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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.
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The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The correct answer is C: Remove the IV, restart it in a new location, and complete the antibiotic administration. This is the correct action because the patient's IV site is showing signs of infection (redness, inflammation, swelling, tenderness). By removing the IV, the nurse can prevent the spread of infection and restart the antibiotic infusion in a new, sterile site to ensure proper treatment.
A: Flushing the IV with normal saline will not address the underlying issue of infection and may worsen the patient's condition.
B: Putting the IV antibiotic on a pump for more accurate infusion does not address the fact that the current IV site is infected and needs to be removed.
D: Allowing the IV to continue to drip slowly is not appropriate when the site is showing signs of infection.
What is the most common reason for late postpartum hemorrhage (PPH)?
- A. Subinvolution of the uterus
- B. Defective vascularity of the decidua
- C. Cervical lacerations
- D. Coagulation disorders
Correct Answer: A
Rationale: Late postpartum hemorrhage (PPH), defined as occurring between 24 hours and up to 12 weeks after delivery, is most commonly due to subinvolution of the uterus. This occurs when the uterus fails to return to its normal pre-pregnancy size. Subinvolution can be caused by retained products of conception, uterine infection, uterine anomalies, or inadequate contraction of the uterine muscles. When the uterus does not contract effectively, it is unable to compress the blood vessels at the site of the placental attachment, leading to persistent bleeding. Subinvolution of the uterus is an important cause of late PPH and requires prompt intervention to prevent excessive blood loss and its associated complications.
The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful?
- A. The woman swallows the tablets whole.
- B. The woman takes the pills between meals.
- C. The woman calls the doctor if she develops a headache.
- D. The woman understands that her urine may turn orange.
Correct Answer: D
Rationale: Colace (docusate sodium) is a stool softener that can turn the urine orange. This is a common side effect and should be discussed with the patient during teaching to avoid unnecessary concern.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective?
- A. She pumps her breasts after each feeding.
- B. She feeds her baby every 2 to 3 hours.
- C. She feeds her baby 10 minutes on each side.
- D. She supplements each feeding with formula.
Correct Answer: B
Rationale: Feeding every 2-3 hours helps maintain milk production and prevents engorgement.
What symptom differentiates baby blues from PPD?
- A. Baby blues last longer than 14 days.
- B. Baby blues cause hallucinations.
- C. Baby blues occur in the first few days of the postpartum period.
- D. Baby blues are treated with inpatient therapy.
Correct Answer: A
Rationale: The correct answer is A: Baby blues last longer than 14 days. Baby blues typically resolve within 1-2 weeks postpartum. If symptoms persist for more than 14 days, it may indicate postpartum depression (PPD). Choice B is incorrect as hallucinations are not a common symptom of baby blues. Choice C is incorrect because baby blues can occur within the first few weeks postpartum, not just the first few days. Choice D is incorrect because baby blues are usually managed with support, counseling, and self-care, not inpatient therapy.