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: Shiny, hard breasts are characteristic of engorgement.
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A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?
- A. Pulse.
- B. Fundus.
- C. Bladder.
- D. Breast.
Correct Answer: B
Rationale: After delivery, the most critical assessment is to evaluate the fundus to ensure uterine contraction and prevent hemorrhage.
What is a risk factor for PPH found in the prenatal record?
- A. primipara
- B. rubella nonimmune
- C. von Willebrand disorder
- D. history of appendectomy
Correct Answer: C
Rationale: The correct answer is C: von Willebrand disorder. This is a risk factor for postpartum hemorrhage (PPH) as it can lead to abnormal bleeding during and after childbirth. von Willebrand disorder is a hereditary bleeding disorder that affects the blood's ability to clot properly. This can increase the likelihood of excessive bleeding during delivery, putting the mother at risk for PPH.
Choice A: primipara is incorrect, as being a first-time mother (primipara) is not a direct risk factor for PPH.
Choice B: rubella nonimmune is incorrect, as rubella immunity status is not directly related to the risk of PPH.
Choice D: history of appendectomy is incorrect, as a previous appendectomy is not a known risk factor for PPH.
In summary, the presence of von Willebrand disorder in the prenatal record is a significant risk factor for PPH due to its impact on blood clotting ability during childbirth.
The nurse recognizes the postpartum person is in what stage of Rubin 's attachment model when the person is concerned with physical recovery and depends on the nurse or partner for help physically?
- A. Taking In
- B. Taking Hold
- C. Postpartum Maternal Change
- D. Attainment of Change
Correct Answer: A
Rationale: In the 'Taking In' stage the postpartum person is primarily concerned with their physical recovery and may need support from the nurse or partner.
The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects?
- A. Headache.
- B. Nausea.
- C. Cramping.
- D. Fatigue.
Correct Answer: A
Rationale: Methergine is used to prevent postpartum hemorrhage, but it can cause side effects such as headache, nausea, and cramping. The nurse should inform the client about these possible side effects to promote informed decision-making.
The nurse is caring for a postpartum woman and her 2-hour-old baby. The new mother has been preoccupied with breastfeeding and visitors, but suddenly she complains of dizziness and is light-headed. Which response by the nurse is appropriate?
- A. Explain that she needs to drink more fluids and eat because she needs to replace fluids and calories.
- B. Encourage the patient to rest, and ask a family member to watch the newborn in the crib.
- C. Tell the patient that the dizziness is probably caused by her pain medication and that it is normal.
- D. Obtain vital signs, assess fundal tone, and observe for excessive lochia.
Correct Answer: D
Rationale: Obtaining vital signs, assessing fundal tone, and observing for excessive lochia is appropriate to identify the cause of dizziness.