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What nursing diagnosis would be appropriate for the person with a coagulation disorder?
- A. risk for bleeding
- B. risk for fluid overload
- C. risk for breast-feeding failure
- D. risk for hypertension
Correct Answer: B
Rationale: Risk for bleeding is the main diagnosis in patients with coagulation disorders.
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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: Von Willebrand disorder increases the risk of bleeding and PPH.
A woman is receiving patient-controlled analgesia (PCA) post -cesarean section. Which of the following must be included in the patient teaching?
- A. The client should monitor how often she presses the button.
- B. The client should report any feelings of nausea or itching to the nurse.
- C. The family should press the button whenever they feel the woman is in pain.
- D. The family should inform the nurse if the client becomes sleepy.
Correct Answer: B
Rationale: It is important for the client to report any adverse effects, such as nausea or itching, to the nurse while using PCA.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time?
- A. Do nothing. This is a normal finding.
- B. Massage the woman 's fundus.
- C. Take the woman to the bathroom to void.
- D. Notify the woman 's primary health care provider.
Correct Answer: A
Rationale: A firm fundus at the umbilicus and heavy lochia rubra is normal during the first few hours after delivery.
A breastfeeding woman, 1 1/2 months postdelivery, calls the nurse in the obstetrician 's office and states, 'I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me? ' The nurse should base the response to the client on which of the following?
- A. The woman is exhibiting signs of pathological galactorrhea.
- B. The same hormone stimulates orgasms and the milk ejection reflex.
- C. The woman should have a serum galactosemia assessment done.
- D. The baby is stimulating the woman to produce too much milk.
Correct Answer: B
Rationale: The hormone oxytocin is responsible for both milk ejection during breastfeeding and uterine contractions during orgasm, which explains the milk release.
The nurse educates the non -breast-feeding person on breast discomfort caused by engorgement. What instructions would they give?
- A. Massage breasts to release milk.
- B. Apply cold packs and cabbage leaves.
- C. Stand in the warm shower to stimulate letdown.
- D. Do not wear a bra.
Correct Answer: B
Rationale: Cold packs and cabbage leaves help reduce swelling and discomfort caused by engorgement in non-breastfeeding individuals.