Nokea
Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis?
- A. Encourage early ambulation.
- B. Promote oral fluid intake.
- C. Massage the legs of the client twice daily.
- D. Provide the client with high-fiber foods.
Correct Answer: A
Rationale: Early ambulation promotes circulation and reduces the risk of thrombophlebitis after delivery.
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A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse 's best response?
- A. I know that it hurts but it is very important for you to cough.
- B. Let me check your lung fields to see if coughing is really necessary.
- C. If you take a few deep breaths in, that should be as good as coughing.
- D. If you support your incision with a pillow, coughing should hurt less.
Correct Answer: D
Rationale: Supporting the incision with a pillow while coughing reduces the strain on the surgical site, making it less painful.
A breastfeeding woman develops mastitis. She tells the nurse that she will feed her baby formula instead of breastfeeding until the infection is healed. The best nursing response is that:
- A. Emptying the breast is important to prevent an abscess.
- B. A tight breast binder or bra will help reduce engorgement.
- C. She should continue to drink extra fluids while weaning.
- D. Breastfeeding can continue when her temperature is normal.
Correct Answer: A
Rationale: Breastfeeding or regular pumping helps to keep the breast emptied reducing the risk of abscess formation.
Nurses need to understand the basic definitions and incidence data regarding PPH. Which statement regarding this condition is most accurate?
- A. PPH is easy to recognize early; after all, the woman is bleeding.
- B. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH.
- C. If anything, nurses and physicians tend to overestimate the amount of blood loss.
- D. Traditionally, PPH has been classified as early PPH or late PPH with respect to birth.
Correct Answer: B
Rationale: The most accurate statement regarding the basic definitions and incidence data of postpartum hemorrhage (PPH) is statement B. Traditionally, PPH is defined as losing more than 1000 ml of blood after vaginal birth and more than 2500 ml after cesarean birth. This definition helps healthcare providers recognize and diagnose PPH based on the amount of blood loss, which is crucial for prompt intervention and management.
A client G2 P1102 is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client 's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform?
- A. Assess her feet and ankles for pitting edema.
- B. Lower both of her legs at the same time.
- C. Advise the client to stop feeding her baby while her blood pressure is assessed.
- D. Measure the length of the episiotomy and document the findings in the chart.
Correct Answer: A
Rationale: The nurse should assess for signs of deep vein thrombosis (DVT) or pitting edema in the postpartum period, especially after stirrup use during delivery.
The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management?
- A. Application of hot packs to the perineal area
- B. Information applicable to medication therapy
- C. Instructions to improve circulation by ambulating
- D. Medicating for pain above level 4 on a 0 to 10 scale
Correct Answer: B
Rationale: The nurse will need to provide applicable discharge teaching for both antibiotic and analgesic therapy. Antibiotics need to be taken as ordered and until they are gone.