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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 because monitoring lochia flow is crucial post-vaginal delivery to assess for excessive bleeding, which could indicate postpartum hemorrhage. This goal takes precedence over other options as it pertains to the client's immediate health and well-being. A: Wearing a bra does not address any urgent postpartum concerns. B: Eating meals is important but does not take priority over assessing for hemorrhage. D: Ambulation is beneficial but not as critical as monitoring lochia flow for potential complications.
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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 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 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.
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. It is crucial for the nurse to present information on neonatal care in an age-appropriate manner as the mother is an adolescent. This is important to ensure effective communication and understanding. Choice A does not directly impact the neonatal care teaching. Choice B focuses on the parents' expectations, not the neonatal care itself. Choice C emphasizes the father's involvement but does not address the approach to teaching the adolescent mother about neonatal care.
The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide?
- A. The signs and symptoms of uterine infection
- B. The signs and symptoms of secondary hemorrhage
- C. The signs and symptoms of postpartum depression
- D. The signs and symptoms of a boggy uterus
Correct Answer: B
Rationale: The correct answer is B: The signs and symptoms of secondary hemorrhage. This is the most important teaching for the nurse to provide because it is a potentially life-threatening complication that requires immediate medical attention. Secondary hemorrhage can occur after the initial postpartum period and can lead to severe bleeding. Understanding the signs and symptoms of secondary hemorrhage can help the patient seek prompt medical care if needed.
Choice A: The signs and symptoms of uterine infection are important to know, but they are usually treated with antibiotics and are not as immediately life-threatening as secondary hemorrhage.
Choice C: Postpartum depression is a serious concern but does not require immediate medical attention like secondary hemorrhage.
Choice D: A boggy uterus is a sign of uterine atony, which can lead to hemorrhage, but teaching about secondary hemorrhage takes precedence because it directly addresses a more severe form of bleeding that requires urgent intervention.
A postpartum patient comes to the clinic for her 6-week postpartum checkup. When assessing the patient's cervix, how should the nurse expect the cervix to appear?
- A. Noticeable small lacerations
- B. Approximately 3 cm dilated
- C. Symmetrically round external os
- D. Firm and thick
Correct Answer: C
Rationale: The correct answer is C: Symmetrically round external os. At 6 weeks postpartum, the cervix should have returned to its normal appearance, which is symmetrically round. This indicates proper healing and involution of the cervix after childbirth. Noticeable small lacerations (A) would suggest incomplete healing or trauma. Approximately 3 cm dilated (B) is not expected at 6 weeks postpartum as the cervix should be closed. Firm and thick (D) would indicate a cervix that has not undergone involution as expected by this time.