present, indicating severe blood loss. Increased patient restlessness (choice A) and manifestations of severe pain (choice B) are important but do not specifically indicate Stage 3 hemorrhage. Patient requesting water for extreme thirst (choice D) is not a typical sign of hemorrhage. Abnormal vital signs are the key indicator for initiating Stage 3 hemorrhage protocol as they reflect the body's compensatory mechanisms in response to significant blood loss.
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What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: Monitoring for signs of sepsis is crucial in cases of postpartum endometritis.
The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt?
- A. Large doses of vitamin C during pregnancy
- B. Prophylactic antibiotics
- C. Strict aseptic technique, including hand washing, by all health care personnel
- D. Limited protein and fat intake
Correct Answer: C
Rationale: The most important strategy for the nurse to adopt in preventing puerperal infection is option C, which is the strict aseptic technique, including hand washing, by all health care personnel. Puerperal infection, also known as postpartum infection, is a serious complication following childbirth that can lead to severe consequences if not prevented. Maintaining proper hygiene practices, such as hand washing and using aseptic techniques, is crucial in preventing the spread of pathogens that can cause infections. This simple yet effective measure can significantly reduce the risk of puerperal infections among postpartum women. Large doses of vitamin C during pregnancy (option A) may have benefits for overall health but are not specifically proven to prevent puerperal infections. Prophylactic antibiotics (option B) may be used in certain cases but are not the primary strategy for prevention in all cases. Limiting protein and fat intake (option D) is not a recommended approach
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, 'I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest. ' Which of the following actions should the nurse take at this time?
- A. Encourage the woman exclusively to breastfeed her baby.
- B. Have the woman massage her breasts hourly.
- C. Obtain an order to culture her expressed breast milk.
- D. Take the temperature and pulse rate of the woman.
Correct Answer: A
Rationale: Breastfeeding exclusively can help relieve engorgement, and frequent feedings prevent further complications.
A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking 'my baby sister ' home. Which of the following is an appropriate response by the nurse?
- A. It 's always nice when siblings are excited to have the babies go home.
- B. Your daughter is very advanced for her age. She must speak very well.
- C. Your daughter is likely to become very jealous of the new baby.
- D. Older sisters can be very helpful. They love to play mother.
Correct Answer: C
Rationale: It is common for older siblings to feel jealousy when a new baby arrives. Preparing the child for the changes can help manage these feelings.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.