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: Skin tenting indicates dehydration, a sign of fluid volume deficit.
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The nurse is assessing a patient who is 12 hours postpartum. The uterus is firm to palpation, at midline, and is 1 cm below the umbilicus with continuous heavy vaginal bleeding. What is the nurse’s first action?
- A. Massage the uterus and resume the IV Pitocin drip.
- B. Change the peri-pad and reassess the bleeding.
- C. Call the provider to check for a cervical laceration.
- D. Administer the ordered iron supplement and ibuprofen.
Correct Answer: A
Rationale: The nurse must address the uterine tone and bleeding immediately by massaging the uterus and resuming Pitocin to prevent hemorrhage.
A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks?
- A. Skim milk.
- B. Ginger ale.
- C. Orange juice.
- D. Chamomile tea.
Correct Answer: C
Rationale: Iron absorption is enhanced by vitamin C, and orange juice is rich in vitamin C, making it an appropriate drink to take with the supplement.
What assessment data increases the risk of postpartum infection?
- A. precipitous labor
- B. urinary retention
- C. breast-feeding
- D. intact perineum
Correct Answer: A
Rationale: The correct answer is A: precipitous labor. Precipitous labor can cause trauma to the birth canal, leading to increased risk of infection. Urinary retention (B) may lead to urinary tract infections but not necessarily postpartum infections. Breastfeeding (C) and intact perineum (D) are not direct risk factors for postpartum infections.
Which classification of placental separation is not recognized as an abnormal adherence pattern?
- A. Placenta accreta
- B. Placenta increta
- C. Placenta percreta
- D. Placenta abruptio
Correct Answer: D
Rationale: Placenta abruptio, also known as abruptio placentae, is the premature separation of the placenta from the uterine wall before delivery. It is not classified as an abnormal adherence pattern like placenta accreta, increta, and percreta. Placenta accreta occurs when the placenta attaches too deeply into the uterine wall. Placenta increta is when the placenta invades the myometrium, and placenta percreta is when it penetrates through the myometrium and reaches the serosa. These abnormal adherence patterns are associated with risks and complications during pregnancy and delivery, while placenta abruptio is a separate condition related to premature placental separation.
Postpartum teaching related to urinary health should emphasize:
- A. Drinking any type of fluid whenever thirsty.
- B. Allowing the bladder to fill to promote emptying.
- C. Cleansing the perineum in a front-to-back direction.
- D. Eating two servings of acidic fruits or vegetables each day.
Correct Answer: C
Rationale: Proper perineal care such as wiping front to back is essential to prevent urinary tract infections after birth.