Nokea
What does the nurse suspect from these symptoms?
- A. Phlebitis
- B. Puerperal infection
- C. Late postpartum hemorrhage
- D. Mastitis
Correct Answer: A
Rationale: The complaints related to the leg, such as redness and pain, are indicative of phlebitis. The other signs are normal in the postpartum patient.
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What complication should the nurse be alert for in the immediate postpartum period?
- A. Cervical laceration
- B. Hematoma
- C. Endometritis
- D. Retained placental fragments
Correct Answer: B
Rationale: Delivering a large infant and a prolonged labor are risk factors for hematoma formation.
What action should the nurse implement?
- A. Notify the charge nurse of a possible infection.
- B. Prepare to put the patient in isolation.
- C. Have the infant removed from the room and returned to the nursery.
- D. Assess the patient further.
Correct Answer: D
Rationale: A white blood cell count of 20,000 to 30,000 cells/dL is normal in the early postpartum period, so the patient should be assessed further for other signs of infection.
Based on this finding, what does the nurse explain the probable treatment will involve?
- A. Anticoagulants for 6 weeks
- B. Application of ice to the affected leg
- C. Gentle massage of the affected leg
- D. Passive leg exercises twice a day
Correct Answer: A
Rationale: Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism.
What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions?
- A. I will apply cold compresses to the painful areas.'
- B. I will take a warm shower before nursing the baby.'
- C. I will nurse first on the affected side.'
- D. I will empty the affected breast every 8 hours.'
Correct Answer: B
Rationale: Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
How does the nurse most likely feel and react to this finding?
- A. Concerned and reports a probable cervical laceration
- B. Attentive and massages the uterus to expel retained clots
- C. Distressed and reports a possible clotting disorder
- D. Satisfied with the normal early postpartum finding
Correct Answer: A
Rationale: The bright trickle of blood with a firm uterus suggests a cervical laceration.