Nokea
The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record?
- A. Abnormal involution, lochia rubra heavy.
- B. Abnormal involution, lochia serosa scant.
- C. Normal involution, lochia rubra moderate.
- D. Normal involution, lochia serosa heavy.
Correct Answer: C
Rationale: Lochia rubra is expected for the first few days postpartum, and the amount described here is moderate, which is normal.
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The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4 -6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: It is important to wait 4 -6 weeks before placing anything in the vagina to allow for physical recovery and reduce infection risk.
The nurse is assessing a patient who is 12 hours postpartum. The uterus is firm to palpation, at midline, and is 1 cm below the umbilicus with continuous heavy vaginal bleeding. What is the nurse’s first action?
- A. Massage the uterus and resume the IV Pitocin drip.
- B. Change the peri-pad and reassess the bleeding.
- C. Call the provider to check for a cervical laceration.
- D. Administer the ordered iron supplement and ibuprofen.
Correct Answer: A
Rationale: The correct answer is A: Massage the uterus and resume the IV Pitocin drip. The patient is showing signs of uterine atony with heavy vaginal bleeding. Massaging the uterus helps stimulate contractions, controlling bleeding. Resuming IV Pitocin enhances uterine contractions further. Choices B, C, and D are incorrect. Changing the peri-pad does not address the underlying cause of bleeding. Checking for a cervical laceration may be needed later but is not the immediate priority. Administering iron supplement and ibuprofen does not address the acute issue of uterine atony and bleeding.
Which of the following laboratory values would the nurse expect to see in a normal postpartum woman?
- A. Hematocrit, 39%.
- B. White blood cell count, 16,000 cells/mm3.
- C. Red blood cell count, 5 million cells/mm3.
- D. Hemoglobin, 15 grams/dL.
Correct Answer: B
Rationale: A slightly elevated white blood cell count is common postpartum due to the physiological stress of delivery and recovery.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient 's finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: A prolonged capillary refill and pale appearance suggest hypovolemiaand starting an IV bolus can help address fluid loss and support blood pressure.
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: Performing fundal massage is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony. Uterine atony is a common cause of postpartum hemorrhage, where the uterus fails to contract and retract after childbirth, leading to excessive bleeding. Fundal massage helps stimulate uterine contractions and assists in controlling the bleeding. Establishing venous access, preparing the woman for surgical intervention, and catheterizing the bladder are important interventions as well, but fundal massage takes priority in managing uterine atony and preventing further blood loss.