Nokea
What assessment finding suggests a possible infection?
- A. painful fundal massage
- B. breast-feeding every 2 -3 hours
- C. pulse 72
- D. WBCs 10
Correct Answer: A
Rationale: Painful fundal massage can be a sign of uterine infection (endometritis) especially if accompanied by other symptoms like fever.
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The nurse is aware the greatest source of bleeding during childbirth occurs following detachment of the placenta. Which physiological change takes place immediately after the expulsion of the placenta to decrease the amount of blood loss?
- A. Contractions of the uterine myometrium
- B. Factor VIII complex increases during gestation
- C. Platelet activity increases before labor and delivery
- D. Fibrin formation increases before the birth occurs
Correct Answer: A
Rationale: After placenta detachment, contractions of the myometrium compress the blood vessels at the placental site, thus decreasing the amount of blood loss.
The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus?
- A. Scant amount of odorless lochia
- B. Presence of headache, malaise, and chills
- C. Pain or discomfort in the midline lower abdomen
- D. Elevated temperature greater than 100.4°F (38°C)
Correct Answer: D
Rationale: Endometritis from beta-hemolytic streptococcus specifically exhibits scant, odorless lochia in addition to the more universal signs of infection.
What intervention by the nurse can help with PPD?
- A. encouraging the partner to let the postpartum person learn to take care of themself
- B. encouraging the family to have support available for the person and partner
- C. telling the person not to breast-feed if taking antidepressants
- D. keeping the newborn in the nursery most of the day and night
Correct Answer: B
Rationale: Support from the family and partner helps reduce feelings of isolation and provides practical assistance for the postpartum person.
The most effective and least expensive treatment of puerperal infection is prevention. What is the most important strategy for the nurse to adopt?
- A. Large doses of vitamin C during pregnancy
- B. Prophylactic antibiotics
- C. Strict aseptic technique, including hand washing, by all health care personnel
- D. Limited protein and fat intake
Correct Answer: C
Rationale: The most important strategy for the nurse to adopt in preventing puerperal infection is option C, which is the strict aseptic technique, including hand washing, by all health care personnel. Puerperal infection, also known as postpartum infection, is a serious complication following childbirth that can lead to severe consequences if not prevented. Maintaining proper hygiene practices, such as hand washing and using aseptic techniques, is crucial in preventing the spread of pathogens that can cause infections. This simple yet effective measure can significantly reduce the risk of puerperal infections among postpartum women. Large doses of vitamin C during pregnancy (option A) may have benefits for overall health but are not specifically proven to prevent puerperal infections. Prophylactic antibiotics (option B) may be used in certain cases but are not the primary strategy for prevention in all cases. Limiting protein and fat intake (option D) is not a recommended approach
The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple:
- A. On admission to the labor room.
- B. In the client room after the delivery.
- C. When the client put the baby to the breast for the first time.
- D. The day before the client and baby are to leave the hospital.
Correct Answer: D
Rationale: Teaching about the need for an infant car seat should occur before discharge to ensure the parents have time to arrange for one, typically the day before discharge.