Nokea
The nurse is developing a plan of care for the postpartum client during the 'taking hold ' phase. Which of the following should the nurse include in the plan?
- A. Provide the client with a nutritious meal.
- B. Encourage the client to take a nap.
- C. Assist the client with activities of daily living.
- D. Assure the client that she is an excellent mother.
Correct Answer: C
Rationale: During the 'taking hold' phase, the mother is more focused on newborn care and regaining control. Assisting with daily activities supports her autonomy.
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A bottle-feeding woman, 11 1/2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate?
- A. You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided.
- B. You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up.
- C. It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly.
- D. It is important for you to be examined by the doctor today. Let me check to see when you can come in.
Correct Answer: D
Rationale: Saturating 2 pads in 1 hour could indicate abnormal bleeding or a complication. Immediate evaluation by a healthcare provider is necessary.
What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony?
- A. Establishing venous access
- B. Performing fundal massage
- C. Preparing the woman for surgical intervention
- D. Catheterizing the bladder
Correct Answer: B
Rationale: The correct answer is B: Performing fundal massage. Fundal massage helps to stimulate contractions of the uterus, which can help control bleeding in cases of uterine atony. This is a primary nursing responsibility to address the immediate cause of the hemorrhage. Establishing venous access (choice A) is important but not the primary responsibility in this situation. Preparing for surgical intervention (choice C) may be necessary if conservative measures fail, but it is not the initial step. Catheterizing the bladder (choice D) is not directly related to managing obstetric hemorrhage associated with uterine atony.
The nurse educates the postpartum person on bowel discomfort. What instructions would they give?
- A. Limit water intake.
- B. Use laxatives daily.
- C. Ambulate often.
- D. Avoid stool softeners.
Correct Answer: C
Rationale: Ambulating helps improve bowel motility and prevent constipation which can lead to bowel discomfort after childbirth.
What is characteristic of an early (primary) PPH?
- A. occurs after 12 weeks postpartum
- B. is not an emergency
- C. often occurs due to uterine atony
- D. is diagnosed after the person is discharged
Correct Answer: C
Rationale: Early (primary) postpartum hemorrhage is usually due to uterine atony and requires immediate medical intervention.
The nurse's initial response if a pulmonary embolism is suspected should be to:
- A. Start a second intravenous (IV) line and prepare for transfusion.
- B. Raise the head of the bed and administer oxygen.
- C. Insert a catheter to monitor urine output.
- D. Lower the head of the bed and elevate the legs.
Correct Answer: B
Rationale: In cases of pulmonary embolism oxygen should be administered to support breathing and help oxygenate the blood. oxygen should be administered to support breathing and help oxygenate the blood.