Nokea
Which of the following is a priority nursing diagnosis for a woman, G10 P6226, who is PP1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage?
- A. Alteration is comfort related to afterbirth pains.
- B. Risk for altered parenting related to grand multiparity.
- C. Fluid volume deficit related to blood loss.
- D. Risk for sleep deprivation related to mothering role.
Correct Answer: C
Rationale: Hemorrhage causes fluid loss.
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What is the term for the separation found in the midline of the abdomen after birth?
- A. uterine subinvolution
- B. umbilical hernia
- C. striae
- D. diastasis recti abdominus
Correct Answer: D
Rationale: The correct answer is D: diastasis recti abdominus. This term refers to the separation of the rectus abdominis muscles along the midline of the abdomen. This condition commonly occurs after pregnancy due to the stretching of the abdominal muscles. It is important to differentiate diastasis recti from other conditions such as uterine subinvolution, which is the delayed return of the uterus to its normal size postpartum; umbilical hernia, which is a protrusion of abdominal contents through the umbilical ring; and striae, which are stretch marks caused by rapid stretching of the skin. Diastasis recti is characterized by a visible gap between the muscles, often causing a bulge in the midline of the abdomen. Treatment usually involves specific exercises to strengthen the abdominal muscles and improve the condition.
The person with a cesarean birth has additional nursing concerns beyond those of a person with a vaginal birth. What concern should the nurse anticipate for the cesarean birth?
- A. increased risk for DVT
- B. faster recovery
- C. less use of pain medication
- D. less risk for infection
Correct Answer: A
Rationale: The correct answer is A: increased risk for DVT. Cesarean birth increases the risk of Deep Vein Thrombosis (DVT) due to reduced mobility and potential blood clot formation. This is a critical concern as DVT can lead to serious complications like pulmonary embolism. Choices B and C are incorrect as cesarean birth typically results in longer recovery time and increased need for pain medication compared to vaginal birth. Choice D is incorrect as cesarean birth poses a higher risk of infection due to the surgical incision.
The nurse recognizes the postpartum person is in what stage of Rubin’s attachment model when the person is concerned with physical recovery and depends on the nurse or partner for help physically?
- A. Taking In
- B. Taking Hold
- C. Postpartum Maternal Change
- D. Attainment of Change
Correct Answer: A
Rationale: The correct answer is A: Taking In. In Rubin's attachment model, this stage occurs immediately after childbirth when the person focuses on their own physical recovery and relies on others for assistance. This stage is characterized by passivity and dependence. The other choices are incorrect because: B) Taking Hold is the stage where the person starts to take on more responsibility for themselves and the baby; C) Postpartum Maternal Change is not a recognized stage in Rubin's model; D) Attainment of Change is not a stage in Rubin's model either.
A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see?
- A. Engorgement.
- B. Mastitis.
- C. Blocked milk duct.
- D. Low milk supply.
Correct Answer: B
Rationale: Retained fragments increase infection risk.
A serum electrolyte report for a client, 1 day post-cesarean delivery for eclampsia, has just been received by the nurse. The client is receiving 5% dextrose in 1/2 normal saline IV at 125 mL/hr and magnesium sulfate 2 G/hr IV via infusion pump. Which of the following values should the nurse report to the surgeon?
- A. Magnesium 7 mg/dL.
- B. Sodium 136 mg/dL.
- C. Potassium 3.0 mg/dL.
- D. Calcium 9 mg/dL.
Correct Answer: A
Rationale: Elevated magnesium levels indicate toxicity.