Nokea
The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?
- A. To validate the presence of clotting
- B. To determine the presence of tissue
- C. To obtain an accurate description
- D. To document the number of clots
Correct Answer: B
Rationale: The correct answer is B: To determine the presence of tissue. By examining the large collected clots, the nurse can differentiate between clots and actual tissue, which is crucial for identifying any potential complications postpartum. This step ensures accurate assessment and appropriate intervention if necessary.
Incorrect choices:
A: To validate the presence of clotting - This is not necessary as the presence of large clots already indicates clotting.
C: To obtain an accurate description - While important, the primary purpose of examining large clots in this context is to differentiate tissue from clots.
D: To document the number of clots - While documenting the number of clots is important, it is not the main reason for examining them in this scenario.
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The nurse is educating the postpartum client on lactation suppression. Which instructions to the client regarding lactation suppression should be included? Select all that apply.
- A. "Take warm showers twice a day."
- B. "Pump each breast three times a day."
- C. "Apply a heating pad to each breast."
- D. "Wear a well-fitting bra for the first 5 to 6 days."
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
- Wearing a well-fitting bra provides support and pressure on the breasts, which can help decrease milk production and relieve discomfort during lactation suppression.
- Warm showers, pumping, and applying a heating pad can actually stimulate milk production rather than suppress it, so they are not appropriate instructions for lactation suppression.
- Therefore, option D is the correct choice as it promotes effective lactation suppression by providing proper breast support.
The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend?
- A. Emergency contraceptives
- B. Oral estrogen/progesterone pill
- C. Depo-Provera
- D. Natural family planning
Correct Answer: C
Rationale: The correct answer is C: Depo-Provera.
Rationale:
1. Long-acting: Depo-Provera is a highly effective contraceptive method lasting for 3 months.
2. High efficacy: It has a very low failure rate (<1%).
3. Reversible: Fertility returns after discontinuation.
4. Patient certainty: The couple's certainty about avoiding pregnancy for 2 years aligns well with the 3-month duration of Depo-Provera.
Summary:
A: Emergency contraceptives are for immediate post-coital use, not long-term contraception.
B: Oral estrogen/progesterone pills require daily adherence, not suitable for long-term certainty.
D: Natural family planning relies on timing of ovulation, not as reliable for couples seeking certainty.
The nurse is preparing to do a morning assessment on a 24-hour postpartum patient. Which nursing intervention is most appropriate initially?
- A. Massage the fundus until it is firm.
- B. Instruct the mother to void prior to the assessment.
- C. Assess the lochia flow while massaging the fundus.
- D. Lower the head of the bed and have the mother lie flat.
Correct Answer: B
Rationale: The correct initial nursing intervention is to instruct the mother to void prior to the assessment (choice B). This is important as a full bladder can interfere with the accuracy of the fundal assessment. By ensuring the mother voids first, the nurse can accurately assess the fundus for any signs of excessive bleeding or abnormalities. This step is crucial in monitoring the postpartum patient's well-being.
Choice A is incorrect as massaging the fundus should come after assessing the lochia flow to prevent potential complications. Choice C is also incorrect as assessing the lochia flow should occur before massaging the fundus. Choice D is incorrect as lowering the head of the bed and having the mother lie flat is not necessary for a postpartum assessment.
The nurse is providing care for a new mother during a follow-up visit 6 weeks after a vaginal delivery. The mother begins to cry and reports difficulty with eating and sleeping. The nurse identifies postpartum blues and cites which reason as the most likely cause?
- A. Fatigue related to a 'fussy' baby
- B. Frustration over physical appearance
- C. Changes in hormonal levels
- D. Stress related to new mother role
Correct Answer: C
Rationale: The correct answer is C: Changes in hormonal levels. During the postpartum period, there is a significant drop in estrogen and progesterone levels, which can contribute to mood swings, emotional instability, and feelings of sadness. This is known as postpartum blues. The other choices are incorrect because fatigue related to a 'fussy' baby (A), frustration over physical appearance (B), and stress related to new mother role (D) are factors that can contribute to postpartum depression, not postpartum blues specifically.
As a result of the previously mentioned research study, the nurses in a postpartum facility will implement which evidence-based change?
- A. Continue to assess the level of fatigue for the mother during postpartum period.
- B. Assist fathers in recognizing and managing stress and depressive symptoms.
- C. Encourage the father to go home and rest while the mother is hospitalized.
- D. Promote strategies to decrease fatigue during both prenatal and postnatal periods.
Correct Answer: D
Rationale: The correct answer is D because promoting strategies to decrease fatigue during both prenatal and postnatal periods aligns with evidence-based practice to improve maternal health outcomes. This approach acknowledges the importance of preventive measures to address fatigue before and after childbirth. Option A focuses solely on assessing fatigue without addressing interventions to mitigate it. Option B, while relevant, does not directly impact maternal fatigue. Option C overlooks the father's role in supporting the mother and infant. In summary, option D is the most appropriate as it addresses fatigue proactively throughout the perinatal period.