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Which nursing care goal is the highest priority for a woman who had a vaginal delivery 3 hours earlier?
- A. The client will wear a well-supported bra.
- B. The client will eat 100% of her meals.
- C. The client will have a moderate lochia flow.
- D. The client will ambulate to the bathroom.
Correct Answer: C
Rationale: The correct answer is C: The client will have a moderate lochia flow. This is the highest priority because excessive or scant lochia flow can indicate postpartum hemorrhage or retained placental fragments, which are serious postpartum complications. Ensuring a moderate lochia flow is essential for assessing the woman's postpartum recovery and preventing potential complications.
Choice A (The client will wear a well-supported bra) is not a priority in the immediate postpartum period and does not directly impact the woman's physical health.
Choice B (The client will eat 100% of her meals) is important for the woman's nutrition and recovery but is not as critical as monitoring the lochia flow to prevent complications like hemorrhage.
Choice D (The client will ambulate to the bathroom) is important for preventing complications like blood clots and promoting circulation, but monitoring the lochia flow takes precedence in the immediate postpartum period to assess for any signs of hemorrhage or infection.
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A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application helps reduce swelling and pain in the perineal area post-tear.
2. Ice packs can promote vasoconstriction, reducing bleeding risk.
3. Ice packs are non-invasive and can offer immediate relief.
Summary:
A: Assessing vital signs every 4 hours is important but not directly related to perineal tear care.
B: Keeping the patient NPO for 12 hours is unnecessary and may lead to dehydration.
C: Catheterization is not typically required for perineal tear care unless there are specific indications.
A nurse is taking care of a G2P2 woman with a third-degree perineal tear during the fourth stage of labor. The nurse should include which intervention in the plan of care during her 12-hour shift?
- A. Assess vital signs every 4 hours.
- B. Keep patient NPO for first 12 hours.
- C. Catheterize patient prior to first ambulation.
- D. Prepare ice pack for application to perineal area.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Ice pack application reduces swelling and provides comfort to the perineal tear.
2. Ice packs help to decrease pain and promote healing in the perineal area.
3. Ice packs are a non-invasive and non-pharmacological method of pain relief.
4. Ice packs can be safely used without interfering with the wound healing process.
Summary of Incorrect Choices:
A: Assessing vital signs every 4 hours is important but not specific to managing perineal tear pain.
B: Keeping the patient NPO is not necessary for perineal tear management unless indicated for other reasons.
C: Catheterization prior to ambulation is not directly related to perineal tear care and may not be necessary during the fourth stage of labor.
The nurse is providing postpartum care for an adolescent mother and her family. Which factor is most important for the nurse to consider when planning teaching about neonatal care?
- A. The grandparents decided they want to be involved.
- B. The parents need to discuss their expectations of each other.
- C. The mother is determined the father should be involved.
- D. Information must be presented on an age-appropriate level.
Correct Answer: D
Rationale: The correct answer is D: Information must be presented on an age-appropriate level. This is crucial as adolescents may have limited knowledge and understanding of neonatal care. Teaching in a way they can comprehend ensures effective learning.
Incorrect choices:
A: The involvement of grandparents is important but not the most critical factor.
B: Parental expectations are significant, but not directly related to neonatal care teaching.
C: The father's involvement is valuable, but not the primary consideration for teaching about neonatal care.
In summary, choosing answer D ensures effective communication and understanding for the adolescent mother and her family.
The nurse is aware that some parenting skills are acquired through the process of intentional learning. Which activity does the nurse associate with intentional learning?
- A. The couple observes other individuals who are mothers and fathers.
- B. The couple attends hospital classes addressing newborn and infant care.
- C. The couple discusses with each other how they were parented.
- D. The couple watches media containing parenting roles.
Correct Answer: B
Rationale: The correct answer is B because attending hospital classes on newborn and infant care involves intentional learning, where the couple actively seeks out knowledge and skills related to parenting. This choice allows them to receive structured education and guidance from professionals in a focused setting. Observing other individuals (choice A) may provide some insights but lacks the structured learning environment. Discussing their own upbringing (choice C) may be informative but does not necessarily involve intentional learning focused on acquiring new parenting skills. Watching media (choice D) may offer some information but lacks the interactive and hands-on learning experience provided by attending hospital classes.
The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does respond to uterine massage, which actions does the nurse implement?
- A. Assist the patient to the bathroom to void.
- B. Reassess to determine response to treatment.
- C. Administer oxytocin as prescribed.
- D. Place an emergency call to the HCP.
Correct Answer: D
Rationale: The correct answer is D: Place an emergency call to the HCP. In this scenario, the patient is showing signs of uterine atony, which is a common cause of postpartum hemorrhage. A soft, boggy fundus with displacement and moderate bleeding indicates inadequate uterine contractions. If uterine massage does not improve the condition, it is crucial to involve the healthcare provider immediately for further interventions such as administering uterotonic medications or considering manual removal of retained placental fragments. Options A and B are not the priority in this critical situation, and option C, administering oxytocin, can be done but the immediate action should be to seek guidance from the healthcare provider due to the severity of the condition.