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The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?
- A. Massage the uterus.
- B. Notify the obstetrician.
- C. Administer an oxytocic as ordered.
- D. Assist the client to the bathroom.
Correct Answer: C
Rationale: Oxytocics help control uterine atony and bleeding.
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A mother calls the nurse to her room because 'My baby's eyes are bleeding.' The nurse notes bright red hemorrhages in the sclerae of both of the baby's eyes. Which of the following actions by the nurse is appropriate at this time?
- A. Notify the pediatrician immediately and report the finding.
- B. Notify the social worker about the probable maternal abuse.
- C. Reassure the mother that the trauma resulted from pressure changes at birth and the hemorrhages will slowly disappear.
- D. Obtain an ophthalmoscope from the nursery to evaluate the red reflex and condition of the retina in each eye.
Correct Answer: C
Rationale: Subconjunctival hemorrhages are common and resolve spontaneously.
A nurse is developing a teaching plan for parents who are taking home their 2-day-old breastfed baby. Which of the following should the nurse include in the plan?
- A. Wash hands well before picking up the baby.
- B. Refrain from having visitors for the first month.
- C. Wear a mask to prevent transmission of a cold.
- D. Sterilize the breast pump supplies after every use.
Correct Answer: A
Rationale: Hand hygiene is crucial to prevent infection.
A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client?
- A. Seizures.
- B. Hemorrhage.
- C. Infection.
- D. Thrombosis.
Correct Answer: B
Rationale: Macrosomic babies increase the risk of postpartum hemorrhage.
A client who received an epidural for her operative delivery has vomited twice since the surgery. Which of the following prn medications ordered by the anesthesiologist should the nurse administer at this time?
- A. Reglan (metoclopramide).
- B. Demerol (meperidine).
- C. Seconal (secobarbital).
- D. Benadryl (diphenhydramine).
Correct Answer: A
Rationale: Reglan treats nausea.
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: Rationale for Correct Answer (A):
- A: Correct because postpartum women should avoid placing anything in the vagina to prevent infection and allow healing.
- B: Incorrect because ovulation can occur before the first postpartum period.
- C: Incorrect because resuming sexual intercourse should be based on individual healing and comfort, not just discharge.
- D: Incorrect because sexual intimacy is a normal part of relationships and should be discussed postpartum for emotional well-being.