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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 goal because monitoring lochia flow post-vaginal delivery helps assess for excessive bleeding, which is crucial for preventing postpartum hemorrhage. Choice A is not a priority in the immediate postpartum period. Choice B is important but not as critical as monitoring lochia flow. Choice D is also important for preventing complications but not as urgent as assessing for postpartum bleeding.
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The nurse on a postpartum unit is acutely aware that cultural influences impact the patient's process of 'becoming a mother.' For which isn't a cultural influence does the nurse assess?
- A. What amount of time the mother spends in each phase
- B. Differences in the mother's expectation related to ability to rest
- C. How the mother physically recovers from labor and delivery
- D. Mother's involvement in decision making for the first few months
Correct Answer: C
Rationale: The correct answer is C because how a mother physically recovers from labor and delivery is primarily influenced by biological and physiological factors rather than cultural influences. The mother's physical recovery is guided by medical interventions, individual health conditions, and postpartum care practices. On the other hand, choices A, B, and D are all influenced by cultural factors. Choice A pertains to cultural variations in rituals or customs related to the duration of each phase of becoming a mother. Choice B involves cultural beliefs around postpartum rest and support systems. Choice D addresses cultural norms regarding maternal autonomy and decision-making in the early stages of motherhood.
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 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 displaying signs of uterine atony, a condition where the uterus fails to contract properly postpartum, leading to excessive bleeding. The soft and boggy fundus, displacement to the left, and moderate bleeding indicate a serious issue that requires immediate medical attention. By calling the healthcare provider, the nurse can ensure timely intervention and treatment to address the uterine atony and prevent further complications. The other options are not appropriate at this time: A may worsen the situation by increasing bleeding, B delays necessary action, and C may be needed but not as the first priority in this critical situation.
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.
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: The correct answer is D: Prepare ice pack for application to perineal area. This intervention is crucial for managing pain and reducing swelling in the perineal area post third-degree tear. Ice packs help vasoconstriction, decreasing blood flow and minimizing inflammation. It also provides comfort to the patient.
A: Assess vital signs every 4 hours - This is important but not the priority in this situation. Monitoring vital signs is essential, but immediate comfort measures should be prioritized for the patient with a perineal tear.
B: Keep patient NPO for first 12 hours - There is no indication to keep the patient NPO for 12 hours. Adequate hydration and nutrition are important for postpartum recovery.
C: Catheterize patient prior to first ambulation - Catheterization may not be necessary unless there are specific indications. It is not a routine intervention for a perineal tear during the fourth stage of labor.