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: B
Rationale: The dressing should be removed after the first 24 hours and incision care should focus on preventing infection and ensuring proper healing.
You may also like to solve these questions
What is a symptom of engorgement?
- A. protuberant nipples
- B. shiny, hard breast
- C. insufficient milk production
- D. soft, lumpy breast
Correct Answer: B
Rationale: The correct answer is B: shiny, hard breast. Engorgement is characterized by a significant increase in blood and lymph fluid in the breast tissue, causing the breasts to become swollen, shiny, and hard. This occurs when milk production exceeds removal, leading to congestion and inflammation. Protuberant nipples (A) may be a result of engorgement but are not a defining symptom. Insufficient milk production (C) is not a symptom of engorgement but rather a separate issue related to milk supply. Soft, lumpy breast (D) is more indicative of a blocked duct or mastitis, not engorgement.
A woman who is 3 hours postpartum has had difficulty in urinating. She finally urinates 100 mL. The initial nursing action is to:
- A. Insert an indwelling catheter.
- B. Have her drink additional fluids.
- C. Assess the height of her fundus.
- D. Chart the urination amount.
Correct Answer: C
Rationale: Before taking further action, the nurse should assess the height of the fundus to determine if a full bladder may be contributing to urinary retention.
The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
- A. maladaptive parenting
- B. psychosis
- C. postpartum depression
- D. bipolar disorder
Correct Answer: C
Rationale: Risk factors such as those listed increase the likelihood of postpartum depression which affects a person's emotional and mental well-being.
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: A full bladder can displace the uterus and prevent it from contracting properly leading to a boggy fundus.
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
- A. Apply an ice pack to the perineum.
- B. Advise the woman to use a sitz bath after every voiding.
- C. Advise the woman to sit on a pillow.
- D. Teach the woman to insert nothing into her rectum.
Correct Answer: A
Rationale: Applying an ice pack to the perineum helps reduce swelling and provides pain relief after a perineal laceration.