Nokea
The nurse suspects that her postpartum client is experiencing hemorrhagic shock. Which observation indicates or would confirm this diagnosis?
- A. Absence of cyanosis in the buccal mucosa
- B. Cool, dry skin
- C. Calm mental status
- D. Urinary output of at least 30 ml/hr
Correct Answer: D
Rationale: The correct answer is D because a urinary output of at least 30 ml/hr indicates adequate perfusion and kidney function, which is crucial in managing hemorrhagic shock. Low urine output is a sign of poor perfusion and impending organ failure. Absence of cyanosis in the buccal mucosa (choice A) is not specific to hemorrhagic shock. Cool, dry skin (choice B) is a late sign of shock. A calm mental status (choice C) can be seen in the compensatory stage of shock.
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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 is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan?
- A. Assist with stitch removal on third postpartum day.
- B. Administer analgesics every four hours per doctor 's orders.
- C. Teach client to contract her buttocks before sitting.
- D. Irrigate incision twice daily with antibiotic solution
Correct Answer: C
Rationale: Teaching clients to contract their buttocks before sitting helps to relieve pressure on the episiotomy site and promote healing.
The nurse educates the non -breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: Cold packs and cabbage leaves help reduce swelling and discomfort caused by engorgement in non-breastfeeding individuals.
What is the most common reason for late postpartum hemorrhage (PPH)?
- A. Subinvolution of the uterus
- B. Defective vascularity of the decidua
- C. Cervical lacerations
- D. Coagulation disorders
Correct Answer: A
Rationale: Late postpartum hemorrhage (PPH), defined as occurring between 24 hours and up to 12 weeks after delivery, is most commonly due to subinvolution of the uterus. This occurs when the uterus fails to return to its normal pre-pregnancy size. Subinvolution can be caused by retained products of conception, uterine infection, uterine anomalies, or inadequate contraction of the uterine muscles. When the uterus does not contract effectively, it is unable to compress the blood vessels at the site of the placental attachment, leading to persistent bleeding. Subinvolution of the uterus is an important cause of late PPH and requires prompt intervention to prevent excessive blood loss and its associated complications.
What nursing intervention does the nurse include in the plan of care for a person with a perineal laceration infection?
- A. Demonstrate the use of a urinary catheter.
- B. Provide an abdominal binder.
- C. Encourage use of the peri-bottle for cleaning front to back.
- D. Discourage use of pain medications.
Correct Answer: C
Rationale: The peri-bottle helps maintain cleanliness and reduce infection risk in perineal lacerations.