Nokea
What nursing action is the most appropriate to prevent thrombus formation?
- A. Have the woman sit in a chair for meals.
- B. Monitor vital signs every 4 hours and report any changes.
- C. Tell the woman to remain in bed with her legs elevated.
- D. Assist the woman with ambulation for short periods of time.
Correct Answer: D
Rationale: Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.
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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.
Based on this finding, what does the nurse explain the probable treatment will involve?
- A. Anticoagulants for 6 weeks
- B. Application of ice to the affected leg
- C. Gentle massage of the affected leg
- D. Passive leg exercises twice a day
Correct Answer: A
Rationale: Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism.
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.
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 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.