Nokea
The nurse should suspect puerperal infection when a client exhibits which of the following?
- A. Temperature of 100.2°F.
- B. White blood cell count of 14,500 cells/mm3.
- C. Diaphoresis during the night.
- D. Malodorous lochial discharge.
Correct Answer: D
Rationale: Malodorous discharge is a classic sign of infection.
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Postpartal overdistention of the bladder and urinary retention can lead to which complication?
- A. Fever and increased blood pressure
- B. Postpartum hemorrhage and eclampsia
- C. Urinary tract infection and uterine rupture
- D. Postpartum hemorrhage and urinary tract infection
Correct Answer: C
Rationale: Rationale: Postpartal overdistention of the bladder and urinary retention can lead to urinary tract infection and uterine rupture. When the bladder is overdistended, it can cause urinary stasis, leading to bacterial growth and increasing the risk of urinary tract infections. Additionally, the pressure from the distended bladder can impede uterine contractions, potentially causing uterine rupture. Fever and increased blood pressure (Choice A) are not direct complications of bladder overdistention. Postpartum hemorrhage and eclampsia (Choice B) are not typically associated with bladder overdistention. Postpartum hemorrhage and urinary tract infection (Choice D) are not as directly related to the complications of bladder overdistention as urinary tract infection and uterine rupture are.
The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0°F, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings?
- A. Temperature is elevated, a sign of infection.
- B. Pulse is too low, a sign of vagal pathology.
- C. Respirations are too low, a sign of medication toxicity.
- D. Blood pressure is elevated, a sign of preeclampsia.
Correct Answer: C
Rationale: Low respirations may indicate opioid toxicity.
A 4-day-old breastfeeding neonate whose birth weight was 2,678 grams has lost 100 grams since the cesarean birth. Which of the following actions should the nurse take?
- A. Nothing because this is an acceptable weight loss.
- B. Advise the mother to supplement feedings with formula.
- C. Notify the neonatologist of the excessive weight loss.
- D. Give the baby dextrose water between breast feedings.
Correct Answer: A
Rationale: Weight loss within 5% is normal.
Postpartum persons who lack attachment with their newborn exhibit what behavior?
- A. intense eye contact
- B. avoid holding the newborn
- C. cuddling
- D. exploring the newborn
Correct Answer: B
Rationale: The correct answer is B because avoiding holding the newborn is a sign of lack of attachment in postpartum persons. This behavior indicates a lack of desire or ability to bond with the newborn, which is crucial for healthy emotional development. Intense eye contact (choice A) and cuddling (choice C) are typically associated with bonding behaviors. Exploring the newborn (choice D) can also be a positive behavior showing interest. However, the key indicator of attachment issues is the avoidance of holding the newborn, making choice B the correct answer.
The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?
- A. No swelling or edema to the perineal area
- B. Patient complains that the sitz bath is too col
- C. Patient reports she took two sitz baths in 12 hours.
- D. Edges of the perineal laceration are well approximate
Correct Answer: A
Rationale: The correct answer is A because the absence of swelling or edema to the perineal area indicates that the ice sitz baths have been effective in reducing inflammation and promoting healing. Swelling and edema are common postpartum, and the use of ice sitz baths can help reduce these symptoms.
Choice B is incorrect because the patient complaining that the sitz bath is too cold does not provide information on the effectiveness of the treatment, only the patient's comfort level.
Choice C is incorrect because the frequency of sitz baths does not necessarily indicate effectiveness. It is more important to assess the outcomes of the treatment rather than the number of baths taken.
Choice D is incorrect because the approximation of perineal laceration edges may be influenced by other factors such as suturing technique, rather than the effectiveness of the ice sitz baths.