Nokea
The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate?
- A. Irrigate the incision twice daily.
- B. Monitor the incision for drainage.
- C. Apply steristrips to the incision line.
- D. Palpate the incision and assess for pain.
Correct Answer: B
Rationale: Monitoring the incision for drainage is key post-surgery to assess for signs of infection or complications. Irrigating the incision is not a routine practice unless instructed by a physician.
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The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The primary care provider needs to be contacted about the assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: Precipitous labor can increase the risk of infection due to the rapid and potentially traumatic delivery process.
Hemabate has been ordered for a postpartum patient who has uncontrolled bleeding and uterine atony. Which is the appropriate nursing action?
- A. Check the patient’s vital signs first for hypotension, and lower the head of the bed.
- B. Check the patient’s blood glucose and increase the IV fluid rate.
- C. Check the patient’s record for a history of asthma, and ask the licensed provider for an order of an antidiarrheal medication.
- D. Check the patient’s record for a history of hypothyroid, and ask the licensed provider to order something for nausea.
Correct Answer: C
Rationale: The correct answer is C. The rationale is as follows:
1. Hemabate is a medication used to treat postpartum hemorrhage due to uterine atony.
2. Checking the patient's record for a history of asthma is crucial as Hemabate can exacerbate asthma symptoms.
3. Asking the provider for an antidiarrheal medication is appropriate to manage potential side effects of Hemabate.
4. Checking vital signs for hypotension (Choice A) is important but not the immediate nursing action.
5. Checking blood glucose and increasing IV fluids (Choice B) are not directly related to the administration of Hemabate.
6. Checking for a history of hypothyroid and asking for anti-nausea medication (Choice D) is irrelevant to Hemabate administration.
Which medications are used to manage PPH? (Select all that apply.)
- A. Oxytocin
- B. Methergine
- C. Terbutaline
- D. Hemabate
Correct Answer: A
Rationale: The correct answer is A: Oxytocin. Oxytocin is the first-line medication for managing postpartum hemorrhage (PPH) as it helps in the contraction of the uterus to control bleeding. Methergine (B) is used for uterine atony but is not the first-line choice. Terbutaline (C) is a tocolytic agent and not indicated for PPH. Hemabate (D) is used as a second-line medication for PPH after oxytocin.
What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: Risk for bleeding is the main diagnosis in patients with coagulation disorders.