Nokea
The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The primary care provider needs to be contacted about the assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed.
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A post -cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, 'I have decided to make sure that I feel as little pain from this experience as possible. ' Which of the following should the nurse conclude in relation to this woman 's behavior?
- A. The woman needs a stronger narcotic order.
- B. The woman is high risk for severe constipation.
- C. The woman 's breast milk volume may drop while taking the medicine.
- D. The woman 's newborn may become addicted to the medication.
Correct Answer: C
Rationale: Frequent use of narcotic analgesics can affect breast milk production, potentially causing a decrease in supply.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population.
Incorrect choices:
A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding.
C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder.
D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.
The nurse is caring for a birth mother who is relinquishing her newborn. What intervention is appropriate for the nurse?
- A. Use words like 'giving away your child' or 'giving up for adoption.'
- B. Tell the person not to hold the baby.
- C. Ask the person why she is giving up her baby.
- D. Ask about the patient 's expectations for having newborn photos or video.
Correct Answer: D
Rationale: The nurse should support the person's emotional needs including helping with decision-making and documenting memories.
The nurse notices the uterus is boggy and the bladder is full. What intervention should the nurse perform next?
- A. Call for help.
- B. Start IV bolus.
- C. Get the person out of bed to walk to restroom.
- D. Massage the fundus and assess the lochia.
Correct Answer: D
Rationale: A boggy uterus and full bladder may indicate uterine atonyand fundal massage is the first intervention to promote uterine contraction.
What is a risk factor for PPD?
- A. vaginal birth
- B. family support
- C. traumatic birth
- D. breast-feeding
Correct Answer: C
Rationale: PPD is more common after traumatic births and with lack of support.