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The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal?
- A. Fundus 1 cm above the umbilicus, lochia rosa.
- B. Fundus 2 cm above the umbilicus, lochia alba.
- C. Fundus 2 cm below the umbilicus, lochia rubra.
- D. Fundus 3 cm below the umbilicus, lochia serosa.
Correct Answer: C
Rationale: At 3 days postpartum, the fundus should be approximately 2 cm below the umbilicus, and lochia rubra is expected.
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The nurse is admitting a 38-year-old patient to triage in early labor with ruptured membranes. Her history includes a previous vaginal delivery 4 years ago and the presence of a uterine fibroid. What interventions are appropriate based on the hemorrhage risk for this patient?
- A. The patient is a moderate hemorrhage risk, so a type and screen should be ordered.
- B. The patient is a high hemorrhage risk, so 4 units of packed red blood cells should be ordered.
- C. The patient is a low hemorrhage risk, so a hold tube should be drawn.
- D. The patient is a moderate hemorrhage risk, but blood is not drawn at this time.
Correct Answer: A
Rationale: Since the patient has a previous history of delivery and uterine fibroids, she is considered at moderate hemorrhage risk and a type and screen should be ordered.
The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply.
- A. Foul-smelling lochia
- B. Hot, red, painful breasts
- C. Mild headache
- D. Not sleeping well
Correct Answer: A
Rationale: The correct answer is A: Foul-smelling lochia. This indicates a possible infection in the uterus, which requires medical attention to prevent complications. Hot, red, painful breasts (B) may indicate mastitis, which also requires medical intervention. Mild headache (C) and not sleeping well (D) are common postpartum issues but do not typically require immediate medical attention. In summary, choices B, C, and D are incorrect because they are common postpartum symptoms that do not necessarily warrant contacting the primary care provider, unlike foul-smelling lochia (A), which could indicate a serious issue.
What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: The correct answer is A: Monitor for signs of sepsis. Postpartum endometritis is a bacterial infection of the uterine lining that can lead to sepsis if not treated promptly. Monitoring for signs of sepsis is crucial for early detection and intervention to prevent serious complications. Option B is incorrect because breastfeeding is encouraged to promote bonding and provide nutrition. Option C is incorrect as fundal assessment is necessary to monitor uterine involution. Option D is incorrect as increasing family visiting hours is not directly related to managing postpartum endometritis.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for hypertension
- B. risk for bleeding
- C. risk for fluid overload
- D. risk for breast-feeding failure
Correct Answer: B
Rationale: Coagulation disorders like von Willebrand increase the risk for bleeding and hemorrhage.
What is the term for the separation found in the midline of the abdomen after birth?
- A. uterine subinvolution
- B. umbilical hernia
- C. striae
- D. diastasis recti abdominus
Correct Answer: D
Rationale: Diastasis recti abdominus refers to the separation of the rectus muscles along the midline of the abdomen after birth.