Nokea
The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?
- A. To prevent uterine prolapse.
- B. To prevent uterine movement
- C. To prevent uterine hemorrhage
- D. To prevent uterine inversion
Correct Answer: D
Rationale: The correct answer is D: To prevent uterine inversion. Placing a hand just above the symphysis pubis helps support the uterus and prevent it from turning inside out. This is crucial postpartum to avoid complications such as hemorrhage and shock. Choices A, B, and C are incorrect as palpating the uterus in this manner is specifically aimed at preventing uterine inversion, not prolapse, movement, or hemorrhage.
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The nurse is researching for evidence-based practice related to a mother's response during the postpartum period. Based on research by Rubin and Mercer, which finding will the nurse be able to easily implement to change the culture of the unit?
- A. Satisfaction questionnaires
- B. Alterations in terminology
- C. Decrease nurse/patient ratios
- D. Soliciting paternal expectations
Correct Answer: B
Rationale: The correct answer is B: Alterations in terminology. Rubin and Mercer's research emphasizes the importance of language in shaping attitudes and behaviors during the postpartum period. By changing the terminology used in the unit to promote positive and empowering language, the nurse can easily implement this finding to change the unit's culture. This can have a significant impact on how mothers perceive their experiences and how they are supported.
Incorrect choices:
A: Satisfaction questionnaires - While important for feedback, satisfaction questionnaires do not directly address changing the culture of the unit.
C: Decrease nurse/patient ratios - This may improve patient care but does not specifically relate to changing the culture of the unit.
D: Soliciting paternal expectations - While involving fathers is important, it does not directly address changing the language and culture of the unit.
The nurse is assessing her patient, who is 1 day postpartum. The nurse notes that the fundus is firm and at midline, the lochia is moderate in amount, and the presence of rubra with two dime-sized clots is on her peri-pad. What should the nurse determine from these assessment findings?
- A. They are normal.
- B. They indicate the presence of infection.
- C. The physician should be notified of the abnormal findings.
- D. The patient should be instructed to increase her fluid intake.
Correct Answer: A
Rationale: The correct answer is A, as the assessment findings described are normal for a patient who is 1 day postpartum. A firm and midline fundus indicates proper uterine involution. Moderate lochia is expected at this stage, and the presence of small clots is normal. The overall picture suggests the normal process of healing after childbirth.
Choice B is incorrect because the assessment findings do not indicate signs of infection such as foul-smelling lochia, fever, or elevated white blood cell count.
Choice C is incorrect as there are no abnormal findings that would warrant immediate notification of the physician.
Choice D is incorrect as there is no indication from the assessment findings that the patient needs to increase her fluid intake; the findings are within the expected range for a patient 1 day postpartum.
The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding/attachment. Which situations does the nurse NOT recognize as a cause for bonding/attachment problems?
- A. The mother experienced eclampsia in the third trimester of pregnancy.
- B. The neonate is being treated for meconium aspiration syndrome.
- C. The mother experienced dystocia in the second phase of labor.
- D. The father of the neonate is in the military and not yet home on leave.
Correct Answer: D
Rationale: The correct answer is D because the father being in the military and not yet home on leave does not directly impact bonding/attachment between the parents and the neonate. Bonding issues are typically related to factors such as maternal health conditions (choice A), neonatal health complications (choice B), or labor complications experienced by the mother (choice C). In contrast, the father's absence due to military service, while potentially challenging emotionally, does not inherently cause bonding/attachment problems as the mother and baby can still form a strong attachment bond. Choices A, B, and C are incorrect as they can directly affect the bonding/attachment process due to physical health issues of the mother and baby during pregnancy and labor.
The nurse is assessing her patient, who is 1 day postpartum. The nurse notes that the fundus is firm and at midline, the lochia is moderate in amount, and the presence of rubra with two dime-sized clots is on her peri-pad. What should the nurse determine from these assessment findings?
- A. They are normal.
- B. They indicate the presence of infection.
- C. The physician should be notified of the abnormal findings.
- D. The patient should be instructed to increase her fluid intake.
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct:
1. Fundus is firm and at midline: Indicates normal involution of the uterus post-delivery.
2. Lochia is moderate with rubra and small clots: Expected findings in the early postpartum period.
3. Overall assessment findings within normal range: Indicate normal postpartum recovery.
Summary of why other choices are incorrect:
B. Presence of infection would usually be indicated by abnormal signs such as foul-smelling lochia or fever, which are absent in this case.
C. No abnormal findings are present that would necessitate physician notification.
D. Fluid intake is important postpartum, but there are no signs in this scenario indicating a need for increased fluid intake.
The nurse is educating a new postpartum woman about peri-care. Which action by the client indicates understanding?
- A. The woman applied her peri-pad from back to front.
- B. The woman performed peri-care three times a day.
- C. The woman washed her hands before and after performing peri-care.
- D. The woman mixed tap water and hydrogen peroxide in her peri-bottle.
Correct Answer: C
Rationale: The correct answer is C because washing hands before and after performing peri-care is essential to prevent the spread of infections. Before touching the perineal area, proper hand hygiene reduces the risk of introducing harmful bacteria. After caring for the perineum, washing hands again prevents transferring any bacteria to other parts of the body. This demonstrates understanding of infection prevention.
Choice A is incorrect because applying the peri-pad from back to front can introduce bacteria from the rectal area to the vaginal area, increasing the risk of infection.
Choice B is incorrect because the frequency of performing peri-care depends on individual needs and hygiene practices, so stating a fixed number of times is not indicative of understanding.
Choice D is incorrect because mixing tap water and hydrogen peroxide in the peri-bottle is not a recommended practice for peri-care and may cause irritation or disrupt the natural balance of the vaginal flora.