Nokea
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.
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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.
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: A. Operative and precipitate births: Obstetric lacerations of the lower genital tract are more likely to occur during operative deliveries (such as forceps or vacuum-assisted deliveries) and precipitate births (very rapid deliveries) due to the increased forces and speed involved during these types of deliveries.
What nursing intervention does the nurse include in the plan of care for a person with postpartum endometritis?
- A. Monitor for signs of sepsis.
- B. Discourage breast-feeding.
- C. Avoid fundal assessment.
- D. Increase family visiting hours.
Correct Answer: A
Rationale: Monitoring for signs of sepsis is crucial in cases of postpartum endometritis.
The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol?
- A. Increased patient restlessness.
- B. Manifestations of severe pain.
- C. Development of abnormal vital signs.
- D. Patient requests water for extreme thirst.
Correct Answer: C
Rationale: Vital signs will remain normal during Stages 1 and 2. The evidence of abnormal vital signs is one indicator of Stage 3 hemorrhage.
Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis?
- A. Encourage early ambulation.
- B. Promote oral fluid intake.
- C. Massage the legs of the client twice daily.
- D. Provide the client with high-fiber foods.
Correct Answer: A
Rationale: Early ambulation promotes circulation and reduces the risk of thrombophlebitis after delivery.