Nokea
What is the first sign of hypovolemic shock from postpartum hemorrhage?
- A. Cold, clammy skin
- B. Tachycardia
- C. Hypotension
- D. Decreased urinary output
Correct Answer: B
Rationale: Tachycardia is usually the first sign of inadequate blood volume.
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A postpartum woman is not immune to rubella. What will the nurse expect?
- A. The rubella virus vaccine should be administered before discharge.
- B. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
- C. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
- D. No intervention is indicated at this time because the woman is not at risk for rubella.
Correct Answer: A
Rationale: The woman who is not immune to rubella is immunized in the immediate postpartum period, because there is no danger of her being pregnant.
Below what blood glucose level is the newborn considered hypoglycemic?
- A. Below 70 mg/dL
- B. Below 60 mg/dL
- C. Below 50 mg/dL
- D. Below 40 mg/dL
Correct Answer: D
Rationale: A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.
What will the nurse's instructions for a new mother to care for the infant's umbilical cord include?
- A. Keeping the area covered with a sterile dressing
- B. Dressing the stump with antibiotic ointment at every diaper change
- C. Fastening the diaper low to allow for air circulation
- D. Giving the newborn a daily tub bath until the cord falls off
Correct Answer: C
Rationale: Diaper placement below the umbilical stump allows for drying by air circulation.
What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.)
- A. Abdominal tighteners
- B. Head lift
- C. Pelvic tilt
- D. Kegel exercises
- E. Leg lifts
Correct Answer: A,B,C,D
Rationale: Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.
What instruction should the nurse teach the postpartum woman about perineal self-care?
- A. Perform perineal self-care at least twice a day.
- B. Cleanse with warm water in a squeeze bottle from front to back.
- C. Remove perineal pads from the rectal area toward the vagina.
- D. Use cool water to decrease edema of the perineum.
Correct Answer: B
Rationale: Cleansing from front to back prevents contamination from the rectal area.