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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.
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Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate?
- A. Provide the woman with warm blankets.
- B. Put the woman in the Trendelenburg position.
- C. Notify the primary health care provider.
- D. Increase the intravenous infusion.
Correct Answer: A
Rationale: Shaking or chills immediately after delivery is common due to the drop in body temperature. Providing warm blankets helps alleviate this discomfort.
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: Painful fundal massage can indicate a potential infection.
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate?
- A. Suggest that the woman bottle feed for a few days.
- B. Instruct the patient on how to massage her fundus.
- C. Instruct the patient to feed using an alternate position.
- D. Discuss the action of breastfeeding hormones.
Correct Answer: D
Rationale: Breastfeeding stimulates the release of oxytocin, which causes uterine contractions that may lead to cramping.
A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed?
- A. Respiratory rate 8 rpm.
- B. Complaint of thirst.
- C. Urinary output of 250 mL/hr.
- D. Numbness of feet and ankles.
Correct Answer: A
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, which must be reported immediately as a potential complication of narcotic use.
The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room?
- A. Ask the patient how many peripads she considered to be “soaked.”
- B. Collect blood in calibrated, under-buttocks drapes for vaginal birth.
- C. Place a basin at the foot of the delivery table to catch any blood.
- D. Rely on the primary health care provider’s estimate of blood loss.
Correct Answer: B
Rationale: The correct answer is B because collecting blood in calibrated, under-buttocks drapes for vaginal birth allows for a more accurate estimation of postpartum blood loss. This method provides a quantitative measurement, unlike the subjective method in option A. Option C does not provide a direct measurement of blood loss and may not be accurate. Option D relies on the health care provider's estimate, which may not always be precise or consistent. By using calibrated drapes, the nurse can easily measure and monitor blood loss, ensuring better patient care and outcomes.