Nokea
The nurse places one hand above the symphysis pubis during uterine massage to:
- A. Make the massage more comfortable for the woman.
- B. Increase the effectiveness of the procedure.
- C. Help prevent the uterus from inverting.
- D. Help determine the firmness of the uterus.
Correct Answer: C
Rationale: By placing a hand above the symphysis pubis, the nurse can help prevent uterine inversion and provide better support during the massage.
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What is one of the initial signs and symptoms of puerperal infection in the postpartum client?
- A. Fatigue continuing for longer than 1 week
- B. Pain with voiding
- C. Profuse vaginal lochia with ambulation
- D. Temperature of 38° C (100.4° F) or higher on 2 successive days
Correct Answer: D
Rationale: The correct answer is D because a temperature of 38°C (100.4°F) or higher on 2 successive days is a key sign of puerperal infection. This is due to the body's response to infection. Fatigue (choice A) can be a symptom but is nonspecific. Pain with voiding (choice B) may indicate a urinary tract infection. Profuse vaginal lochia (choice C) may be normal postpartum.
What is a risk factor for PPH found in the prenatal record?
- A. primipara
- B. rubella nonimmune
- C. von Willebrand disorder
- D. history of appendectomy
Correct Answer: C
Rationale: The correct answer is C: von Willebrand disorder. This is a risk factor for postpartum hemorrhage (PPH) as it can lead to abnormal bleeding during and after childbirth. von Willebrand disorder is a hereditary bleeding disorder that affects the blood's ability to clot properly. This can increase the likelihood of excessive bleeding during delivery, putting the mother at risk for PPH.
Choice A: primipara is incorrect, as being a first-time mother (primipara) is not a direct risk factor for PPH.
Choice B: rubella nonimmune is incorrect, as rubella immunity status is not directly related to the risk of PPH.
Choice D: history of appendectomy is incorrect, as a previous appendectomy is not a known risk factor for PPH.
In summary, the presence of von Willebrand disorder in the prenatal record is a significant risk factor for PPH due to its impact on blood clotting ability during childbirth.
A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination, the nurse notices warmth and redness over an enlarged, hardened area. Which condition should the nurse suspect, and how will it be confirmed?
- A. Disseminated intravascular coagulation (DIC); asking for laboratory tests
- B. von Willebrand disease (vWD); noting whether bleeding times have been extended
- C. Thrombophlebitis; using real-time and color Doppler ultrasound
- D. Idiopathic or immune thrombocytopenic purpura (ITP); drawing blood for laboratory analysis
Correct Answer: C
Rationale: The correct answer is C: Thrombophlebitis; using real-time and color Doppler ultrasound. Thrombophlebitis is the inflammation of a vein with the formation of a blood clot. In this scenario, the woman's symptoms of pain, tenderness, warmth, redness, and an enlarged, hardened area in her leg are indicative of thrombophlebitis. Using real-time and color Doppler ultrasound will confirm the diagnosis by visualizing the blood clot in the affected vein. This diagnostic method is effective in detecting thrombosis and determining the extent of the clot, guiding appropriate treatment.
Incorrect choices:
A: Disseminated intravascular coagulation (DIC) is a systemic process causing widespread clotting in small blood vessels, leading to bleeding. Asking for laboratory tests wouldn't be the appropriate way to confirm thrombophlebitis.
B: von Willebrand disease (vWD) is a genetic bleeding disorder, and checking
The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate?
- A. Irrigate the incision twice daily.
- B. Monitor the incision for drainage.
- C. Apply steristrips to the incision line.
- D. Palpate the incision and assess for pain.
Correct Answer: B
Rationale: Monitoring the incision for drainage is key post-surgery to assess for signs of infection or complications. Irrigating the incision is not a routine practice unless instructed by a physician.
A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion?
- A. The father may become sad and weepy.
- B. Postpartum blues last about a week or two.
- C. Medications are available to relieve the symptoms.
- D. Very few women experience postpartum blues.
Correct Answer: B
Rationale: Postpartum blues are common and typically last 1-2 weeks. Medications are usually not needed unless symptoms persist or worsen.