Nokea
The nurse recognizes the postpartum person is in what stage of Rubin 's attachment model when the person is concerned with physical recovery and depends on the nurse or partner for help physically?
- A. Taking In
- B. Taking Hold
- C. Postpartum Maternal Change
- D. Attainment of Change
Correct Answer: A
Rationale: In the 'Taking In' stage the postpartum person is primarily concerned with their physical recovery and may need support from the nurse or partner.
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The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The correct answer is C: Contact the primary care provider for further evaluation. The patient's symptoms of severe perineal pain, discoloration on the labia, and tenderness indicate a potential complication such as hematoma or infection. Contacting the primary care provider is essential for prompt assessment and appropriate intervention to prevent further complications. Continuing to apply ice (A) may not address the underlying issue and could potentially worsen the condition. Monitoring vital signs (B) is important but may not provide direct insight into the specific problem. Relieving pressure by placing the patient in a side-lying position (D) is not the priority in this situation and may not address the underlying cause of the symptoms.
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.
The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation?
- A. Blood pressure may be elevated from prenatal conditions.
- B. Respirations are increased due to activity of labor.
- C. Changes in blood pressure may not be an immediate sign.
- D. Heart rate may increase with intensity of labor.
Correct Answer: C
Rationale: Changes in blood pressure may not be an immediate sign of hemorrhage in a postpartum patient. OB patients may not show the same signs and symptoms observed in nonpregnant patients during hemorrhage until approximately one-third of the woman’s entire blood volume is lost.
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: The correct answer is D. Weighing the blood-soaked linens provides an accurate measurement of the additional blood loss, which is crucial for assessing the patient's condition accurately. Here's the rationale step-by-step:
1. Weighing the blood-soaked linens is an objective and precise method to quantify the additional blood loss.
2. This measurement helps to determine the total blood loss accurately, which is essential for assessing postpartum hemorrhage.
3. Providing this quantitative data to the provider enables them to make informed decisions about further interventions.
4. Estimating blood loss visually is subjective and can be inaccurate, leading to potential underestimation or overestimation.
5. Drawing hematocrit levels (choice C) may provide valuable information but does not directly address the immediate need to quantify the additional blood loss.
6. Encouraging the mother to report bleeding (choice B) is important for ongoing assessment but does not provide an objective measurement of the blood loss.
In summary
The nurse is developing a plan of care for the postpartum client during the 'taking in ' phase. Which of the following should the nurse include in the plan?
- A. Teach baby-care skills like diapering.
- B. Discuss the labor and birth with the mother.
- C. Discuss contraceptive choices with the mother.
- D. Teach breastfeeding skills like pumping.
Correct Answer: B
Rationale: During the 'taking in' phase, the mother is focused on her own recovery and reliving the birth experience. Discussing the labor and birth is appropriate at this time.