Nokea
The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? Select all that apply.
- A. Walking at least four times in 24 hours
- B. Receiving a prescribed oral antibiotic
- C. Applying warm packs to the breasts
- D. Getting a prescribed anti-inflammatory drug
- E. Limiting oral fluid intake to 1000 mL per day
- F. Emptying the milk from her breasts frequently
Correct Answer: B,C,D,F
Rationale: Rest is important to promote healing. Bed rest may be initially prescribed for 24 hours. Treatment for mastitis includes administration of antibiotics to treat the infection. Application of warm packs decreases pain and promotes milk flow and breast emptying. Treatment for mastitis includes anti-inflammatory medications to treat fever and decrease breast inflammation. Increasing fluid intake to at least 2 to 3 liters is recommended, not limiting intake. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased.
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The nurse’s laboring client is being electronically monitored during her labor. The baseline FHR throughout the labor has been in the 130s. In the last 2 hours, the baseline has decreased to the 100s. How should the nurse document this FHR?
- A. Tachycardia
- B. Bradycardia
- C. Late deceleration
- D. Within normal limits
Correct Answer: B
Rationale: An FHR baseline less than 110 is classified as bradycardia. Tachycardia occurs when the baseline is greater than 160 bpm. A prolonged deceleration is defined as a change from the baseline FHR that occurs for 2 to 10 minutes before returning to baseline. A late deceleration is a gradual decrease and return of the FHR to baseline, associated with a uterine contraction. A decrease to the 100s is not within the normal range. The normal FHR is 120 to 160 bpm.
The postpartum client, who is 24 hours post—vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her prepregnancy body shape. Which response by the nurse is correct?
- A. “Simple abdominal and pelvic exercises can begin right now.”
- B. “You will need to wait until after your 6-week postpartum checkup.”
- C. “Once your lochia has stopped, you can begin exercising.”
- D. “You should not exercise while you are breastfeeding.”
Correct Answer: A
Rationale: On the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises. Abdominal and pelvic exercises can begin right away and not wait for the 6-week postpartum checkup. There is no reason for the client to wait until the lochia has stopped before beginning exercises. There is no reason that a breastfeeding mother should not begin abdominal and pelvic exercises now.
The nurse advises the client to practice which technique to cope with labor pain?
- A. Lamaze breathing
- B. Holding her breath
- C. Tensing muscles
- D. Avoiding movement
Correct Answer: A
Rationale: Lamaze breathing helps manage labor pain by promoting relaxation and focus, unlike tensing or breath-holding.
The nurse is caring for four postpartum clients. Which client should be the nurse’s priority for monitoring for uterine atony?
- A. Client who is 2 hours post-cesarean birth for a breech baby
- B. Client who delivered a macrosomic baby after a 12-hour labor
- C. Client who has a firm fundus after a vaginal delivery 4 hours ago
- D. Client receiving oxytocin intravenously for past 2 hours
Correct Answer: B
Rationale: Although the client post—cesarean birth for a breech baby may be at risk for uterine atony and should be monitored, the client who delivered a macrosomic baby is more at risk. This client is the nurse’s priority for monitoring for uterine atony. A macrosomic baby stretches the client’s uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively. A firm fundus indicates that the client’s uterine muscles are contracting. Oxytocin (Pitocin) is being administered to increase uterine contractions. Although prolonged use of oxytocin can result in uterine exhaustion, two hours of use is not prolonged.
The client presents with vaginal bleeding at 7 weeks. Which action should be taken by the nurse first?
- A. Take the client’s vital signs
- B. Prepare examination equipment
- C. Give 2 liters oxygen per nasal cannula
- D. Assess the client’s response to the situation
Correct Answer: A
Rationale: Assessing the client’s VS should be completed first. Bleeding can cause hypotension. Although preparing examination equipment is important, the nurse should first focus on the client. Having oxygen available is important, but there is no indication that the client needs oxygen at this time. Assessing the client’s response is important, but assessment of physiological problems should occur first.