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What important assessment should the nurse perform on all postpartum persons?
- A. Screen for PPD with the EPDS.
- B. Screen for drug use with a urine drug screen.
- C. Screen for breast-feeding failure.
- D. Screen for contraception contraindications.
Correct Answer: A
Rationale: Using the Edinburgh Postnatal Depression Scale (EPDS) helps identify postpartum depression and provides early intervention.
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The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
- A. Apply an ice pack to the perineum.
- B. Advise the woman to use a sitz bath after every voiding.
- C. Advise the woman to sit on a pillow.
- D. Teach the woman to insert nothing into her rectum.
Correct Answer: A
Rationale: Applying an ice pack to the perineum helps reduce swelling and provides pain relief after a perineal laceration.
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, 'I really don 't need to go. ' Which of the following responses by the nurse is appropriate?
- A. Okay. I must be palpating your uterus.
- B. I understand but I still would like you to try to urinate.
- C. You still must be numb from the local anesthesia.
- D. That is a problem. I will have to catheterize you.
Correct Answer: B
Rationale: A distended bladder can lead to complications such as uterine atony. The nurse should encourage the woman to attempt urination, but if she refuses, further action may be necessary.
What is a symptom of engorgement?
- A. protuberant nipples
- B. shiny, hard breast
- C. insufficient milk production
- D. soft, lumpy breast
Correct Answer: B
Rationale: The correct answer is B: shiny, hard breast. Engorgement is characterized by a significant increase in blood and lymph fluid in the breast tissue, causing the breasts to become swollen, shiny, and hard. This occurs when milk production exceeds removal, leading to congestion and inflammation. Protuberant nipples (A) may be a result of engorgement but are not a defining symptom. Insufficient milk production (C) is not a symptom of engorgement but rather a separate issue related to milk supply. Soft, lumpy breast (D) is more indicative of a blocked duct or mastitis, not engorgement.
What is the most common reason for late postpartum hemorrhage (PPH)?
- A. Subinvolution of the uterus
- B. Defective vascularity of the decidua
- C. Cervical lacerations
- D. Coagulation disorders
Correct Answer: A
Rationale: The correct answer is A: Subinvolution of the uterus. This is the most common cause of late postpartum hemorrhage (PPH) due to incomplete contraction and retraction of the uterus leading to persistent bleeding. Subinvolution can result from retained placental fragments, uterine infections, or inadequate involution. Choice B, defective vascularity of the decidua, is less common and not typically associated with late PPH. Cervical lacerations (Choice C) usually cause immediate bleeding after delivery, not late PPH. Coagulation disorders (Choice D) can cause both early and late PPH but are less common than subinvolution.
The nurse notices the person with a PPH looks pale and their capillary refill is >3 seconds. What intervention can the nurse initiate?
- A. Wrap the person in a warm blanket.
- B. Put a pulse oximeter on the patient’s finger.
- C. Sit the person up at 90 degrees.
- D. Start an IV bolus.
Correct Answer: D
Rationale: The correct answer is D: Start an IV bolus. In postpartum hemorrhage (PPH), the priority is to restore circulating volume quickly to prevent shock. Starting an IV bolus with fluids or blood products helps improve perfusion and oxygenation. Choice A is incorrect as warming the person does not address the underlying issue of hypovolemia. Choice B is incorrect as monitoring oxygen saturation is not the immediate priority. Choice C is incorrect as sitting the person up could potentially worsen their condition by reducing venous return.