Nokea
The nurse educates the person recovering from a cesarean birth on how to care for the incision. What education is discussed?
- A. Scrub the incision well twice daily.
- B. Remove the dressing the day after birth.
- C. Staples will be removed the day after birth.
- D. Vertical incisions heal faster with less pain.
Correct Answer: A
Rationale: Proper care and cleaning of the cesarean incision are essential for recovery.
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What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population.
Incorrect choices:
A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding.
C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder.
D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.
The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, 'I don 't know what is wrong with me. I feel terrible. I should be happy, but I 'm not. ' Which of the following nursing diagnoses is appropriate for this client?
- A. Suicidal thoughts related to psychotic ideations.
- B. Post-trauma response related to traumatic delivery.
- C. Ineffective individual coping related to hormonal shifts.
- D. Spiritual distress related to immature belief systems.
Correct Answer: C
Rationale: The client 's symptoms suggest ineffective coping due to hormonal shifts commonly experienced during the postpartum period, possibly indicating postpartum blues.
A breastfeeding woman, 1 1/2 months postdelivery, calls the nurse in the obstetrician 's office and states, 'I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me? ' The nurse should base the response to the client on which of the following?
- A. The woman is exhibiting signs of pathological galactorrhea.
- B. The same hormone stimulates orgasms and the milk ejection reflex.
- C. The woman should have a serum galactosemia assessment done.
- D. The baby is stimulating the woman to produce too much milk.
Correct Answer: B
Rationale: The hormone oxytocin is responsible for both milk ejection during breastfeeding and uterine contractions during orgasm, which explains the milk release.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: Hemorrhagic shock is characterized by inadequate tissue perfusion due to severe blood loss, leading to decreased circulating volume. The body's compensatory mechanisms kick in to maintain blood pressure, causing the peripheral blood vessels to constrict. This constriction can lead to cool, clammy, and pale skin as the body shunts blood away from the skin's surface to the vital organs. The skin may also feel cool to the touch due to reduced perfusion. This observation is significant in indicating hemorrhagic shock because it signifies the body's response to the insufficient circulating volume and the need to prioritize perfusion to essential organs.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like 'giving away your child' or 'giving up for adoption.'
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient 's expectations for having newborn photos or video.
Correct Answer: D
Rationale: The nurse should support the person's emotional needs including helping with decision-making and documenting memories.