Nokea
The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply.
- A. Foul-smelling lochia
- B. Hot, red, painful breasts
- C. Mild headache
- D. Not sleeping well
Correct Answer: A
Rationale: Foul-smelling lochia is a sign of infection. Hot, red, painful breasts are a sign of infection. Frequent, painful urination is a sign of infection.
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A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse 's first action should be to:
- A. Determine whether the bleeding slows to normal or remains as a large volume.
- B. Observe vital signs for signs of hypovolemic shock.
- C. Check to see what her previous lochia flow has been.
- D. Identify the type of pain relief that was given when she was in labor.
Correct Answer: A
Rationale: The nurse should first determine whether the bleeding slows or continues to be excessive, as it may be a normal occurrence post-ambulation or indicative of a complication.
The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance, the day before. The baby 's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate?
- A. Sometimes babies just don 't deliver the way we expect them to.
- B. With all of your preparations, it must have been disappointing for you to have had a cesarean.
- C. I know you had to have surgery, but you are very lucky that your baby was born healthy.
- D. At least your husband was able to be with you when the baby was born.
Correct Answer: B
Rationale: The nurse should acknowledge the emotional impact of an unplanned cesarean section while validating the mother's feelings.
An Asian client 's temperature 10 hours after delivery is 100.2°F, but when encouraged she refuses to drink her ice water. Which of the following nursing actions is most appropriate?
- A. Replace the ice water with hot water.
- B. Notify the client 's health care provider.
- C. Reassess the temperature in one half hour.
- D. Remind the client that drinking is very important.
Correct Answer: A
Rationale: Cultural preferences may influence responses to care. In some cultures, hot liquids are preferred, and providing hot water is culturally appropriate.
The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately?
- A. The uterus is displaced.
- B. The uterine fundus is boggy.
- C. Small clots are expressed with massage.
- D. Peripad weighs 100 g within 15 minutes.
Correct Answer: D
Rationale: The nurse will monitor the amount and characteristics of each patient’s lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss.
Why does the nurse encourage ambulation in a patient who has experienced a cesarean birth?
- A. Ambulation helps to prevent DVT.
- B. Ambulation causes the person to lose weight in the hospital.
- C. Ambulation helps with breast-feeding.
- D. Ambulation decreases peristalsis.
Correct Answer: B
Rationale: The correct answer is B because ambulation after a cesarean birth helps the patient to lose weight. Walking promotes circulation, aids in healing, and can prevent complications such as blood clots and pneumonia. It also helps to restore strength and energy levels. Choices A, C, and D are incorrect because ambulation primarily benefits the patient's overall well-being and recovery, rather than directly preventing DVT, aiding breastfeeding, or decreasing peristalsis.