Nokea
The nurse teaches the client to report which postpartum symptom immediately?
- A. Mild cramping
- B. Foul-smelling lochia
- C. Light vaginal bleeding
- D. Fatigue after delivery
Correct Answer: B
Rationale: Foul-smelling lochia may indicate infection, requiring immediate reporting to prevent complications.
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The nurse is caring for the 30-weeks-pregnant client who is having contractions every 1½ to 2 minutes with spontaneous rupture of membranes 2 hours ago. Her cervix is 8 cm dilated and 100% effaced. The nurse determines that delivery is imminent. What intervention is the most important at this time?
- A. Administering a tocolytic agent
- B. Providing teaching information on premature infant care
- C. Notifying neonatology of the impending birth
- D. Preparing for a cesarean section birth
Correct Answer: C
Rationale: The most important intervention is to notify the neonatal team of the delivery because the team members will be needed for respiratory support and possible resuscitation. Tocolytic agents, such as nifedipine (Procardia), can be used for short-term intervention to slow down contractions and delay birth, but it is too late to administer a tocolytic agent. Teaching is important but is not appropriate at this time. A cesarean birth is indicated if there are other obstetrical needs.
The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?
- A. “You need to come to the clinic immediately.”
- B. “Decrease physical activity until the bleeding stops.”
- C. “There is no need for concern; this is expected after birth.”
- D. “Call next week if the bleeding has not stopped by then.”
Correct Answer: A
Rationale: Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge. Increased physical activity can lead to increased lochial discharge, but the client is reporting continuous lochia rubra, which is abnormal. Lochia rubra is expected to last for up to 3 days after birth, not 20 days. Waiting until next week to be seen only delays determining the cause for her abnormal bleeding and increases the risk of the client for other complications.
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.
Which method best promotes client comfort during the pelvic examination?
- A. Have the client lift her head off the table.
- B. Have the client press her back into the examination table.
- C. Have the client tighten her buttocks.
- D. Tell the client to let her knees fall outward.
Correct Answer: D
Rationale: Letting the knees fall outward relaxes the pelvic muscles, reducing discomfort during the pelvic examination.
The client tells the nurse that she is using cocoa butter on her abdomen to prevent stretch marks. Which is the most accurate response from the nurse?
- A. “That is wonderful. If you continue to use cocoa butter daily, you should have no stretch marks after delivery.”
- B. “The cocoa butter will not prevent stretch marks completely, but it will help to reduce their number.”
- C. “The cocoa butter will not prevent stretch marks but will decrease the appearance of the linea nigra.”
- D. “Cocoa butter does not prevent stretch marks, but it soothes itching that occurs as your abdomen enlarges.”
Correct Answer: D
Rationale: Cocoa butter is an emollient and provides moisture to the skin, thereby decreasing the itching associated with stretching of the skin as the abdomen enlarges. Cocoa butter does not prevent striae gravidarum. Cocoa butter does not decrease the incidence of striae gravidarum. Cocoa butter does not prevent the appearance of linea nigra.