Nokea
Within the first hour following a vaginal delivery the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurse's reaction to the assessment?
- A. This is a normal occurrence.
- B. This is abnormal and should be reported.
- C. The patient should be administered a blood thinner.
- D. The patient should be restricted to bed rest.
Correct Answer: A
Rationale: A bright red drainage is normal immediately after delivery. The patient should be monitored at regular intervals. Bed rest is not indicated. A blood thinner would not be given.
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The new mother tells the home health nurse that she is concerned about her 5-day-old infant's hard dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off?
Correct Answer: 10 to 14 days
Rationale: The umbilical stump will turn brownish black and fall off within 10 to 14 days after birth.
What is the appropriate way to assess the fundus of the postpartum patient?
- A. Using the side of one hand moving down from the umbilicus
- B. Using one hand over the lower segment of the uterus
- C. Using one hand pushing upward from the lower uterus
- D. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
Correct Answer: D
Rationale: The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
- A. Offer a suppository or enema.
- B. Encourage ambulation.
- C. Offer stool softeners as prescribed.
- D. Offer pain medication before defecating.
Correct Answer: C
Rationale: Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma. Suppositories or enemas are contraindicated in mothers with third or fourth degree lacerations. Pain medications can often cause constipation. Ambulation may aid in defecation, but will not soften the stool.
During the immediate postpartum period the mother has a temperature of 100.2°F (37.8°C) pulse 52 respirations 18 BP 138/84. What should the nurse do?
- A. Report the temperature as abnormal.
- B. Continue to monitor every 15 minutes.
- C. Report the pulse as abnormal.
- D. Nothing as the vital signs are normal.
Correct Answer: D
Rationale: The vital signs are normal for a new postpartum patient.
Which of the following measures could help prevent infant abduction?
- A. Only transport infants by carrying them.
- B. Require staff members to wear appropriate identification badges.
- C. Respond immediately when an alarm sounds.
- D. Never leave infants unattended at any time.
- E. Take all the infants to their mothers at the same time.
Correct Answer: B,C,D
Rationale: Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time.