Nokea
The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.)
- A. Leave abdominal dressing open to air.
- B. Position patient with back to water stream.
- C. Cover infusion site with rubber glove.
- D. Provide a shower chair.
- E. Confirm ambulation ability.
Correct Answer: B,C,D,E
Rationale: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.
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A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia?
- A. Lochia should disappear 2 to 4 weeks postpartum.
- B. It is normal for the lochia to have a slightly foul odor.
- C. A change in lochia from pink to bright red should be reported.
- D. A decrease in flow will be noticed with ambulation and activity.
Correct Answer: C
Rationale: A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.
What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.)
- A. Abdominal tighteners
- B. Head lift
- C. Pelvic tilt
- D. Kegel exercises
- E. Leg lifts
Correct Answer: A,B,C,D
Rationale: Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.
What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
- A. Well-contracted with its upper border at or just below the umbilicus
- B. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
- C. Relaxed with its upper border level with the umbilicus
- D. Relaxed with its upper border two or three fingerbreadths below the umbilicus
Correct Answer: A
Rationale: Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.
What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?
- A. Ask, 'Is this your band number?'
- B. Confirm room number of mother.
- C. Ask the mother to identify herself verbally.
- D. Check the band number of the infant with that of the mother.
Correct Answer: D
Rationale: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.
Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.)
- A. Thin, transparent skin
- B. Vernix only in the body creases
- C. Folded ear springs back slowly
- D. Breast tissue under the nipple
- E. Creases over entire sole
Correct Answer: A,C
Rationale: The only signs of preterm are the thin skin and the slowly responding ear.