Nokea
The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period?
- A. Decreased urinary output.
- B. Increased blood pressure.
- C. Decreased blood volume.
- D. Increased estrogen level.
Correct Answer: C
Rationale: During the early postpartum period, the body loses blood volume, and the circulatory system adjusts to the new state, which can result in changes in vital signs.
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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: A
Rationale: Ambulation encourages circulation and reduces the risk of deep vein thrombosis (DVT) after cesarean birth.
A client G2 P1102 is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client 's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform?
- A. Assess her feet and ankles for pitting edema.
- B. Lower both of her legs at the same time.
- C. Advise the client to stop feeding her baby while her blood pressure is assessed.
- D. Measure the length of the episiotomy and document the findings in the chart.
Correct Answer: A
Rationale: The nurse should assess for signs of deep vein thrombosis (DVT) or pitting edema in the postpartum period, especially after stirrup use during delivery.
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
- A. assessment of partner changing a diaper
- B. assessment of vaginal bleeding
- C. assessment of social support
- D. assessment of family dynamics
Correct Answer: B
Rationale: Monitoring vaginal bleeding in the first 8 hours postpartum helps detect any potential complications such as postpartum hemorrhage.
What nursing intervention does the nurse include in the plan of care for a person with a wound infection?
- A. Reassure the postpartum person that infection will resolve without antibiotics.
- B. Assess for REEDA.
- C. Call health-care provider when temperature is 99.0° F.
- D. Scrub the incision vigorously with soap and water.
Correct Answer: B
Rationale: The correct answer is B: Assess for REEDA. REEDA stands for Redness, Edema, Ecchymosis, Drainage, and Approximation, which are key indicators of wound infection. By assessing for REEDA, the nurse can monitor and evaluate the progress of the infection. This intervention allows for early detection and prompt treatment of wound infections.
Choice A is incorrect because reassuring the postpartum person without antibiotics may lead to worsening infection. Choice C is incorrect as a temperature of 99.0° F is not necessarily indicative of a wound infection. Choice D is incorrect as scrubbing the incision vigorously with soap and water can introduce more bacteria and worsen the infection.
What is characteristic of an early (primary) PPH?
- A. occurs after 12 weeks postpartum
- B. is not an emergency
- C. often occurs due to uterine atony
- D. is diagnosed after the person is discharged
Correct Answer: C
Rationale: Early (primary) postpartum hemorrhage is usually due to uterine atony and requires immediate medical intervention.