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The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The IV site indicates phlebitis, and the appropriate action is to remove and restart the IV to avoid further complications.
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The nurse educates the person recovering from a cesarean birth on how to care for the incision. What education is discussed?
- A. Scrub the incision well twice daily.
- B. Remove the dressing the day after birth.
- C. Staples will be removed the day after birth.
- D. Vertical incisions heal faster with less pain.
Correct Answer: A
Rationale: The correct answer is A: Scrub the incision well twice daily. This is the correct answer because it emphasizes proper hygiene to prevent infection without causing harm to the incision site. Cleaning the incision twice daily helps to keep it clean and reduce the risk of infection.
B: Removing the dressing the day after birth is incorrect as it may disrupt the healing process and increase the risk of infection.
C: Staples being removed the day after birth is incorrect because staple removal timing varies depending on individual healing progress and is typically done by a healthcare provider.
D: Vertical incisions healing faster with less pain is incorrect as healing time and pain tolerance vary among individuals and are not solely determined by the incision type.
What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: Monitoring for signs of sepsis is important in postpartum endometritis as it can lead to severe complications if untreated.
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.
The postpartum nurse notices that the last dose of IV Cefazolin is not running well. The patient’s IV site appears red, inflamed, and swollen. The patient states that the IV is tender and sore. What are the nurse’s next actions?
- A. Flush the IV with normal saline to improve the flow rate.
- B. Put the IV antibiotic on a pump for more accurate infusion of the correct dose.
- C. Remove the IV, restart it in a new location, and complete the antibiotic administration.
- D. Allow the IV to continue to drip slowly since it is her last dose.
Correct Answer: C
Rationale: The correct answer is C: Remove the IV, restart it in a new location, and complete the antibiotic administration. This is the correct action because the patient's IV site is showing signs of infection (redness, inflammation, swelling, tenderness). By removing the IV, the nurse can prevent the spread of infection and restart the antibiotic infusion in a new, sterile site to ensure proper treatment.
A: Flushing the IV with normal saline will not address the underlying issue of infection and may worsen the patient's condition.
B: Putting the IV antibiotic on a pump for more accurate infusion does not address the fact that the current IV site is infected and needs to be removed.
D: Allowing the IV to continue to drip slowly is not appropriate when the site is showing signs of infection.
A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate?
- A. You must wait to begin to perform exercises until after your six-week postpartum checkup.
- B. You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe.
- C. By next week you will be able to return to the exercise schedule you had during your prepregnancy.
- D. You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks.
Correct Answer: D
Rationale: Kegel exercises can be started early postpartum to help strengthen pelvic floor muscles. Other exercises can be gradually increased after approval from the healthcare provider.