Nokea
Which fundal assessment finding at 12 hours after birth requires further assessment?
- A. The fundus is palpable at the level of the umbilicus.
- B. The fundus is palpable two fingerbreadths above the umbilicus.
- C. The fundus is palpable one fingerbreadth below the umbilicus.
- D. The fundus is palpable two fingerbreadths below the umbilicus.
Correct Answer: A
Rationale: Rationale:
- A: Fundus palpable at umbilicus level at 12 hours postpartum is concerning for uterine atony or retained placental fragments.
- B, C, D: These findings are within normal range for fundal height postpartum and do not require further assessment.
Summary:
- Choice A is correct because it indicates a potential issue with uterine involution.
- Choices B, C, D are incorrect as they reflect normal fundal height findings postpartum.
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A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform?
- A. Cover the wound with sterile wet dressings.
- B. Notify the surgeon.
- C. Elevate the head of the client's bed slightly.
- D. Flex the client's knees.
Correct Answer: B
Rationale: Immediate surgical intervention is required for wound separation.
A mother, G4 P4004, is 15 minutes postpartum. Her baby weighed 4,595 grams at birth. For which of the following complications should the nurse monitor this client?
- A. Seizures.
- B. Hemorrhage.
- C. Infection.
- D. Thrombosis.
Correct Answer: B
Rationale: Macrosomic babies increase the risk of postpartum hemorrhage.
A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make?
- A. Place the client flat in bed.
- B. Assess for dependent edema.
- C. Auscultate lung fields.
- D. Check patellar reflexes.
Correct Answer: C
Rationale: General anesthesia can impair lung function, necessitating lung auscultation.
During the first 8 hours postpartum, the nurse will demonstrate how to perform a fundal massage and assist with breast-feeding techniques. What other assessment is important at this time?
- A. assessment of partner changing a diaper
- B. assessment of vaginal bleeding
- C. assessment of social support
- D. assessment of family dynamics
Correct Answer: B
Rationale: The correct answer is B: assessment of vaginal bleeding. During the first 8 hours postpartum, it is crucial to monitor vaginal bleeding to assess for any signs of excessive bleeding or hemorrhage, which are common postpartum complications. This assessment helps in early detection and prompt intervention if necessary.
Other choices are incorrect:
A: assessment of partner changing a diaper - While involving the partner in care is beneficial, it is not a priority assessment during this crucial postpartum period.
C: assessment of social support - Important for overall well-being but not as critical as monitoring vaginal bleeding for immediate postpartum complications.
D: assessment of family dynamics - While family dynamics play a role in postpartum care, it is not a priority assessment in the initial 8 hours.
The nurse screens for risk factors such as an infant in the neonatal intensive care unit (NICU), difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support for what complication?
- A. maladaptive parenting
- B. psychosis
- C. postpartum depression
- D. bipolar disorder
Correct Answer: C
Rationale: The correct answer is C: postpartum depression. Screening for risk factors such as a baby in the NICU, difficulty in role transition, birth complications, unmet social and physical needs, and lack of partner support are all associated with an increased risk for postpartum depression. Postpartum depression is a common complication that affects many new mothers and can have significant impacts on both the mother and the baby's well-being. It is important for healthcare providers to be vigilant in screening for these risk factors to identify and support mothers at risk for postpartum depression.
Summary:
A: maladaptive parenting - Not directly related to the risk factors listed.
B: psychosis - Not typically associated with the listed risk factors.
D: bipolar disorder - While bipolar disorder can occur postpartum, the listed risk factors are more specifically linked to postpartum depression.