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What nursing intervention does the nurse include in the plan of care for a person with mastitis?
- A. Provide antipyretic.
- B. Stop antibiotics when redness is resolved.
- C. Encourage the person to stop breast-feeding.
- D. Start an IV and prepare for signs of sepsis.
Correct Answer: A
Rationale: Correct Answer: A. Provide antipyretic.
Rationale:
1. Mastitis is an inflammation of the breast tissue usually caused by infection.
2. Antipyretics help reduce fever, a common symptom of infection.
3. Providing antipyretics can help alleviate discomfort and promote healing.
4. Stopping antibiotics when redness is resolved (choice B) may lead to recurrence of infection.
5. Encouraging the person to stop breast-feeding (choice C) can negatively impact milk production and bonding.
6. Starting an IV and preparing for signs of sepsis (choice D) is an extreme measure not indicated unless sepsis is confirmed.
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The nurse is performing an assessment of the uterus 30 minutes after a normal delivery and finds the fundus to be soft and boggy. IV Pitocin is infusing at 150 mL/hr. What is the priority nursing intervention?
- A. Increase the Pitocin, assess the fundus in 15 minutes, and update the licensed provider.
- B. Perform external massage of the uterus until it is firm, assess for additional bleeding on the pad, and update the licensed provider.
- C. Notify the provider of the increase in blood loss.
- D. Assist the patient to the bathroom and reassess the fundus after the patient voids.
Correct Answer: B
Rationale: The correct answer is B because a soft and boggy fundus after delivery indicates uterine atony, which can lead to postpartum hemorrhage. Performing external massage of the uterus will help stimulate contractions and firm up the fundus. Assessing for additional bleeding is crucial to monitor for hemorrhage. Updating the licensed provider is important for further management.
Choice A is incorrect because simply increasing Pitocin without addressing the uterine atony may not resolve the issue. Choice C is incorrect as notifying the provider of increased blood loss is not the immediate priority; addressing the uterine atony is. Choice D is incorrect as assisting the patient to the bathroom does not address the soft and boggy fundus issue.
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
- A. Apply antibiotic ointment to the perineum daily.
- B. Change the peripad at each voiding.
- C. Void at least every two hours.
- D. Spray the perineum with povidone-iodine after toileting.
Correct Answer: B
Rationale: Changing peripads frequently helps prevent the growth of bacteria and reduces the risk of infection.
A breastfeeding client, 7 weeks postpartum, complains to an obstetrician 's triage nurse that when she and her husband had intercourse for the first time after the delivery, 'I couldn 't stand it. It was so painful. The doctor must have done something terrible to my vagina. ' Which of the following responses by the nurse is appropriate?
- A. After a delivery the vagina is always very tender. It should feel better the next time you have intercourse. '
- B. Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina. '
- C. Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort. '
- D. Sometimes the stitches of episiotomies heal too tight. Why don 't you come in to be checked? '
Correct Answer: C
Rationale: Vaginal dryness is a common issue for breastfeeding women, and using a vaginal lubricant can help reduce discomfort during intercourse.
What postpartum infection is caused by STIs and chorioamnionitis?
- A. mastitis
- B. pneumonia
- C. cesarean wound infection
- D. postpartum endometritis
Correct Answer: D
Rationale: The correct answer is D, postpartum endometritis. This infection is commonly caused by sexually transmitted infections (STIs) and chorioamnionitis. Endometritis is inflammation of the endometrium lining the uterus after childbirth. Mastitis (A) is a breast infection, pneumonia (B) is a lung infection, and cesarean wound infection (C) is an infection at the site of the cesarean incision. These options are incorrect as they do not specifically relate to the postpartum infection caused by STIs and chorioamnionitis.
The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, 'I really don 't need to go. ' Which of the following responses by the nurse is appropriate?
- A. Okay. I must be palpating your uterus.
- B. I understand but I still would like you to try to urinate.
- C. You still must be numb from the local anesthesia.
- D. That is a problem. I will have to catheterize you.
Correct Answer: B
Rationale: A distended bladder can lead to complications such as uterine atony. The nurse should encourage the woman to attempt urination, but if she refuses, further action may be necessary.