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Why does the nurse encourage ambulation in a patient who has experienced a cesarean birth?
- A. Ambulation helps to prevent DVT.
- B. Ambulation causes the person to lose weight in the hospital.
- C. Ambulation helps with breast-feeding.
- D. Ambulation decreases peristalsis.
Correct Answer: A
Rationale: Ambulation encourages circulation and reduces the risk of deep vein thrombosis (DVT) after cesarean birth.
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The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus?
- A. Scant amount of odorless lochia
- B. Presence of headache, malaise, and chills
- C. Pain or discomfort in the midline lower abdomen
- D. Elevated temperature greater than 100.4°F (38°C)
Correct Answer: D
Rationale: Endometritis from beta-hemolytic streptococcus specifically exhibits scant, odorless lochia in addition to the more universal signs of infection.
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
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.
What theory developed by Ramona Mercer focused on the process of becoming a mother?
- A. Maternal Role Attainment
- B. Postpartum Adapting
- C. Postpartum Maternal Change
- D. Maternal Encouragement
Correct Answer: A
Rationale: Ramona Mercer's theory of Maternal Role Attainment focuses on how women adapt and assume the maternal role following childbirth.
What nursing intervention does the nurse include in the plan of care for a person with mastitis?
- A. Provide antipyretic.
- B. Stop antibiotics when redness is resolved.
- C. Encourage the person to stop breast-feeding.
- D. Start an IV and prepare for signs of sepsis.
Correct Answer: A
Rationale: Antipyretics help manage the fever associated with mastitis along with antibiotic therapy to treat the infection.