Nokea
The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement?
- A. Maintain client in left lateral recumbent position.
- B. Teach sitz bath use on second postoperative day.
- C. Perform active range-of-motion exercises until ambulating.
- D. Assess central venous pressure during first postoperative day.
Correct Answer: B
Rationale: Sitz baths promote healing and comfort.
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A breastfeeding woman, 6 weeks postdelivery, must go into the hospital for a hemorrhoidectomy. Which of the following is the best intervention regarding infant feeding?
- A. Have the woman wean the baby to formula.
- B. Have the baby stay in the hospital room with the mother.
- C. Have the woman pump and dump her milk for two weeks.
- D. Have the baby bottle fed milk that the mother has stored.
Correct Answer: D
Rationale: Stored milk ensures continued breastfeeding.
The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time?
- A. Hand the baby to the woman.
- B. Explain “taking-in” to the woman.
- C. Offer to hand the baby to the woman.
- D. No action, because this situation is perfectly acceptabl
Correct Answer: B
Rationale: The correct answer is B: Explain "taking-in" to the woman. This action allows the nurse to educate the woman on the normal postpartum adjustment period. By explaining "taking-in," the nurse helps the woman understand her current need for rest and reflection without feeling guilty about not immediately attending to her newborn. This approach promotes bonding by reducing anxiety and enhancing the mother's confidence in her abilities.
Summary of other choices:
A: Hand the baby to the woman - This choice may not address the woman's emotional needs and understanding of her current state.
C: Offer to hand the baby to the woman - While offering is a good gesture, it may not address the underlying need for education and reassurance.
D: No action, because this situation is perfectly acceptable - Ignoring the opportunity to provide guidance and support may lead to confusion and insecurity for the woman.
The physician declares after delivering the placenta of a client during a cesarean section that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis?
- A. Blood loss of 2,000 mL.
- B. Blood pressure of 160/110.
- C. Jaundiced skin color.
- D. Shortened prothrombin time.
Correct Answer: A
Rationale: Placenta accreta causes significant blood loss.
In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)?
- A. The woman complains of numbness in the toes and heel of one foot.
- B. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed.
- C. One of the woman's calves is swollen, red, and warm to the touch.
- D. The veins in the ankle of one of the woman's legs are spider-like and purple.
Correct Answer: C
Rationale: Swelling, redness, and warmth are classic signs of DVT.
A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse’s most appropriate response at this time?
- A. “When did these symptoms begin?”
- B. “Sounds like normal postpartum depression.”
- C. “Are you having trouble getting enough sleep?”
- D. “Are you able to get out of bed and provide care for your baby?”
Correct Answer: A
Rationale: The correct answer is A: "When did these symptoms begin?" The nurse's response should address the patient's concerns and gather more information to assess the situation accurately. By asking when the symptoms began, the nurse can determine the duration and severity of the symptoms, enabling appropriate intervention.
Choice B is incorrect because assuming the symptoms are due to "normal postpartum depression" without further assessment is premature and may overlook other potential causes. Choice C focuses solely on sleep and may not address the underlying issues causing the patient's symptoms. Choice D assumes the patient's ability to provide care for the baby without first addressing the patient's emotional well-being.