Nokea
When teaching a new mother how to perform perineal care, which instruction should be included?
- A. Use a front-to-back motion when cleaning the perineal area
- B. Use a peri-bottle filled with warm water after each voiding
- C. Avoid using any cleansing solution on the perineal area
- D. Apply powder to the perineal area to keep it dry
Correct Answer: B
Rationale: Using a peri-bottle filled with warm water after each voiding is essential for proper perineal care as it helps cleanse the area without causing irritation and promotes healing. It is important to avoid using a back-to-front motion to prevent introducing bacteria into the urethra, and using powder may increase the risk of infection. Cleansing solutions specifically formulated for perineal care may be recommended but should be used under healthcare provider guidance.
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A postpartum client is experiencing heavy lochia and a boggy uterus. What should be the nurse's initial action?
- A. Administer a uterotonic medication
- B. Encourage the client to void
- C. Perform fundal massage
- D. Increase the client's fluid intake
Correct Answer: C
Rationale: The correct initial action for a postpartum client experiencing heavy lochia and a boggy uterus is to perform fundal massage. Fundal massage helps to firm the uterus and reduce bleeding by promoting uterine contractions, which can assist in preventing postpartum hemorrhage. Administering uterotonic medication may be necessary in some cases but should not be the initial action. Encouraging the client to void and increasing fluid intake can be important interventions but are not the priority in this situation where immediate uterine firmness is needed to control bleeding.
The healthcare provider assesses a postpartum client who is 1 day post-delivery. Which finding would require immediate intervention?
- A. Lochia rubra with a few small clots
- B. Fundus firm and midline
- C. Temperature of 100.4°F (38°C)
- D. Saturated perineal pad in 15 minutes
Correct Answer: D
Rationale: A saturated perineal pad in 15 minutes indicates excessive bleeding, which is abnormal postpartum. This finding could suggest hemorrhage, requiring immediate intervention to prevent further complications like hypovolemic shock. Monitoring and managing postpartum bleeding are crucial to ensure the client's safety and prevent serious consequences.
The healthcare provider is providing postpartum care to a client who had a vaginal delivery. Which finding would require further assessment?
- A. Perineal swelling
- B. Moderate lochia serosa
- C. Headache unrelieved by analgesics
- D. Breast engorgement
Correct Answer: C
Rationale: A headache unrelieved by analgesics can be a sign of a serious condition such as preeclampsia, which is a life-threatening condition characterized by high blood pressure and often protein in the urine. Prompt assessment and intervention are crucial to prevent complications for both the mother and baby.
The healthcare provider is preparing to administer Rh immune globulin (RhoGAM) to a postpartum client. This medication is indicated for:
- A. Rh-negative individuals with Rh-positive infants
- B. Rh-positive individuals with Rh-negative infants
- C. All individuals regardless of Rh status
- D. Individuals with a history of Rh incompatibility
Correct Answer: A
Rationale: Rh immune globulin (RhoGAM) is administered to Rh-negative individuals who have given birth to Rh-positive infants to prevent Rh sensitization. When an Rh-negative individual gives birth to an Rh-positive infant, there is a risk of the mother developing antibodies against the Rh-positive blood cells, which can lead to hemolytic disease of the newborn in subsequent pregnancies. Rh immune globulin is given to prevent this sensitization in Rh-negative individuals who deliver Rh-positive infants.
The nurse is assessing a postpartum client's fundus. Where should the nurse expect to find the fundus 24 hours after delivery?
- A. At the level of the umbilicus
- B. 1 cm above the symphysis pubis
- C. At the level of the xiphoid process
- D. 2 cm below the umbilicus
Correct Answer: A
Rationale: After delivery, the fundus is expected to be at the level of the umbilicus 24 hours postpartum. This position indicates that the uterus is involuting properly. Assessing the fundal height helps monitor the progress of uterine involution and can identify any potential complications like postpartum hemorrhage.