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The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states 'I don 't use those. I always use tampons. ' Which of the following actions by the nurse is appropriate at this time?
- A. Remove the peripad and insert a tampon into the woman 's vagina.
- B. Advise the client that for the first two days she will be bleeding too heavily for a tampon.
- C. State that it is unsafe to place anything into the vagina until involution is complete.
- D. Remind the client that a tampon would hurt until the soreness from the delivery resolves.
Correct Answer: B
Rationale: The nurse should explain that for the first two days after delivery, the bleeding is too heavy to use tampons, and this could increase the risk of infection.
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The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate?
- A. Positive bonding and client needs little teaching.
- B. Positive bonding but teaching related to newborn care is needed.
- C. Poor bonding and referral to a child abuse agency is essential.
- D. Poor bonding but there is potential for positive mothering.
Correct Answer: B
Rationale: The mother is engaging with the baby, indicating positive bonding, but further teaching on newborn care is still necessary.
A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient’s medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply.
- A. Neonatal macrosomia
- B. Use of a vacuum extractor
- C. Poor oral fluid intake
- D. Urinary catheter during labor
Correct Answer: C
Rationale: The correct answer is C: Poor oral fluid intake. Postpartum patients are at increased risk for UTIs due to physiological changes and decreased fluid intake. Poor hydration can lead to concentrated urine, making it easier for bacteria to grow. Neonatal macrosomia (A) and use of a vacuum extractor (B) are not directly associated with UTIs. While a urinary catheter during labor (D) can increase the risk of UTIs, it is not the most relevant factor in this scenario compared to poor oral fluid intake.
The nurse is aware of concern about the increasing numbers of severe maternal morbidity (SMM). It is believed to be related to changes in the overall health of the population of women giving birth. Which reasons does the nurse identify as causes of SMM? Select all that apply.
- A. Increases in maternal age
- B. Prepregnancy obesity
- C. Cesarean deliveries
- D. Inability to pay for health care
Correct Answer: B
Rationale: The correct answer is B: Prepregnancy obesity. This is because obesity is a well-established risk factor for severe maternal morbidity. Obesity increases the likelihood of complications during pregnancy and childbirth, such as gestational diabetes, preeclampsia, and cesarean deliveries.
A: Increases in maternal age may be a risk factor for certain complications but not directly related to SMM.
C: Cesarean deliveries can be a risk factor for SMM, but it is not the main cause.
D: Inability to pay for health care is a social determinant of health and may impact access to care, but it is not a direct cause of SMM.
A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with 'latch on ' and recommends that the mother do which of the following?
- A. Use a nipple shield at each breastfeeding.
- B. Cleanse the nipples with soap 3 times a day.
- C. Rotate the baby 's positions at each feed.
- D. Bottle feed for 2 days then resume breastfeeding.
Correct Answer: C
Rationale: Rotating positions during breastfeeding helps to prevent sore spots and promotes proper latch.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.