Nokea
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.
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The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
- A. maladaptive parenting
- B. psychosis
- C. postpartum depression
- D. bipolar disorder
Correct Answer: C
Rationale: Risk factors such as those listed increase the likelihood of postpartum depression which affects a person's emotional and mental well-being.
The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The IV site indicates phlebitis, and the appropriate action is to remove and restart the IV to avoid further complications.
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room?
- A. Ask the patient how many peripads she considered to be “soaked.”
- B. Collect blood in calibrated, under-buttocks drapes for vaginal birth.
- C. Place a basin at the foot of the delivery table to catch any blood.
- D. Rely on the primary health care provider’s estimate of blood loss.
Correct Answer: B
Rationale: The correct answer is B because collecting blood in calibrated, under-buttocks drapes for vaginal birth allows for a more accurate estimation of postpartum blood loss. This method provides a quantitative measurement, unlike the subjective method in option A. Option C does not provide a direct measurement of blood loss and may not be accurate. Option D relies on the health care provider's estimate, which may not always be precise or consistent. By using calibrated drapes, the nurse can easily measure and monitor blood loss, ensuring better patient care and outcomes.
The nurse assesses for signs of depression or postpartum blues. How can the nurse explain the difference?
- A. PPD is less severe and resolves in a few weeks.
- B. Postpartum blues can last up to a year.
- C. PPD is a normal expectation of postpartum.
- D. Postpartum blues symptoms include irritability and sadness.
Correct Answer: D
Rationale: Postpartum blues are more temporary and less severe whereas postpartum depression (PPD) involves more severe symptoms and requires treatment.