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What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2–3 hours
- C. pulse 72
- D. WBCs 10,000
Correct Answer: D
Rationale: The correct answer is D: WBCs 10,000. An elevated white blood cell count (WBC) is a common sign of infection as the body produces more WBCs to fight off pathogens. This increase in WBC count is known as leukocytosis and is a key indicator of an ongoing infection. In contrast, choices A, B, and C are not direct indicators of infection. A painful fundal massage may suggest uterine atony, breast-feeding every 2-3 hours is a normal part of postpartum care, and a pulse rate of 72 is within the normal range. Therefore, the most reliable assessment finding suggesting a possible infection is an elevated WBC count.
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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: The correct answer is B: risk for fluid overload. A person with a coagulation disorder is at risk for excessive bleeding, which may lead to fluid overload due to blood loss and subsequent fluid replacement. This nursing diagnosis addresses the potential complications related to fluid imbalance in this population.
Incorrect choices:
A: risk for bleeding - While bleeding is a concern for someone with a coagulation disorder, this choice does not address the potential fluid overload that may result from excessive bleeding.
C: risk for breast-feeding failure - This choice is not relevant to the immediate health concerns of a person with a coagulation disorder.
D: risk for hypertension - Hypertension is not directly related to a coagulation disorder, therefore this choice is not appropriate as a nursing diagnosis in this context.
The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful?
- A. The woman swallows the tablets whole.
- B. The woman takes the pills between meals.
- C. The woman calls the doctor if she develops a headache.
- D. The woman understands that her urine may turn orange.
Correct Answer: D
Rationale: Colace (docusate sodium) is a stool softener that can turn the urine orange. This is a common side effect and should be discussed with the patient during teaching to avoid unnecessary concern.
A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?
- A. Pulse.
- B. Fundus.
- C. Bladder.
- D. Breast.
Correct Answer: B
Rationale: After delivery, the most critical assessment is to evaluate the fundus to ensure uterine contraction and prevent hemorrhage.
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
- A. Apply antibiotic ointment to the perineum daily.
- B. Change the peripad at each voiding.
- C. Void at least every two hours.
- D. Spray the perineum with povidone-iodine after toileting.
Correct Answer: B
Rationale: Changing peripads frequently helps prevent the growth of bacteria and reduces the risk of infection.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.