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What action should the nurse implement?
- A. Notify the charge nurse of a possible infection.
- B. Prepare to put the patient in isolation.
- C. Have the infant removed from the room and returned to the nursery.
- D. Assess the patient further.
Correct Answer: D
Rationale: A white blood cell count of 20,000 to 30,000 cells/dL is normal in the early postpartum period, so the patient should be assessed further for other signs of infection.
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A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
- A. Provision of IV fluids
- B. Placement of an indwelling Foley catheter
- C. Assessment of oxygen saturation
- D. Administration of anticoagulants
- E. Blood transfusion
Correct Answer: A,B,C,E
Rationale: Management of hypovolemic shock includes stopping blood loss, giving IV fluids, placing a Foley catheter, assessing oxygen saturation, and giving blood transfusions. Anticoagulants are not used.
What will the nurse instruct this woman is the antidote for warfarin overdose?
- A. Vitamin A
- B. Vitamin B
- C. Vitamin E
- D. Vitamin K
Correct Answer: D
Rationale: The antidote for warfarin overdose is vitamin K.
What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions?
- A. I will apply cold compresses to the painful areas.'
- B. I will take a warm shower before nursing the baby.'
- C. I will nurse first on the affected side.'
- D. I will empty the affected breast every 8 hours.'
Correct Answer: B
Rationale: Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
What will the nurse anticipate might be ordered by the physician?
- A. Ritodrine
- B. Magnesium sulfate
- C. Oxytocin
- D. Bromocriptine
Correct Answer: C
Rationale: Oxytocin (Pitocin) is the most common drug ordered to control uterine atony.
What is the first sign of hypovolemic shock from postpartum hemorrhage?
- A. Cold, clammy skin
- B. Tachycardia
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: Tachycardia is usually the first sign of inadequate blood volume.