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The nurse is caring for a woman who is 6 hours postpartum after a vaginal delivery. She has a history of labial varicose veins and is reporting perineal pain of 8 on a 10-point scale. What interventions should the nurse include in the plan of care?
- A. Provide the patient with an inflatable donut ring to sit on and administer her oral pain medication.
- B. Explain that this is normal after a vaginal delivery and assist her to a side-lying position.
- C. Assess the perineum for a hematoma or inflamed varicosities, and administer oral pain medication.
- D. Administer oral stool softeners and encourage fluids.
Correct Answer: C
Rationale: Assessing the perineum for hematoma or varicosities is critical for perineal pain, and oral pain medication should be administered.
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The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states 'I don 't use those. I always use tampons. ' Which of the following actions by the nurse is appropriate at this time?
- A. Remove the peripad and insert a tampon into the woman 's vagina.
- B. Advise the client that for the first two days she will be bleeding too heavily for a tampon.
- C. State that it is unsafe to place anything into the vagina until involution is complete.
- D. Remind the client that a tampon would hurt until the soreness from the delivery resolves.
Correct Answer: B
Rationale: The nurse should explain that for the first two days after delivery, the bleeding is too heavy to use tampons, and this could increase the risk of infection.
The nurse educates the non -breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: Cold packs and cabbage leaves help reduce swelling and discomfort caused by engorgement in non-breastfeeding individuals.
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: The correct answer is D: WBCs 10,000. An elevated white blood cell count (WBC) is a common sign of infection as the body produces more WBCs to fight off pathogens. This increase in WBC count is known as leukocytosis and is a key indicator of an ongoing infection. In contrast, choices A, B, and C are not direct indicators of infection. A painful fundal massage may suggest uterine atony, breast-feeding every 2-3 hours is a normal part of postpartum care, and a pulse rate of 72 is within the normal range. Therefore, the most reliable assessment finding suggesting a possible infection is an elevated WBC count.
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
- A. Moderate serosanguinous drainage.
- B. Well-approximated edges.
- C. Ecchymotic area distal to the episiotomy.
- D. An area of redness adjacent to the incision.
Correct Answer: B
Rationale: A well-approximated episiotomy will have edges that are aligned and close together, indicating proper healing.
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: The correct answer is A: Subinvolution of the uterus. This is the most common cause of late postpartum hemorrhage (PPH) due to incomplete contraction and retraction of the uterus leading to persistent bleeding. Subinvolution can result from retained placental fragments, uterine infections, or inadequate involution. Choice B, defective vascularity of the decidua, is less common and not typically associated with late PPH. Cervical lacerations (Choice C) usually cause immediate bleeding after delivery, not late PPH. Coagulation disorders (Choice D) can cause both early and late PPH but are less common than subinvolution.