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: Step 1: The nurse examines the large collected clots to determine the presence of tissue.
Step 2: Presence of tissue may indicate retained placental fragments, which can lead to postpartum hemorrhage.
Step 3: Identifying tissue is crucial for proper management and prevention of complications.
Step 4: Validating clotting (Choice A) is important but not the primary reason for examining the clots.
Step 5: Obtaining an accurate description (Choice C) and documenting the number of clots (Choice D) are less critical compared to identifying tissue.
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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 answer is B: Instruct the mother to void prior to the assessment. This is the most appropriate initial nursing intervention because a full bladder can impede proper assessment of the fundus and lochia flow. Voiding before assessment ensures accurate findings and reduces the risk of discomfort for the patient.
A: Massaging the fundus until it is firm is important but should not be the initial step as assessing the bladder status is crucial first.
C: Assessing the lochia flow while massaging the fundus is important but should come after ensuring the bladder is empty.
D: Lowering the head of the bed and having the mother lie flat does not address the immediate need to empty the bladder for accurate assessment.
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: Rationale: Option D is correct because wearing a well-fitting bra provides support and helps reduce stimulation to the breasts, aiding in lactation suppression. Warm showers, pumping, and applying heating pads can all increase milk production, which is counterproductive to lactation suppression. Therefore, options A, B, and C are incorrect.
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 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. The couple wants to avoid pregnancy for at least 2 years. Depo-Provera is a highly effective long-acting reversible contraceptive that only requires an injection every 3 months, providing reliable contraception for an extended period. It does not rely on daily adherence like the oral pill (B) or emergency contraceptives (A). Natural family planning (D) may not be the best choice for a couple wanting to avoid pregnancy with certainty for 2 years due to its reliance on tracking menstrual cycles and abstinence during fertile periods.
A G1P1 has just experienced a 24-hour labor that included a 3-hour second stage. The woman states to the nurse, "I just can't feed my baby now. All I want to do is sleep." What is the appropriate response from the nurse?
- A. Discuss with the woman that the needs of her infant should come first
- B. Recognize this as a behavior of the taking-hold stage
- C. Record the behavior as ineffective bonding/attachment
- D. Reassure the woman that it is okay for her to rest at this time
Correct Answer: D
Rationale: The correct answer is D because after a long labor, it is crucial for the woman to rest and recover. By reassuring her that it is okay to rest, the nurse acknowledges the importance of self-care for the mother's well-being, which ultimately benefits the baby. This response promotes maternal mental health and physical recovery, which are essential for successful breastfeeding and bonding with the baby.
Choice A is incorrect as it may create unnecessary guilt and pressure on the mother. Choice B is incorrect as the behavior described does not specifically align with the taking-hold stage. Choice C is incorrect as labeling the behavior as ineffective bonding/attachment without further assessment could be harmful and premature.