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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: Antipyretics help manage the symptoms of mastitis.
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A woman who is 3 hours postpartum has had difficulty in urinating. She finally urinates 100 mL. The initial nursing action is to:
- A. Insert an indwelling catheter.
- B. Have her drink additional fluids.
- C. Assess the height of her fundus.
- D. Chart the urination amount.
Correct Answer: C
Rationale: Before taking further action, the nurse should assess the height of the fundus to determine if a full bladder may be contributing to urinary retention.
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.
The nurse is developing a plan of care for the postpartum client during the 'taking in ' phase. Which of the following should the nurse include in the plan?
- A. Teach baby-care skills like diapering.
- B. Discuss the labor and birth with the mother.
- C. Discuss contraceptive choices with the mother.
- D. Teach breastfeeding skills like pumping.
Correct Answer: B
Rationale: During the 'taking in' phase, the mother is focused on her own recovery and reliving the birth experience. Discussing the labor and birth is appropriate at this time.
The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate?
- A. Positive bonding and client needs little teaching.
- B. Positive bonding but teaching related to newborn care is needed.
- C. Poor bonding and referral to a child abuse agency is essential.
- D. Poor bonding but there is potential for positive mothering.
Correct Answer: B
Rationale: The mother is engaging with the baby, indicating positive bonding, but further teaching on newborn care is still necessary.
A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate?
- A. Take the woman 's temperature.
- B. Advise the woman to decrease her fluid intake.
- C. Reassure the woman that this is normal.
- D. Notify the neonate 's pediatrician.
Correct Answer: C
Rationale: Profuse diaphoresis is a common and normal occurrence in the first 24 hours postpartum as the body works to eliminate excess fluid accumulated during pregnancy.