Nokea
What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
- A. Teach the patient how to massage the abdomen and then get help.
- B. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
- C. Begin massaging the fundus while another person notifies the physician.
- D. Ask the patient to void and reassess fundal tone and location.
Correct Answer: C
Rationale: When the uterus is boggy, the nurse should immediately massage it until it becomes firm.
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What complication should the nurse be alert for in the immediate postpartum period?
- A. Cervical laceration
- B. Hematoma
- C. Endometritis
- D. Retained placental fragments
Correct Answer: B
Rationale: Delivering a large infant and a prolonged labor are risk factors for hematoma formation.
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.
What will the nurse teach a nursing mother to do to reduce the risk of mastitis?
- A. Limit fluid intake to 1 liter per day.
- B. Empty both breasts with each feeding.
- C. Take warm showers.
- D. Wear a supportive bra.
- E. Pump breasts to ensure emptying.
Correct Answer: B,C,D,E
Rationale: Nursing mothers should take in about 3 liters of fluid a day. Emptying both breasts, taking warm showers, wearing a supportive bra, and pumping breasts reduce the risk of mastitis.
When weaning a newborn from breastfeeding, what should the mother do?
- A. Eliminate one feeding at a time.
- B. Eliminate the favorite feeding last.
- C. Expect the need for comfort feeding.
- D. Substitute formula for younger infants.
- E. Pump breasts in place of eliminated feeding.
Correct Answer: B,C,D
Rationale: When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last, one feeding at a time, and expect the need for comfort feeding. In younger infants, formula will need to be substituted. Pumping in place of eliminated feeding would continue milk production.
What should the nurse's next assessment be?
- A. Fullness of the bladder
- B. Amount of lochia
- C. Blood pressure
- D. Level of pain
Correct Answer: A
Rationale: Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.