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The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because physical recovery from labor and delivery is a biological process rather than a cultural influence. The nurse assesses cultural influences, such as beliefs and practices, which shape the mother's experience of motherhood. Choices A, B, and D are influenced by cultural factors, such as time spent in each phase, expectations related to rest, and involvement in decision-making, respectively. These aspects reflect how cultural norms, values, and traditions impact the transition to motherhood.
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A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.
A postpartum patient comes to the clinic for her 6-week postpartum checkup. When assessing the patient's cervix, how should the nurse expect the cervix to appear?
- A. Noticeable small lacerations
- B. Approximately 3 cm dilated
- C. Symmetrically round external os
- D. Firm and thick
Correct Answer: C
Rationale: The correct answer is C: Symmetrically round external os. At 6 weeks postpartum, the cervix should have healed, and the external os should appear symmetrically round. This indicates proper healing and restoration of the cervix to its pre-pregnancy state. Small lacerations (choice A) would not be expected at this point as healing should have occurred. A dilation of 3 cm (choice B) is not appropriate as the cervix should be closed postpartum. A firm and thick cervix (choice D) would not be expected as the cervix should have softened and returned to its normal consistency by this time.
The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D: Information must be presented on an age-appropriate level. This is crucial as adolescents may have limited knowledge and understanding of neonatal care. Teaching in a way they can comprehend ensures effective learning.
Incorrect choices:
A: The involvement of grandparents is important but not the most critical factor.
B: Parental expectations are significant, but not directly related to neonatal care teaching.
C: The father's involvement is valuable, but not the primary consideration for teaching about neonatal care.
In summary, choosing answer D ensures effective communication and understanding for the adolescent mother and her family.
The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is showing signs of uterine atony, which is a common cause of postpartum hemorrhage. A soft, boggy fundus with displacement and moderate bleeding indicates inadequate uterine contractions. If uterine massage does not improve the condition, it is crucial to involve the healthcare provider immediately for further interventions such as administering uterotonic medications or considering manual removal of retained placental fragments. Options A and B are not the priority in this critical situation, and option C, administering oxytocin, can be done but the immediate action should be to seek guidance from the healthcare provider due to the severity of the condition.