Nokea
The nurse evaluates a postpartum couplet for parent-infant attachment. What finding would be concerning?
- A. The postpartum person is sleepy.
- B. Parents are both caring for the infant.
- C. The parent is disinterested in the infant.
- D. The family is involved.
Correct Answer: C
Rationale: A lack of interest or emotional engagement with the infant is a concerning sign that may indicate attachment issues.
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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: Rationale:
Choice C is correct because strict aseptic technique, including hand washing, is crucial in preventing puerperal infection by minimizing the transmission of pathogens. Proper hand hygiene is a fundamental practice in infection control. Choices A, B, and D are incorrect because large doses of vitamin C, prophylactic antibiotics, and limited protein and fat intake do not directly address the primary mode of infection transmission and prevention for puerperal infection. Vitamin C, antibiotics, and dietary restrictions are not the primary strategies in preventing puerperal infections compared to the importance of proper hand hygiene and aseptic technique.
Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum.
- A. Apply antibiotic cream to the area three times each day.
- B. Squirt warm water over the perineum after voiding or stooling.
- C. Maintain cold packs to the area at all times for the first 3 days.
- D. Check the leukocyte level daily and report changes.
Correct Answer: B
Rationale: Squatting warm water over the perineum after voiding or stooling helps to soothe and cleanse the area, promoting healing.
What nursing intervention does the nurse include in the plan of care for a person with a wound infection?
- A. Reassure the postpartum person that infection will resolve without antibiotics.
- B. Assess for REEDA.
- C. Call health-care provider when temperature is 99.0° F.
- D. Scrub the incision vigorously with soap and water.
Correct Answer: B
Rationale: The correct answer is B: Assess for REEDA. REEDA stands for Redness, Edema, Ecchymosis, Drainage, and Approximation, which are key indicators of wound infection. By assessing for REEDA, the nurse can monitor and evaluate the progress of the infection. This intervention allows for early detection and prompt treatment of wound infections.
Choice A is incorrect because reassuring the postpartum person without antibiotics may lead to worsening infection. Choice C is incorrect as a temperature of 99.0° F is not necessarily indicative of a wound infection. Choice D is incorrect as scrubbing the incision vigorously with soap and water can introduce more bacteria and worsen the infection.
Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains?
- A. Lie prone with a small pillow cushioning her abdomen.
- B. Contract her abdominal muscles for a count of ten.
- C. Slowly ambulate in the hallways.
- D. Drink ice tea with lemon or lime.
Correct Answer: A
Rationale: Afterbirth pains are caused by uterine contractions. Lying prone with a pillow can help reduce discomfort by applying pressure and providing support to the abdomen. Ambulating or contracting the abdominal muscles is not generally recommended in this scenario.
A bottle-feeding woman, 11 1/2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate?
- A. You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided.
- B. You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up.
- C. It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly.
- D. It is important for you to be examined by the doctor today. Let me check to see when you can come in.
Correct Answer: D
Rationale: Saturating 2 pads in 1 hour could indicate abnormal bleeding or a complication. Immediate evaluation by a healthcare provider is necessary.