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While assessing the postpartum client who is 10 hours post—vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?
- A. “How often are you experiencing uterine cramping?”
- B. “When was the last time you changed your peri-pad?”
- C. “Are you having any bladder urgency or frequency?”
- D. “Did you pass clots that required changing your peri-pad?”
Correct Answer: B
Rationale: Once the nurse has determined the length of time the pad has been in place, the nurse could decide if asking about uterine cramping is appropriate. The amount of lochia on a perineal pad is influenced by the individual client’s pad changing practices. Thus, the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning. Although bladder incontinence could cause pad saturation, it is more important to ask about the length of time the pad has been in place. Based on the client’s answer, the nurse could decide if asking about bladder urgency or frequency needs further assessment. Passing clots may require more frequent pad change, but first the nurse should determine if the reason for the saturated pad is the length of time it has been in place.
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The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct?
- A. “You need to come to the clinic immediately.”
- B. “Decrease physical activity until the bleeding stops.”
- C. “There is no need for concern; this is expected after birth.”
- D. “Call next week if the bleeding has not stopped by then.”
Correct Answer: A
Rationale: Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge. Increased physical activity can lead to increased lochial discharge, but the client is reporting continuous lochia rubra, which is abnormal. Lochia rubra is expected to last for up to 3 days after birth, not 20 days. Waiting until next week to be seen only delays determining the cause for her abnormal bleeding and increases the risk of the client for other complications.
Which client statement indicates a need for immediate intervention?
- A. I feel the baby move daily.
- B. I have mild swelling in my ankles.
- C. I haven't felt the baby move today.
- D. I'm eating a balanced diet.
Correct Answer: C
Rationale: A lack of fetal movement may indicate fetal distress, requiring immediate assessment and intervention.
The laboring client’s amniotic membranes have just ruptured. Which nursing action should be priority?
- A. Monitor maternal temperature.
- B. Inspect characteristics of the fluid.
- C. Perform a sterile vaginal examination.
- D. Assess the fetal heart rate pattern.
Correct Answer: D
Rationale: The priority nursing action is to assess the FHR pattern for several minutes immediately after membrane rupture to determine fetal well being. The umbilical cord may prolapse as a result of the rupture, causing life-threatening changes in the FHR. The maternal temperature should be monitored during labor and at least every two hours after the membranes rupture to assess for possible infection. However, this is not the priority nursing action. Characteristics of the fluid (color, odor, and estimated amount) should be assessed and documented after rupture, but this is not the priority at this time. A vaginal exam that assesses the progress of labor does need to be performed right after membrane rupture, but it is not the priority.
When the client asks why folic acid is important, which response by the nurse is most accurate?
- A. Folic acid helps prevent neural tube defects such as spina bifida.
- B. Folic acid helps build strong bones for your baby.
- C. Folic acid helps your baby become resistant to infections.
- D. Folic acid prevents your baby from becoming anemic.
Correct Answer: A
Rationale: Folic acid is critical for preventing neural tube defects like spina bifida by supporting early fetal development.
The nurse is teaching the postpartum client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include?
- A. “Orgasm may decrease the amount of breast milk you produce.”
- B. “You may need to use lubrication when resuming sexual intercourse.”
- C. “You should not have sexual intercourse until two months postpartum.”
- D. “Your HCP will let you know when you can resume sexual activity.”
Correct Answer: B
Rationale: Oxytocin is released when the client has an orgasm and may cause breast milk to leak or squirt from the breasts. The production of breast milk may increase, not decrease. The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness. Women should refrain from sexual intercourse until lochia has ceased, which usually takes about 3 weeks. There is no need to wait two months if the lochia has ceased. The client’s HCP does not need to give approval to return to sexual activity.