Nokea
What is the best nursing response to the woman's statement?
- A. How is your partner adjusting to the change?'
- B. I hear this from a lot of first-time mothers.'
- C. Have you told anyone else about your feelings?'
- D. Tell me how things are different.'
Correct Answer: D
Rationale: The nurse may help the new mother by being a sympathetic listener and eliciting her feelings about motherhood and her infant.
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What should the nurse's next assessment be?
- A. Fullness of the bladder
- B. Amount of lochia
- C. Blood pressure
- D. Level of pain
Correct Answer: A
Rationale: Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.
A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
- A. Provision of IV fluids
- B. Placement of an indwelling Foley catheter
- C. Assessment of oxygen saturation
- D. Administration of anticoagulants
- E. Blood transfusion
Correct Answer: A,B,C,E
Rationale: Management of hypovolemic shock includes stopping blood loss, giving IV fluids, placing a Foley catheter, assessing oxygen saturation, and giving blood transfusions. Anticoagulants are not used.
The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it.What would the nurse expect to find on further assessment?
- A. A firm fundus the size of a grapefruit
- B. A full bladder
- C. Retained placental fragments
- D. Vital signs indicative of shock
- E. A soft, boggy fundus
Correct Answer: B,E
Rationale: Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.
What does the nurse recognize these signs indicate?
- A. Uterine atony
- B. Uterine dystocia
- C. Uterine hypoplasia
- D. Uterine dysfunction
Correct Answer: A
Rationale: Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.
What will the nurse instruct this woman is the antidote for warfarin overdose?
- A. Vitamin A
- B. Vitamin B
- C. Vitamin E
- D. Vitamin K
Correct Answer: D
Rationale: The antidote for warfarin overdose is vitamin K.