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Exam (elaborations) obstetric nursing: postpartum

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ENTAILS QUESTIONS AND ANSWERS

Institution
Obstetric Nursing: Postpartum
Course
Obstetric nursing: postpartum

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obstetric nursing: postpartum

,A postpartum nurse is preparing to care for a woman who has just delivered a healthy
newborn infant. In the immediate postpartum period the nurse plans to take the
woman's vital signs:

Every 30 minutes during the first hour and then every hour for the next two hours.
Every 15 minutes during the first hour and then every 30 minutes for the next two hours.
Every hour for the first 2 hours and then every 4 hours
Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. -
CORRECT ANSWERS-2

A postpartum nurse is taking the vital signs of a woman who delivered a healthy
newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F.
Which of the following actions would be most appropriate?

Retake the temperature in 15 minutes
Notify the physician
Document the findings
Increase hydration by encouraging oral fluids - CORRECT ANSWERS-4. The mother's
temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4
(38 C) in the first 24 hours after birth are often related to the dehydrating effects of
labor. The most appropriate action is to increase hydration by encouraging oral fluids,
which should bring the temperature to a normal reading. Although the nurse would
document the findings, the most appropriate action would be to increase the hydration.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy
infant. The client complains to the nurse of feelings of faintness and dizziness. Which of
the following nursing actions would be most appropriate?

Obtain hemoglobin and hematocrit levels
Instruct the mother to request help when getting out of bed
Elevate the mother's legs
Inform the nursery room nurse to avoid bringing the newborn infant to the mother until
the feelings of light-headedness and dizziness have subsided. - CORRECT ANSWERS-
2. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of
faintness or dizziness are signs that should caution the nurse to be aware of the client's
safety. The nurse should advise the mother to get help the first few times the mother
gets out of bed. Obtaining an H/H requires a physicians order.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial
nursing action in performing this assessment is which of the following?

Ask the client to turn on her side
Ask the client to lie flat on her back with the knees and legs flat and straight.
Ask the mother to urinate and empty her bladder
Massage the fundus gently before determining the level of the fundus. - CORRECT
ANSWERS-3. Before starting the fundal assessment, the nurse should ask the mother

, to empty her bladder so that an accurate assessment can be done. When the nurse is
performing fundal assessment, the nurse asks the woman to lie flat on her back with the
knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and
soft, and then it should be massaged gently until firm.

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia
is red and has a foul-smelling odor. The nurse determines that this assessment finding
is:

Normal
Indicates the presence of infection
Indicates the need for increasing oral fluids
Indicates the need for increasing ambulation - CORRECT ANSWERS-2. Lochia, the
discharge present after birth, is red for the first 1 to 3 days and gradually decreases in
amount. Normal lochia has a fleshy odor. Foul smelling or purulent lochia usually
indicates infection, and these findings are not normal. Encouraging the woman to drink
fluids or increase ambulation is not an accurate nursing intervention.

When performing a PP assessment on a client, the nurse notes the presence of clots in
the lochia. The nurse examines the clots and notes that they are larger than 1 cm.
Which of the following nursing actions is most appropriate?

Document the findings
Notify the physician
Reassess the client in 2 hours
Encourage increased intake of fluids. - CORRECT ANSWERS-2. Normally, one may
find a few small clots in the first 1 to 2 days after birth from pooling of blood in the
vajayjay. Clots larger than 1 cm are considered abnormal. The cause of these clots,
such as uterine atony or retained placental fragments, needs to be determined and
treated to prevent further blood loss. Although the findings would be documented, the
most appropriate action is to notify the physician.

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected
lochia drainage. The nurse instructs the mother that the normal amount of lochia may
vary but should never exceed the need for:

One peripad per day
Two peripads per day
Three peripads per day
Eight peripads per day - CORRECT ANSWERS-4. The normal amount of lochia may
vary with the individual but should never exceed 4 to 8 peripads per day. The average
number of peripads is 6 per day.

A PP nurse is providing instructions to a woman after delivery of a healthy newborn
infant. The nurse instructs the mother that she should expect normal bowel elimination
to return:

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Institution
Obstetric nursing: postpartum
Course
Obstetric nursing: postpartum

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