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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: Painful fundal massage can indicate a potential infection.
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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.
The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation?
- A. Blood pressure may be elevated from prenatal conditions.
- B. Respirations are increased due to activity of labor.
- C. Changes in blood pressure may not be an immediate sign.
- D. Heart rate may increase with intensity of labor.
Correct Answer: C
Rationale: Changes in blood pressure may not be an immediate sign of hemorrhage in a postpartum patient. OB patients may not show the same signs and symptoms observed in nonpregnant patients during hemorrhage until approximately one-third of the woman’s entire blood volume is lost.
The nurse and provider estimate the blood loss at delivery to be 400 mL in the measuring drape; now when doing the initial perineal care, the nurse finds a large amount of blood underneath the patient. What action reflects safe and accurate nursing care?
- A. Estimate the amount of blood loss from the sheet and client clothing, and notify the physician.
- B. Encourage the mother to report any additional bleeding or clots.
- C. Draw the ordered hematocrit and notify the provider if the result is less than 28.
- D. Weigh the blood-soaked linens and notify the provider of the additional blood loss.
Correct Answer: D
Rationale: Weighing the blood-soaked linens is a safe and accurate method to estimate blood loss.
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate?
- A. Take the woman 's temperature.
- B. Advise the woman to decrease her fluid intake.
- C. Reassure the woman that this is normal.
- D. Notify the neonate 's pediatrician.
Correct Answer: C
Rationale: Profuse diaphoresis is a common and normal occurrence in the first 24 hours postpartum as the body works to eliminate excess fluid accumulated during pregnancy.
The nurse educates the non -breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: Cold packs and cabbage leaves help reduce swelling and discomfort caused by engorgement in non-breastfeeding individuals.