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What is a risk factor for uterine atony?
- A. small for gestational age
- B. primipara
- C. multiple gestation
- D. intrauterine growth restriction
Correct Answer: C
Rationale: The correct answer is C: multiple gestation. Multiple gestation is a risk factor for uterine atony due to the increased uterine size and stretched muscle fibers, which can lead to decreased uterine tone postpartum. This can result in excessive bleeding.
A: Small for gestational age is not typically a risk factor for uterine atony as it refers to the size of the baby, not the uterus.
B: Primipara (first-time mother) may have a higher risk of uterine atony due to less uterine tone from lack of previous pregnancies, but it is not as significant as multiple gestation.
D: Intrauterine growth restriction refers to the baby's growth, not the mother's risk of uterine atony.
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A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking 'my baby sister ' home. Which of the following is an appropriate response by the nurse?
- A. It 's always nice when siblings are excited to have the babies go home.
- B. Your daughter is very advanced for her age. She must speak very well.
- C. Your daughter is likely to become very jealous of the new baby.
- D. Older sisters can be very helpful. They love to play mother.
Correct Answer: C
Rationale: It is common for older siblings to feel jealousy when a new baby arrives. Preparing the child for the changes can help manage these feelings.
A patient delivered vaginally 20 minutes ago. Prophylactic Pitocin is infusing intravenously. During the initial postpartum assessment, the nurse notes a heavy amount of bleeding on the perineal pad. What are the priority nursing actions?
- A. Assess the perineum for lacerations and provide a clean peri-pad and ice pack.
- B. Assess the fundus and massage the uterus to determine uterine tone and location.
- C. Assess to see if the bladder is full and place an indwelling urinary catheter.
- D. Assess for clots, determine if this is a normal amount, and provide privacy during a pad change.
Correct Answer: B
Rationale: The correct answer is B. Assess the fundus and massage the uterus to determine uterine tone and location. This is the priority action because heavy bleeding postpartum could indicate uterine atony, a common cause of postpartum hemorrhage. By assessing the fundus and massaging the uterus, the nurse can determine if the uterus is firm and well contracted, which helps to control bleeding. Other choices are incorrect as they do not address the immediate concern of uterine atony. Choice A focuses on the perineum and does not address the potential cause of bleeding. Choice C addresses bladder fullness, which is important but not as urgent as assessing for uterine atony. Choice D focuses on clots and privacy but does not address the primary concern of uterine tone.
The nurse is developing a plan of care for the postpartum client during the 'taking hold ' phase. Which of the following should the nurse include in the plan?
- A. Provide the client with a nutritious meal.
- B. Encourage the client to take a nap.
- C. Assist the client with activities of daily living.
- D. Assure the client that she is an excellent mother.
Correct Answer: C
Rationale: During the 'taking hold' phase, the mother is more focused on newborn care and regaining control. Assisting with daily activities supports her autonomy.
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.
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.