Nokea
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: An increase in redness in the incisional margins is a likely sign of developing wound infection. When the skin around a surgical incision is notably warm to the touch, it is likely a sign of a developing wound infection.
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The nurse is admitting a 38-year-old patient to triage in early labor with ruptured membranes. Her history includes a previous vaginal delivery 4 years ago and the presence of a uterine fibroid. What interventions are appropriate based on the hemorrhage risk for this patient?
- A. The patient is a moderate hemorrhage risk, so a type and screen should be ordered.
- B. The patient is a high hemorrhage risk, so 4 units of packed red blood cells should be ordered.
- C. The patient is a low hemorrhage risk, so a hold tube should be drawn.
- D. The patient is a moderate hemorrhage risk, but blood is not drawn at this time.
Correct Answer: A
Rationale: Since the patient has a previous history of delivery and uterine fibroids, she is considered at moderate hemorrhage risk and a type and screen should be ordered.
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: The correct answer is B. The nurse should ask the postpartum person if they are feeling depressed, hopeless, afraid, or overwhelmed. This is important because it can help assess the person's mental and emotional state, which could be contributing to their refusal to hold the newborn. It also shows empathy and support for the person's feelings.
Choice A is incorrect because calling Child Protective Services (CPS) would be premature and could escalate the situation unnecessarily. Choice C is incorrect as starting an antidepressant should only be considered after a thorough evaluation by a healthcare provider. Choice D is incorrect because it does not address the underlying issue of the person's emotional state and may come off as judgmental.
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: The correct answer is A: Pump between nursing sessions. This intervention helps stimulate milk production by emptying the breasts more frequently. Pumping increases demand for milk, signaling the body to produce more. Nursing every 6 hours (B) reduces milk supply due to less frequent stimulation. Keeping newborn in bassinet (C) limits nursing opportunities. Offering a pacifier (D) may decrease milk supply by reducing nursing frequency. Therefore, option A is the most effective intervention to increase milk supply.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: Precipitous labor increases the risk of postpartum infection.
What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony?
- A. Establishing venous access
- B. Performing fundal massage
- C. Preparing the woman for surgical intervention
- D. Catheterizing the bladder
Correct Answer: B
Rationale: The correct answer is B: Performing fundal massage. Fundal massage helps to stimulate contractions of the uterus, which can help control bleeding in cases of uterine atony. This is a primary nursing responsibility to address the immediate cause of the hemorrhage. Establishing venous access (choice A) is important but not the primary responsibility in this situation. Preparing for surgical intervention (choice C) may be necessary if conservative measures fail, but it is not the initial step. Catheterizing the bladder (choice D) is not directly related to managing obstetric hemorrhage associated with uterine atony.