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: Vital signs will remain normal during Stages 1 and 2. The evidence of abnormal vital signs is one indicator of Stage 3 hemorrhage.
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The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply.
- A. Temperature increase from 99.8°F to 100.5°F
- B. Incisional tenderness with palpation
- C. Increased margins of incisional redness
- D. Notably warm skin around the incision
Correct Answer: C
Rationale: The correct answer is C because increased margins of incisional redness are indicative of a wound infection, showing an inflammatory response. This can be a sign of localized infection spreading. The other choices are incorrect as follows: A: A slight temperature increase alone is not specific to wound infection and can be attributed to other factors. B: Incisional tenderness can be expected post-surgery and does not necessarily indicate infection. D: Notably warm skin around the incision can also occur due to normal healing processes and inflammation. Therefore, only choice C directly indicates a developing wound infection.
A 2-day-postpartum breastfeeding woman states, 'I am sick of being fat. When can I go on a diet? ' Which of the following responses is appropriate?
- A. It is fine for you to start dieting right now as long as you drink plenty of milk. '
- B. Your breast milk will be low in vitamins if you start to diet while breastfeeding. '
- C. You must eat at least 3,000 calories per day in order to produce enough milk for your baby. '
- D. Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day. '
Correct Answer: D
Rationale: Breastfeeding can help with postpartum weight loss, as the body burns calories producing milk.
What postpartum infection can be transferred between the breast-feeding person and newborn if both are not treated appropriately?
- A. wound infection
- B. urinary tract infection
- C. thrush
- D. mastitis
Correct Answer: C
Rationale: The correct answer is C: thrush. Thrush is a fungal infection caused by Candida that can be transmitted between the breast-feeding person and the newborn if not treated appropriately. The infection can pass back and forth during breastfeeding. Thrush manifests as white patches on the tongue and inside the mouth of the newborn and as nipple pain and redness in the breast-feeding person. Wound infection (A) typically refers to an infection at the site of a surgical incision and is not transmitted between the breast-feeding person and newborn. Urinary tract infection (B) is a bacterial infection of the urinary tract and is not typically transmitted through breastfeeding. Mastitis (D) is a bacterial infection of the breast tissue and is not directly transferred between the breast-feeding person and the newborn.
The nurse is taking the postpartum patient’s vital signs. The newborn is across the room in the bassinet, and the postpartum person refuses to hold the newborn. What should the nurse do?
- A. Call CPS for risk of child abuse
- B. Ask the person if they are feeling depressed, hopeless, afraid, or overwhelmed.
- C. Ask the health-care provider to order an antidepressant.
- D. Discuss how good parents hold and talk to their newborns.
Correct Answer: B
Rationale: Assessing for signs of depression or anxiety is important if a postpartum person is disengaged from their newborn.
A patient delivered vaginally 20 minutes ago. Prophylactic Pitocin is infusing intravenously. During the initial postpartum assessment, the nurse notes a heavy amount of bleeding on the perineal pad. What are the priority nursing actions?
- A. Assess the perineum for lacerations and provide a clean peri-pad and ice pack.
- B. Assess the fundus and massage the uterus to determine uterine tone and location.
- C. Assess to see if the bladder is full and place an indwelling urinary catheter.
- D. Assess for clots, determine if this is a normal amount, and provide privacy during a pad change.
Correct Answer: B
Rationale: The correct answer is B. Assess the fundus and massage the uterus to determine uterine tone and location. This is the priority action because heavy bleeding postpartum could indicate uterine atony, a common cause of postpartum hemorrhage. By assessing the fundus and massaging the uterus, the nurse can determine if the uterus is firm and well contracted, which helps to control bleeding. Other choices are incorrect as they do not address the immediate concern of uterine atony. Choice A focuses on the perineum and does not address the potential cause of bleeding. Choice C addresses bladder fullness, which is important but not as urgent as assessing for uterine atony. Choice D focuses on clots and privacy but does not address the primary concern of uterine tone.