Nokea
The nurse is preparing to do a morning assessment on a 24-hour postpartum patient. Which nursing intervention is most appropriate initially?
- A. Massage the fundus until it is firm.
- B. Instruct the mother to void prior to the assessment.
- C. Assess the lochia flow while massaging the fundus.
- D. Lower the head of the bed and have the mother lie flat.
Correct Answer: B
Rationale: The correct initial nursing intervention is to instruct the mother to void prior to the assessment (choice B). This is important as a full bladder can interfere with the accuracy of the fundal assessment. By ensuring the mother voids first, the nurse can accurately assess the fundus for any signs of excessive bleeding or abnormalities. This step is crucial in monitoring the postpartum patient's well-being.
Choice A is incorrect as massaging the fundus should come after assessing the lochia flow to prevent potential complications. Choice C is also incorrect as assessing the lochia flow should occur before massaging the fundus. Choice D is incorrect as lowering the head of the bed and having the mother lie flat is not necessary for a postpartum assessment.
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As a result of the previously mentioned research study, the nurses in a postpartum facility will implement which evidence-based change?
- A. Continue to assess the level of fatigue for the mother during postpartum period.
- B. Assist fathers in recognizing and managing stress and depressive symptoms.
- C. Encourage the father to go home and rest while the mother is hospitalized.
- D. Promote strategies to decrease fatigue during both prenatal and postnatal periods.
Correct Answer: D
Rationale: The correct answer is D because promoting strategies to decrease fatigue during both prenatal and postnatal periods aligns with the goal of improving maternal well-being and outcomes. This approach focuses on preventive measures to address fatigue before and after childbirth, which can positively impact the mother's recovery and overall health. Assessing fatigue (Option A) is important but addressing strategies to decrease it is more proactive. Assisting fathers (Option B) is valuable, but the primary focus should be on the mother's well-being in a postpartum facility. Encouraging the father to rest (Option C) may not address the mother's needs or promote her recovery effectively.
The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?
- A. To validate the presence of clotting
- B. To determine the presence of tissue
- C. To obtain an accurate description
- D. To document the number of clots
Correct Answer: B
Rationale: The correct answer is B: To determine the presence of tissue. By examining the large collected clots, the nurse can differentiate between clots and actual tissue, which is crucial for identifying any potential complications postpartum. This step ensures accurate assessment and appropriate intervention if necessary.
Incorrect choices:
A: To validate the presence of clotting - This is not necessary as the presence of large clots already indicates clotting.
C: To obtain an accurate description - While important, the primary purpose of examining large clots in this context is to differentiate tissue from clots.
D: To document the number of clots - While documenting the number of clots is important, it is not the main reason for examining them in this scenario.
As a result of the previously mentioned research study, the nurses in a postpartum facility will implement which evidence-based change?
- A. Continue to assess the level of fatigue for the mother during postpartum period.
- B. Assist fathers in recognizing and managing stress and depressive symptoms.
- C. Encourage the father to go home and rest while the mother is hospitalized.
- D. Promote strategies to decrease fatigue during both prenatal and postnatal periods.
Correct Answer: D
Rationale: The correct answer is D because promoting strategies to decrease fatigue during both prenatal and postnatal periods aligns with evidence-based practice to improve maternal health outcomes. This approach acknowledges the importance of preventive measures to address fatigue before and after childbirth. Option A focuses solely on assessing fatigue without addressing interventions to mitigate it. Option B, while relevant, does not directly impact maternal fatigue. Option C overlooks the father's role in supporting the mother and infant. In summary, option D is the most appropriate as it addresses fatigue proactively throughout the perinatal period.
The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots?
- A. To validate the presence of clotting
- B. To determine the presence of tissue
- C. To obtain an accurate description
- D. To document the number of clots
Correct Answer: B
Rationale: The correct answer is B: To determine the presence of tissue. By examining the large collected clots, the nurse can identify if there is any tissue present, which could indicate a potential complication like retained placental tissue. This is crucial for the patient's health and further management.
Incorrect choices:
A: To validate the presence of clotting - This is not the primary reason for examining the clots in this scenario.
C: To obtain an accurate description - While important, the main focus is on identifying tissue presence.
D: To document the number of clots - The primary concern is not the number of clots but rather the presence of tissue.
The nurse is educating the postpartum client on lactation suppression. Which instructions to the client regarding lactation suppression should be included? Select all that apply.
- A. "Take warm showers twice a day."
- B. "Pump each breast three times a day."
- C. "Apply a heating pad to each breast."
- D. "Wear a well-fitting bra for the first 5 to 6 days."
Correct Answer: D
Rationale: Rationale: Option D is correct because wearing a well-fitting bra provides support and pressure on the breasts, which can help reduce milk production. The compression can help suppress lactation.
Summary of Incorrect Choices:
A: Taking warm showers can actually stimulate milk production, so it would not help in lactation suppression.
B: Pumping each breast can also stimulate milk production, which is counterproductive for lactation suppression.
C: Applying a heating pad can increase blood flow to the breasts, leading to increased milk production and is not recommended for lactation suppression.