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The nurse is developing a plan of care for the postpartum client during the 'taking in ' phase. Which of the following should the nurse include in the plan?
- A. Teach baby-care skills like diapering.
- B. Discuss the labor and birth with the mother.
- C. Discuss contraceptive choices with the mother.
- D. Teach breastfeeding skills like pumping.
Correct Answer: B
Rationale: During the 'taking in' phase, the mother is focused on her own recovery and reliving the birth experience. Discussing the labor and birth is appropriate at this time.
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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 can increase the risk of infection due to the rapid and potentially traumatic delivery process.
To help the postpartum woman avoid constipation, the nurse should teach her to:
- A. Avoid intake of foods such as milk, cheese, or yogurt.
- B. Take a laxative for the first 3 postpartum days.
- C. Drink at least 1600 mL of noncaffeinated fluids daily.
- D. Limit her walking until the episiotomy is fully healed.
Correct Answer: C
Rationale: Drinking at least 1600 mL of noncaffeinated fluids daily helps to prevent constipation by promoting hydration, which is essential in the postpartum period.
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed?
- A. Disseminated intravascular coagulation (DIC); asking for laboratory tests
- B. von Willebrand disease (vWD); noting whether bleeding times have been extended
- C. Thrombophlebitis; using real-time and color Doppler ultrasound
- D. Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis
Correct Answer: C
Rationale: The correct answer is C: Thrombophlebitis; using real-time and color Doppler ultrasound. Thrombophlebitis is the inflammation of a vein with the formation of a blood clot. In this scenario, the woman's symptoms of pain, tenderness, warmth, redness, and an enlarged, hardened area in her leg are indicative of thrombophlebitis. Using real-time and color Doppler ultrasound will confirm the diagnosis by visualizing the blood clot in the affected vein. This diagnostic method is effective in detecting thrombosis and determining the extent of the clot, guiding appropriate treatment.
Incorrect choices:
A: Disseminated intravascular coagulation (DIC) is a systemic process causing widespread clotting in small blood vessels, leading to bleeding. Asking for laboratory tests wouldn't be the appropriate way to confirm thrombophlebitis.
B: von Willebrand disease (vWD) is a genetic bleeding disorder, and checking
Which medications are used to manage PPH? (Select all that apply.)
- A. Oxytocin
- B. Methergine
- C. Terbutaline
- D. Hemabate
Correct Answer: A
Rationale: 1. Oxytocin: Oxytocin is a commonly used medication to manage postpartum hemorrhage (PPH) because it helps to contract the uterus, which can reduce bleeding after childbirth. It is often the first-line treatment in cases of PPH.
The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan?
- A. Assist with stitch removal on third postpartum day.
- B. Administer analgesics every four hours per doctor 's orders.
- C. Teach client to contract her buttocks before sitting.
- D. Irrigate incision twice daily with antibiotic solution
Correct Answer: C
Rationale: Teaching clients to contract their buttocks before sitting helps to relieve pressure on the episiotomy site and promote healing.