Nokea
The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient’s care plan? (Select all that apply.)
- A. Sitz baths four times a day
- B. Use of only warm water with the sitz baths
- C. Topical anesthetic spray after perineal care
- D. Ice pack to the perineum for the first 24 hours
Correct Answer: A
Rationale: The correct answer is A: Sitz baths four times a day. Sitz baths promote healing, reduce swelling, and provide comfort after a vaginal birth. Warm water helps to soothe the perineal area. Choices B, C, and D are incorrect because using warm water alone may not be as effective as sitz baths, topical anesthetic spray may not be necessary for routine care, and ice packs may not be recommended for the first 24 hours due to the risk of vasoconstriction and decreased blood flow to the area.
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The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
- A. Temperature is elevated, a sign of infection.
- B. Pulse is too low, a sign of vagal pathology.
- C. Respirations are too low, a sign of medication toxicity.
- D. Blood pressure is elevated, a sign of preeclampsia.
Correct Answer: C
Rationale: Low respirations may indicate opioid toxicity.
A client is 3 days post-cesarean delivery for eclampsia. The client is receiving hydralazine (Apresoline) 10 mg 4 times a day by mouth. Which of the following findings would indicate that the medication is effective?
- A. The client has had no seizures since delivery.
- B. The client's blood pressure has dropped from 160/120 to 130/90.
- C. The client's postoperative weight has dropped from 154 to 144 lb.
- D. The client states that her headache is gone.
Correct Answer: B
Rationale: Hydralazine lowers blood pressure.
Which of the following actions would encourage the baby to open the mouth wide for feeding?
- A. Holding the baby in the en face position.
- B. Pushing down on the baby's lower jaw.
- C. Tickling the baby's lips with the nipple.
- D. Giving the baby a trial bottle of formula.
Correct Answer: C
Rationale: Tickling the lips stimulates rooting reflex.
The nurse is evaluating the effectiveness of an intervention when assisting a woman whose baby has been latched to the nipple only rather than to the nipple and the areola. Which response would indicate that further intervention is needed?
- A. The client states that the pain has decreased.
- B. The nurse hears the baby swallow after each suck.
- C. The baby's jaws move up and down once every second.
- D. The baby's cheeks move in and out with each suck.
Correct Answer: C
Rationale: Rapid jaw movements without swallowing suggest ineffective feeding.
The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
- A. Saturated peripad
- B. 10 to 15 cm (4- to 6-inch) stain on the peripad
- C. 2.5 to 10 cm (1- to 4-inch) stain on the peripad
- D. Less than a 1-inch stain on the peripad
Correct Answer: B
Rationale: The correct answer is B (10 to 15 cm (4- to 6-inch) stain on the peripad) because a moderate amount of lochia typically indicates a blood stain of 10 to 15 cm within 1 hour postpartum. This amount of lochia signifies a normal postpartum bleeding pattern.
Incorrect answers:
A: Saturated peripad indicates a heavy amount of lochia, not moderate.
C: 2.5 to 10 cm (1- to 4-inch) stain on the peripad is considered light, not moderate.
D: Less than a 1-inch stain on the peripad is minimal lochia, not moderate.