Nokea
Which of the following is the priority nursing action during the immediate postpartum period?
- A. Palpate fundus.
- B. Check pain level.
- C. Perform pericare.
- D. Assess breasts.
Correct Answer: A
Rationale: Palpating the fundus is the priority to assess for uterine involution and prevent postpartum hemorrhage.
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Which client is at greatest risk for early PPH?
- A. Primiparous woman (G 2, P 1-0-0-1) being prepared for an emergency cesarean birth for fetal distress
- B. Woman with severe preeclampsia on magnesium sulfate whose labor is being
- C. Multiparous woman (G 3, P 2-0-0-2) with an 8-hour labor
- D. Primigravida in spontaneous labor with preterm twins
Correct Answer: B
Rationale: The correct answer is B because a woman with severe preeclampsia on magnesium sulfate is at the greatest risk for early postpartum hemorrhage (PPH) due to the increased risk of placental abruption, coagulopathy, and uterine atony associated with preeclampsia and magnesium sulfate use. Preeclampsia can lead to poor placental perfusion, increasing the risk of hemorrhage during and after delivery. Magnesium sulfate can also affect blood clotting mechanisms, further increasing the risk of excessive bleeding. The other choices are less likely to be at greatest risk for early PPH. Choice A involves a primiparous woman with cesarean delivery, which may have controlled bleeding. Choice C is a multiparous woman with a relatively short labor duration, which is not a significant risk factor for early PPH. Choice D is a primigravida with preterm twins, which does not inherently increase the risk of early PPH
A 2-day-postpartum breastfeeding woman states, 'I am sick of being fat. When can I go on a diet? ' Which of the following responses is appropriate?
- A. It is fine for you to start dieting right now as long as you drink plenty of milk. '
- B. Your breast milk will be low in vitamins if you start to diet while breastfeeding. '
- C. You must eat at least 3,000 calories per day in order to produce enough milk for your baby. '
- D. Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day. '
Correct Answer: D
Rationale: Breastfeeding can help with postpartum weight loss, as the body burns calories producing milk.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, 'I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest. ' Which of the following actions should the nurse take at this time?
- A. Encourage the woman exclusively to breastfeed her baby.
- B. Have the woman massage her breasts hourly.
- C. Obtain an order to culture her expressed breast milk.
- D. Take the temperature and pulse rate of the woman.
Correct Answer: A
Rationale: Breastfeeding exclusively can help relieve engorgement, and frequent feedings prevent further complications.
What assessment finding would indicate a fluid volume deficit?
- A. skin tenting with testing of skin turgor
- B. hypertension
- C. bradycardia
- D. bounding pulse
Correct Answer: A
Rationale: Skin tenting indicates dehydration, a sign of fluid volume deficit.
The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform?
- A. Intermittently apply ice packs to her axillae and breasts.
- B. Apply lanolin to her breasts and nipples every 3 hours.
- C. Express milk from the breasts every 3 hours.
- D. Ask the primary health care provider to order a milk suppressant.
Correct Answer: A
Rationale: Ice packs can help reduce inflammation and pain associated with engorgement in women who choose to bottle-feed.