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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: A pale appearance with delayed capillary refill is indicative of shock and may require rapid intervention.
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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 caring for a postpartum woman and her 2-hour-old baby. The new mother has been preoccupied with breastfeeding and visitors, but suddenly she complains of dizziness and is light-headed. Which response by the nurse is appropriate?
- A. Explain that she needs to drink more fluids and eat because she needs to replace fluids and calories.
- B. Encourage the patient to rest, and ask a family member to watch the newborn in the crib.
- C. Tell the patient that the dizziness is probably caused by her pain medication and that it is normal.
- D. Obtain vital signs, assess fundal tone, and observe for excessive lochia.
Correct Answer: D
Rationale: Obtaining vital signs, assessing fundal tone, and observing for excessive lochia is appropriate to identify the cause of dizziness.
To help the postpartum woman avoid constipation, the nurse should teach her to:
- A. Avoid intake of foods such as milk, cheese, or yogurt.
- B. Take a laxative for the first 3 postpartum days.
- C. Drink at least 1600 mL of noncaffeinated fluids daily.
- D. Limit her walking until the episiotomy is fully healed.
Correct Answer: C
Rationale: Drinking at least 1600 mL of noncaffeinated fluids daily helps to prevent constipation by promoting hydration, which is essential in the postpartum period.
The nurse and provider estimate the blood loss at delivery to be 400 mL in the measuring drape; now when doing the initial perineal care, the nurse finds a large amount of blood underneath the patient. What action reflects safe and accurate nursing care?
- A. Estimate the amount of blood loss from the sheet and client clothing, and notify the physician.
- B. Encourage the mother to report any additional bleeding or clots.
- C. Draw the ordered hematocrit and notify the provider if the result is less than 28.
- D. Weigh the blood-soaked linens and notify the provider of the additional blood loss.
Correct Answer: D
Rationale: Weighing the blood-soaked linens is a safe and accurate method to estimate blood loss.
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.