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The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: The correct answer is B: WBC laboratory level of 30,000/mm a few hours after delivery. Postpartum, a temporary increase in white blood cells (WBCs) is normal due to the body's response to delivery and potential inflammation. This increase is known as leukocytosis and helps the body combat potential infections. The other choices are incorrect because: A is more related to hypovolemia than to cardiovascular changes. C is incorrect as clotting factors increase postpartum to reduce the risk of hemorrhage. D is incorrect as a hemoglobin level less than 11 g/dL postpartum may indicate anemia, not normalcy.
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The nurse is educating a new postpartum woman about peri-care. Which action by the client indicates understanding?
- A. The woman applied her peri-pad from back to front.
- B. The woman performed peri-care three times a day.
- C. The woman washed her hands before and after performing peri-care.
- D. The woman mixed tap water and hydrogen peroxide in her peri-bottle.
Correct Answer: C
Rationale: The correct answer is C because washing hands before and after performing peri-care is crucial to prevent infection. Beforehand, it reduces the risk of introducing harmful bacteria into the perineal area. Afterward, it prevents potential contamination of hands. This action demonstrates understanding of maintaining proper hygiene during peri-care.
Explanation of other choices:
A: Applying the peri-pad from back to front is incorrect as it can introduce bacteria from the rectal area to the vaginal area, increasing the risk of infection.
B: Performing peri-care three times a day is not necessarily an indication of understanding proper technique and hygiene. Frequency alone does not ensure correct practice.
D: Mixing tap water and hydrogen peroxide in the peri-bottle is not recommended as it can disrupt the natural flora in the perineal area and cause irritation.
Which best represents the process of postpartum diuresis in a postpartum client?
- A. A nervous response to vasomotor changes
- B. Elimination of excess fluid through the skin
- C. Underarm perspiration that occurs after ambulation
- D. Loss of fluid from expulsion of the placenta and amniotic fluid
Correct Answer: D
Rationale: Postpartum diuresis is the increased urine output that occurs after childbirth. The correct answer, D, explains this process accurately as the loss of fluid from expulsion of the placenta and amniotic fluid triggers the body to eliminate excess fluid through increased urination. Choice A is incorrect as it does not directly relate to the process of postpartum diuresis. Choice B is incorrect because excess fluid is primarily eliminated through urine, not the skin. Choice C is incorrect as underarm perspiration is not a significant factor in postpartum diuresis.
The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis?
- A. To prevent uterine prolapse.
- B. To prevent uterine movement
- C. To prevent uterine hemorrhage
- D. To prevent uterine inversion
Correct Answer: D
Rationale: The correct answer is D: To prevent uterine inversion. Placing a hand just above the symphysis pubis helps support the uterus and prevent it from turning inside out. This is crucial postpartum to avoid complications such as hemorrhage and shock. Choices A, B, and C are incorrect as palpating the uterus in this manner is specifically aimed at preventing uterine inversion, not prolapse, movement, or hemorrhage.
The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system?
- A. Patient reporting of being cold related to blood loss
- B. WBC laboratory level of 30,000/mm a few hours after delivery
- C. Risk for hemorrhage due to decrease in circulating clotting factors
- D. A normal postpartum hemoglobin laboratory value of less than 11 g/dL
Correct Answer: B
Rationale: Step 1: Postpartum patients may have an increased WBC count due to the stress of delivery.
Step 2: A WBC level of 30,000/mm postpartum indicates a normal physiological response.
Step 3: This increase helps the body fight potential infections post-delivery.
Step 4: Therefore, choice B is correct as it aligns with normal postpartum physiology.
Summary: Choices A, C, and D are incorrect as they do not directly relate to postpartum physiology. A is more related to thermoregulation, C is about clotting factors, and D is about hemoglobin levels which may vary postpartum.
A postpartum patient states, " am really in pain."For which sources of pain will the nurse not assess the patient?
- A. Uterine contractions
- B. Perineal trauma
- C. Breast engorgement
- D. General soreness
Correct Answer: D
Rationale: The correct answer is D because general soreness is a vague and nonspecific term that does not provide any specific information on the source or type of pain. In contrast, uterine contractions, perineal trauma, and breast engorgement are common sources of postpartum pain with specific anatomical locations and characteristics. Assessing for general soreness would not lead to identifying potential underlying issues or appropriate interventions. It is important to focus on assessing specific sources of pain to provide targeted care for the postpartum patient.