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What nursing intervention does the nurse include in the plan of care for a person with a wound infection?
- A. Reassure the postpartum person that infection will resolve without antibiotics.
- B. Assess for REEDA.
- C. Call health-care provider when temperature is 99.0° F.
- D. Scrub the incision vigorously with soap and water.
Correct Answer: B
Rationale: The REEDA acronym (Redness Edema Ecchymosis Discharge and Approximation) is used to assess for infection in a wound.
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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.
What important assessment should the nurse perform on all postpartum persons?
- A. Screen for PPD with the EPDS.
- B. Screen for drug use with a urine drug screen.
- C. Screen for breast-feeding failure.
- D. Screen for contraception contraindications.
Correct Answer: A
Rationale: Screening for PPD is essential during postpartum care.
During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
- A. Diaphoresis.
- B. Lochia alba.
- C. Cracked nipples.
- D. Hypertension.
Correct Answer: B
Rationale: By the second week postpartum, lochia typically transitions to alba (white or yellowish discharge).
The nurse assesses the fundus and finds it to be boggy, elevated >2 fingerbreadths above the umbilicus, and deviated to one side. What is the common cause of this finding?
- A. uterine rupture
- B. full bladder
- C. perineal laceration
- D. hematoma
Correct Answer: B
Rationale: A full bladder can displace the uterus and prevent it from contracting properly leading to a boggy fundus.
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse 's response?
- A. The client 's obstetric status is optimal for receiving the vaccine.
- B. The client 's immune system is highly responsive during the postpartum period.
- C. The client 's baby will be high risk for acquiring rubella if the woman does not receive the vaccine.
- D. The client 's insurance company will pay for the shot if it is given during the immediate postpartum period.
Correct Answer: B
Rationale: The postpartum period offers a good opportunity for immunization because the immune system is more responsive. Administering the vaccine before discharge ensures the woman is protected in the future.