Nokea
What assessment finding would indicate a fluid volume deficit?
- A. skin tenting with testing of skin turgor
- B. hypertension
- C. bradycardia
- D. bounding pulse
Correct Answer: A
Rationale: The correct answer is A because skin tenting with testing of skin turgor is a classic sign of fluid volume deficit. When there is a lack of fluid in the body, the skin loses its elasticity, causing it to tent or stay elevated when pinched. This indicates dehydration.
Choice B, hypertension, is incorrect because fluid volume deficit typically leads to hypotension, not hypertension. Choice C, bradycardia, is also incorrect as fluid volume deficit usually causes tachycardia to compensate for decreased blood volume. Choice D, bounding pulse, is incorrect as it is associated with fluid overload, not deficit.
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Which of the following is the priority nursing action during the immediate postpartum period?
- A. Palpate fundus.
- B. Check pain level.
- C. Perform pericare.
- D. Assess breasts.
Correct Answer: A
Rationale: Palpating the fundus is the priority to assess for uterine involution and prevent postpartum hemorrhage.
Lacerations of the cervix, vagina, or perineum are also causes of PPH. Which factors influence the causes and incidence of obstetric lacerations of the lower genital tract? (Select all that apply.)
- A. Operative and precipitate births
- B. Adherent retained placenta
- C. Abnormal presentation of the fetus
- D. Congenital abnormalities of the maternal soft tissue
Correct Answer: A
Rationale: The correct answer is A because operative and precipitate births increase the risk of obstetric lacerations due to the rapid delivery or use of instruments. Operative births involve interventions like forceps or vacuum extraction, which can cause trauma. Precipitate births, characterized by rapid labor and delivery, may lead to tearing of the lower genital tract. Choices B, C, and D are incorrect as they do not directly influence the causes and incidence of obstetric lacerations. Adherent retained placenta, abnormal fetal presentation, and congenital abnormalities of maternal soft tissue are not primary factors contributing to lacerations during childbirth.
The nurse reviews postpartum discharge instructions regarding sexual health. What information is important to review?
- A. Place nothing in the vagina for 4 -6 weeks.
- B. Pregnancy cannot occur until 3 months after birth.
- C. Sexual intercourse can resume after discharge from the facility.
- D. Postpartum persons do not have a need for sexual intimacy.
Correct Answer: A
Rationale: It is important to wait 4 -6 weeks before placing anything in the vagina to allow for physical recovery and reduce infection risk.
A client who is 3 days postpartum asks the nurse, 'When may my husband and I begin having sexual relations again? ' The nurse should encourage the couple to wait until after which of the following has occurred?
- A. The client has had her six-week postpartum checkup.
- B. The episiotomy has healed and the lochia has stopped.
- C. The lochia has turned to pink and the vagina is no longer tender.
- D. The client has had her first postpartum menstrual period.
Correct Answer: A
Rationale: It is recommended to wait until after the six-week postpartum checkup to ensure the woman has fully healed and is physically ready for intercourse.
A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because 'I am so tired right now. I just want to have something to eat and take a nap. ' Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following?
- A. Social deprivation.
- B. Child neglect.
- C. Normal postpartum behavior.
- D. Postpartum depression.
Correct Answer: C
Rationale: Requesting rest after feeding is typical postpartum behavior and does not indicate neglect or depression.