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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 during uterine palpation helps prevent uterine inversion by providing support to the lower segment of the uterus. Uterine prolapse (A) is the downward displacement of the uterus, which is not prevented by this action. Uterine movement (B) is a natural occurrence and not a concern during palpation. Uterine hemorrhage (C) is more related to postpartum bleeding management and is not directly impacted by the hand placement.
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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.
Which best represents the process of postpartum diuresis in a postpartum client?
- A. A nervous response to vasomotor changes
- B. Elimination of excess fluid through the skin
- C. Underarm perspiration that occurs after ambulation
- D. Loss of fluid from expulsion of the placenta and amniotic fluid
Correct Answer: D
Rationale: Postpartum diuresis is the increased urine output that occurs after childbirth. The correct answer, D, explains this process accurately as the loss of fluid from expulsion of the placenta and amniotic fluid triggers the body to eliminate excess fluid through increased urination. Choice A is incorrect as it does not directly relate to the process of postpartum diuresis. Choice B is incorrect because excess fluid is primarily eliminated through urine, not the skin. Choice C is incorrect as underarm perspiration is not a significant factor in postpartum diuresis.
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 focuses on the importance of language and terminology used during the postpartum period. By implementing changes in the unit's terminology to be more supportive and empowering for mothers, the nurse can positively impact the culture of the unit. This can help create a more nurturing and understanding environment for new mothers.
Incorrect choices:
A: Satisfaction questionnaires are not directly related to changing the culture of the unit based on Rubin and Mercer's research.
C: Decreasing nurse/patient ratios may improve patient care but is not specifically mentioned in the research as a way to change the unit's culture.
D: Soliciting paternal expectations is not the focus of Rubin and Mercer's research, which is centered on the mother's response during the postpartum period.
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 postpartum experiences. By changing terminologies used in the unit to be more supportive and empowering, the nurse can easily implement this finding to positively change the culture. Satisfaction questionnaires (A) may not directly address cultural change. Decreasing nurse/patient ratios (C) may require significant resources and restructuring. Soliciting paternal expectations (D) focuses on a different aspect and may not directly impact unit culture.
A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D because general soreness is not a typical source of pain that postpartum patients experience. Uterine contractions, perineal trauma, and breast engorgement are common sources of pain in postpartum patients due to the physiological changes and processes associated with childbirth. General soreness is too vague and nonspecific to specifically assess for in this context. It is important for the nurse to focus on assessing and managing the more common sources of postpartum pain to provide effective care and support for the patient's recovery.