Postpartum 3

juniperk's version from 2017-12-02 03:36


Question Answer
Client delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? In the early postpartum period, up to 24 hours after delivery, the most common reason for clients to have slight temperature elevations is dehydration.
To prevent infection, the nurse teaches the postpartum client to perform what tasks? : Postpartum women should be advised to perform three actions to prevent infections: (1) change their peripads at each toileting because blood is an excellent medium for bacterial growth; (2) spray the perineum, from front to back, with clear water to cleanse the area; and (3) wipe the perineum after toileting from front to back
A breastfeeding woman has been counseled on how to prevent engorgement. What action by the mother shows that the teaching was effective?The best way to prevent engorgement is to feed the baby every 2 to 3 hours
A 2-day-postpartum breastfeeding woman states, “I am sick of being fat. When can I go on a diet?” What response is appropriate? : Mothers should be advised to eat a well-balanced diet and drink sufficient quantities of fluids while breastfeeding.
A client who is 3 days postpartum asks the nurse, “When may my husband and I begin having sexual relations again?” The nurse should encourage the couple to wait until after what has occurred? The client has had her six-week postpartum check-up.
Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit 39%. 2. White blood cell count 16,000 cells/mm3 . 3. Red blood cell count 5 million cells/mm3 . 4. Hemoglobin 15 grams/dL.The WBC elevates late in the third trimester and stays elevated during labor and the early postpartum period
A breastfeeding client, G10P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.An assessment of the woman’s fundus is the most important assessment to perform on this client.
The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.The woman should turn, cough, and deep breathe every 2 hours
The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum. Ice packs help to reduce the inflammatory response and numb the area
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.Well-approximated edges.
The nurse informs a postpartum woman that ibuprofen (Advil) is especially effective for afterbirth pains. What is the scientific rationale for this?Ibuprofen has an antiprostaglandin effect. Prostaglandins are produced as part of the inflammatory response. When ibuprofen is administered, the client receives the pain-reducing action of the medication as well as its anti-inflammatory properties.
The nurse is developing a plan of care for the postpartum client during the “taking in” phase. What should the nurse include in the plan?During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase.
The nurse is developing a plan of care for the postpartum client during the “taking hold” phase. Which of the following should the nurse include in the plan?During the taking hold phase, clients regain their independence. They care for their own bodies and are very receptive to learning about childcare as well as self-care.
A nurse is counseling a woman about postpartum blues. What should be included in the discussion?Postpartum blues is a normal phenomenon related to fatigue, hormonal shifts, and the enormous responsibility of becoming a mother. usually resolve within 2 weeks of delivery.
A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h 4 doses. What assessments should be made before administering each dose of this medication?The blood pressure should be assessed before administering Methergine. The blood pressure may elevate, therefore, to dangerous levels.
The nurse should warn a client who is about to receive Methergine (ergonovine) of what side effects? Cramping is an expected outcome of the administration of Methergine

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