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The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is showing signs of uterine atony, which is a common cause of postpartum hemorrhage. A soft, boggy fundus with displacement and moderate bleeding indicates inadequate uterine contractions. If uterine massage does not improve the condition, it is crucial to involve the healthcare provider immediately for further interventions such as administering uterotonic medications or considering manual removal of retained placental fragments. Options A and B are not the priority in this critical situation, and option C, administering oxytocin, can be done but the immediate action should be to seek guidance from the healthcare provider due to the severity of the condition.
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The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B because attending hospital classes on newborn and infant care involves intentional learning, where the couple actively seeks out knowledge and skills related to parenting. This choice allows them to receive structured education and guidance from professionals in a focused setting. Observing other individuals (choice A) may provide some insights but lacks the structured learning environment. Discussing their own upbringing (choice C) may be informative but does not necessarily involve intentional learning focused on acquiring new parenting skills. Watching media (choice D) may offer some information but lacks the interactive and hands-on learning experience provided by attending hospital classes.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority goal because monitoring lochia flow post-vaginal delivery helps assess for excessive bleeding, which is crucial for preventing postpartum hemorrhage. Choice A is not a priority in the immediate postpartum period. Choice B is important but not as critical as monitoring lochia flow. Choice D is also important for preventing complications but not as urgent as assessing for postpartum bleeding.
The nurse is providing education to a postpartum woman about exercises to strengthen the pelvis musculature. Which instruction should be included?
- A. "Ambulate three times a day."
- B. "Perform Kegel exercises."
- C. "Enroll in an aerobics class after discharge."
- D. "Do passive range-of-motion exercises while lying in bed."
Correct Answer: B
Rationale: The correct answer is B: "Perform Kegel exercises." Kegel exercises strengthen the pelvic floor muscles, which can help prevent urinary incontinence and improve pelvic organ support. Ambulating (choice A) is important for overall mobility but does not specifically target the pelvic muscles. Enrolling in an aerobics class (choice C) focuses on cardiovascular fitness and may not specifically strengthen the pelvis. Doing passive range-of-motion exercises (choice D) does not actively engage and strengthen the pelvic muscles. Kegel exercises are the most appropriate choice as they directly target the pelvic musculature to improve strength and function.
The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is the most important teaching because postpartum hemorrhage can be life-threatening and requires immediate medical attention. The other choices, while important, are not as urgent as secondary hemorrhage. A: Uterine infection signs and symptoms can develop gradually and usually do not pose an immediate threat. C: Postpartum depression is a serious concern but does not require immediate medical intervention. D: A boggy uterus can be a sign of uterine atony but does not necessarily indicate an emergency situation like secondary hemorrhage.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.