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The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform?
- A. Intermittently apply ice packs to her axillae and breasts.
- B. Apply lanolin to her breasts and nipples every 3 hours.
- C. Express milk from the breasts every 3 hours.
- D. Ask the primary health care provider to order a milk suppressant.
Correct Answer: A
Rationale: Ice packs can help reduce inflammation and pain associated with engorgement in women who choose to bottle-feed.
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The nurse develops a plan to increase a patient 's milk supply. What is an intervention they can implement?
- A. Pump between nursing sessions.
- B. Nurse every 6 hours.
- C. Keep newborn in bassinet between sessions.
- D. Offer a pacifier when newborn cries.
Correct Answer: A
Rationale: Pumping between breastfeeding sessions can help stimulate milk production by increasing demand.
A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse 's best response?
- A. I know that it hurts but it is very important for you to cough.
- B. Let me check your lung fields to see if coughing is really necessary.
- C. If you take a few deep breaths in, that should be as good as coughing.
- D. If you support your incision with a pillow, coughing should hurt less.
Correct Answer: D
Rationale: Supporting the incision with a pillow while coughing reduces the strain on the surgical site, making it less painful.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for hypertension
- B. risk for bleeding
- C. risk for fluid overload
- D. risk for breast-feeding failure
Correct Answer: B
Rationale: Coagulation disorders like von Willebrand increase the risk for bleeding and hemorrhage.
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.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient 's finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: A prolonged capillary refill and pale appearance suggest hypovolemiaand starting an IV bolus can help address fluid loss and support blood pressure.