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 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.
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B. A postpartum WBC level of 30,000/mm is expected due to the physiological response to labor and delivery, known as leukocytosis. This is a normal finding as the body increases white blood cell production to fight off potential infections postpartum.
A: Patient feeling cold related to blood loss is more indicative of hypovolemia, a result of excessive blood loss, not a normal cardiovascular response postpartum.
C: Risk for hemorrhage due to decrease in clotting factors is incorrect as postpartum women actually have an increase in circulating clotting factors to prevent excessive bleeding.
D: A normal postpartum hemoglobin level of less than 11 g/dL is incorrect because a hemoglobin level below 11 g/dL would indicate anemia, not a normal postpartum finding.
The nurse is observing a new mother interact with her baby and notices the mother holding the baby close to her body. However, the nurse also notices that the mother does not hold the baby in an enface position. Which question is most appropriate for the nurse to ask?
- A. Can I help you with a nice position in which to hold your baby?'
- B. What can you tell me about your family's beliefs with new babies?'
- C. Is there some reason that I have not seen you look into your baby's eyes?'
- D. Your baby is so expressive, have you looked into his eyes yet?'
Correct Answer: B
Rationale: The correct answer is B: "What can you tell me about your family's beliefs with new babies?" This question allows the nurse to gather valuable cultural information that may explain the mother's behavior of not holding the baby in an enface position. Understanding the family's beliefs helps the nurse provide culturally sensitive care.
A: "Can I help you with a nice position in which to hold your baby?" - This question assumes the mother needs help with positioning, which may not be the case. It does not address the underlying reason for the mother's behavior.
C: "Is there some reason that I have not seen you look into your baby's eyes?" - This question is accusatory and may make the mother defensive. It does not consider cultural reasons for the behavior.
D: "Your baby is so expressive, have you looked into his eyes yet?" - This question assumes the mother has not looked into the baby's eyes, which may not be the case. It does not address the cultural
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: Step 1: Postpartum patients may have an increased WBC count due to the stress of delivery.
Step 2: A WBC level of 30,000/mm postpartum indicates a normal physiological response.
Step 3: This increase helps the body fight potential infections post-delivery.
Step 4: Therefore, choice B is correct as it aligns with normal postpartum physiology.
Summary: Choices A, C, and D are incorrect as they do not directly relate to postpartum physiology. A is more related to thermoregulation, C is about clotting factors, and D is about hemoglobin levels which may vary postpartum.
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: Correct Answer: D - Loss of fluid from expulsion of the placenta and amniotic fluid
Rationale:
1. During childbirth, the placenta and amniotic fluid are expelled, resulting in a sudden decrease in fluid volume in the body.
2. The body undergoes a physiological response known as postpartum diuresis to eliminate excess fluid accumulated during pregnancy.
3. This diuresis helps to restore the body's fluid balance and reduce the risk of postpartum edema.
4. Choices A, B, and C do not accurately represent the process of postpartum diuresis and are unrelated to the specific physiological changes following childbirth.