Nokea
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, 'I really don 't need to go. ' Which of the following responses by the nurse is appropriate?
- A. Okay. I must be palpating your uterus.
- B. I understand but I still would like you to try to urinate.
- C. You still must be numb from the local anesthesia.
- D. That is a problem. I will have to catheterize you.
Correct Answer: B
Rationale: A distended bladder can lead to complications such as uterine atony. The nurse should encourage the woman to attempt urination, but if she refuses, further action may be necessary.
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The nurse is caring for a woman who is 6 hours postpartum after a vaginal delivery. She has a history of labial varicose veins and is reporting perineal pain of 8 on a 10-point scale. What interventions should the nurse include in the plan of care?
- A. Provide the patient with an inflatable donut ring to sit on and administer her oral pain medication.
- B. Explain that this is normal after a vaginal delivery and assist her to a side-lying position.
- C. Assess the perineum for a hematoma or inflamed varicosities, and administer oral pain medication.
- D. Administer oral stool softeners and encourage fluids.
Correct Answer: C
Rationale: The correct answer is C because it addresses the patient's specific issue of perineal pain related to her history of labial varicose veins. By assessing the perineum for a hematoma or inflamed varicosities, the nurse can identify the cause of the pain and provide appropriate treatment. Administering oral pain medication targets the source of discomfort.
Choice A is incorrect because providing an inflatable donut ring may offer temporary relief but does not address the underlying cause of the pain. Administering oral pain medication alone may not be sufficient without assessing the perineum.
Choice B is incorrect because dismissing the patient's pain as normal without further assessment can lead to overlooking potential complications. Assisting the patient to a side-lying position does not address the pain.
Choice D is incorrect because administering stool softeners and encouraging fluids may be beneficial for postpartum care but does not directly address the patient's perineal pain related to varicose veins.
A new father tells a nurse friend that his wife is agitated and acting in a bizarre fashion. She says that she hears voices. Her baby is 2 weeks old. The father is concerned about the care the mother is giving the baby. The nurse should:
- A. Tell the father that this is severe postpartum blues and will pass in a few days if he shows enough support.
- B. Suggest that the father try talking to his wife to find out what is bothering her about being a new mother.
- C. Explain that the mother will probably need psychotherapy and refer him to support groups.
- D. Tell the father to call the physician immediately and not to leave the woman alone with the baby.
Correct Answer: D
Rationale: The symptoms described may indicate postpartum psychosis a serious condition that requires immediate medical intervention to ensure the safety of both the mother and the baby.
What would a steady trickle of bright red blood from the vagina in the presence of a firm fundus suggest to the nurse?
- A. Uterine atony
- B. Lacerations of the genital tract
- C. Perineal hematoma
- D. Infection of the uterus
Correct Answer: A
Rationale: The steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests uterine atony. Uterine atony is a condition where the uterus fails to contract effectively after childbirth, resulting in postpartum hemorrhage. The firm fundus indicates that the uterus is not properly contracting to control bleeding, leading to the continuous flow of blood from the vagina. Prompt intervention is crucial to manage uterine atony and prevent further complications such as excessive blood loss.
The nurse is assisting the primary care provider with the third stage of a vaginal delivery. The patient is multiparous, experienced a precipitous birth, and has a history of hypertension. Which medical prescription does the nurse anticipate for this patient?
- A. Methylergonovine
- B. Fresh frozen plasma
- C. Carboprost-tromethamine
- D. Magnesium sulfate
Correct Answer: C
Rationale: Carboprost-tromethamine is classified as a prostaglandin and is prescribed to maintain contraction of the uterine muscles.
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: The correct answer is D: WBCs 10,000. An elevated white blood cell count (WBC) is a common sign of infection as the body produces more WBCs to fight off pathogens. This increase in WBC count is known as leukocytosis and is a key indicator of an ongoing infection. In contrast, choices A, B, and C are not direct indicators of infection. A painful fundal massage may suggest uterine atony, breast-feeding every 2-3 hours is a normal part of postpartum care, and a pulse rate of 72 is within the normal range. Therefore, the most reliable assessment finding suggesting a possible infection is an elevated WBC count.