TEST 2 PREP U MATERNITY
A client has been in labor for 10 hours and is 6 cm dilated. She has already expressed a desire to use nonpharmacologic pain management techniques. For the past hour, she has been lying in bed with her doula rubbing her back. Now, she has begun to moan loudly, grit her teeth, and bear down with each contraction. She rates her pain as 8 out of 10 with each contraction. What should the nurse do first? You Selected: Instruct the client to do slow-paced breathing. Correct response: Assess for labor progression.
Explanation: Performing breathing exercises, ambulating, changing position, and emptying the bladder all can help the client experience a reduction in pain. However, the best first step is to assess the client for labor progress before assisting her otherwise. Bearing down can be a sign that the client is 10 cm dilated.
The nurse is caring for a client with preeclampsia and understands the need to auscultate this client's lung sounds every 2 hours to detect which condition? You Selected: pulmonary emboli Correct response: pulmonary edema
Explanation: In the hospital, monitor blood pressure at least every 4 hours for mild preeclampsia and more frequently for severe disease. In addition, it is important to auscultate the lungs every 2 hours. Adventitious sounds may indicate developing pulmonary edema.
The nurse is teaching a prenatal class on potential problems during pregnancy to a group of expectant parents. The risk factors for placental abruption (abruptio placentae) are discussed. Which comment validates accurate learning by the parents? You Selected: "Since I am over 30, I run a much higher risk of developing this problem." Correct response: "Placental abruption is quite painful and I will need to let the doctor know if I begin to have abdominal pain."
Explanation: Placental abruption (abruptio placentae) occurs when there is a spontaneous separation of the placenta from the uterine wall. It can occur anywhere on the placenta and will cause painful, dark red vaginal bleeding. If the abruption is small, the ob/gyn will try to deliver the fetus vaginally. But if severe bleeding occurs or there is fetal distress, a cesarean birth will be performed. Women older than 35 are also at higher risk for developing placental abruption.
The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: You Selected: left lower quadrant.
Explanation: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.
The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity? You Selected: magnesium sulfate level Correct response: reflexes
Explanation: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.
A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize? You Selected: maternal hypertension and fetal bradycardia Correct response: maternal hypotension and fetal bradycardia
Explanation: Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.
A nurse has been assigned to assess a pregnant client for placental abruption (abruptio placentae). For which classic manifestation of this condition should the nurse assess? You Selected: painless bright red vaginal bleeding Correct response: "knife-like" abdominal pain with vaginal bleeding
Explanation: The classic manifestations of abruption placenta are painful dark red vaginal bleeding, "knife-like" abdominal pain, uterine tenderness, contractions, and decreased fetal movement. Painless bright red vaginal bleeding is the clinical manifestation of placenta previa. Generalized vasospasm is the clinical manifestation of preeclampsia and not of abruptio placentae.
The pregnant client is planning to hire a doula for support during labor. What statement by the client requires follow-up by the nurse? You Selected: My doula will be able to support both me and my partner during the labor and birth. Correct response: My doula will help me with contractions so I will not need any pain relief in labor.
A doula is a professional support person who can provide continuous support in the prenatal, labor, and postpartum periods for both the client and partner. The doula will provide support for nonpharmacologic pain relief, such as massage. Doula care is associated with less intervention and pharmacologic pain relief in labor but is not a guarantee that pharmacologic pain relief will not be needed; this misconception should be addressed with the client.
The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? You Selected: Staphylococcus aureus Correct response: Escherichia coli
E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.
The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize? You Selected: Fetal heart rate Correct response: Green-colored fluid in the vagina
Explanation: Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? You Selected: applying warm compresses Correct response: applying ice
Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
At which time interval will the nurse assess the fetal heart rate of pregnant clients who are in the early active phase of labor? You Selected: every 10 to 15 minutes Correct response: every 15 to 30 minutes
Explanation: During the active phase of labor, fetal heart rate (FHR) is monitored every 15 to 30 minutes. FHR is assessed every 30 to 60 minutes during the latent phase of labor.
The nurse is assessing the external fetal monitor and notes the following: FHR of 175 bpm, decrease in variability, and late decelerations. Which action should the nurse prioritize at this time? You Selected: Notify the health care provider. Correct response: Have the client change position.
Explanation: Fetal tachycardia, decreased variability, and late decelerations are possible indications of cord compression. The first step is to ask the client to change position to see if that will take the pressure off the cord. The health care provider should be notified, especially if a change of position is ineffective. The nurse should continue to monitor the pattern continuously until the situation is changed and to evaluate the effectiveness of interventions. This could be an ominous sign indicating the need for further interventions to include cesarean delivery.
The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize? You Selected: Notify the health care provider about the mass. Correct response: Check the chart for the last void.
Explanation: The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be handled by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.
The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize? You Selected: Call the anesthetist from the nurse's station to retry the epidural. Correct response: Encourage her through the contractions, explaining why she cannot receive any pain medication.
Explanation: At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.
A woman in her 20s has experienced a spontaneous abortion (miscarriage) at 10 weeks' gestation and asks the nurse at the hospital what went wrong. She is concerned that she did something that caused her to lose her baby. The nurse can reassure the woman by explaining that the most common cause of miscarriage in the first trimester is related to which factor? You Selected: Advanced maternal age Correct response: Chromosomal defects in the fetus
Explanation: Fetal factors are the most common cause of early miscarriages, with chromosomal abnormalities in the fetus being the most common reason. This client fits the criteria for early spontaneous abortion (miscarriage) since she was only 10 weeks' pregnant and early miscarriage occurs before
After a regular prenatal visit, a pregnant client asks the nurse to describe the differences between placental abruption (abruptio placentae) and placenta previa. Which statement will the nurse include in the teaching? You Selected: Placenta previa causes painful, dark red vaginal bleeding during pregnancy. Correct response: Placenta previa is an abnormally implanted placenta that is too close to the cervix.
Explanation: Placenta previa is a condition of pregnancy in which the placenta is implanted abnormally in the lower part of the uterus and is the most common cause of painless, bright red bleeding in the third trimester. Placental abruption is the premature separation of a normally implanted placenta that pulls away from the wall of the uterus either during pregnancy or before the end of labor. Placental abruption can result in concealed or apparent dark red bleeding and is painful. Immediate intervention is required for placental abruption.
A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia? You Selected: Respiration fails after the seizure. Correct response: Coma occurs after seizure.
Explanation: The nurse should know that coma usually follows an eclamptic seizure. Muscle rigidity occurs after facial twitching. Respirations do not become rapid during the seizure; they cease. Coma usually follows the seizure activity, with respiration resuming.
The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize? You Selected: Complete the antibiotic course Correct response: Handwashing
Handwashing is the best defense against the spread of infections. The client is at a higher risk of developing further infections due to her current situation; handwashing before and after using the restroom and doing perineal care will help prevent an infection from occurring. It will also be important for the woman to wash her hands to ensure the infection is not passed to her infant or other family members. The other options of completing the antibiotics, completing proper perineal care, and getting plenty of rest are also important but not a priority.
CHAPTER 22 A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The priority actions of the nurse should be to first Obtain a culture Followed by: Initiate antibiotics encourage intake of fluids
Obtain a culture administer antibiotics Followed by: initiate antibiotics
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and they frequently indulge in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? You Selected: postpartum depression Correct response: postpartum psychosis
The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.
A nurse is caring for a pregnant client admitted with mild preeclampsia. Which assessment finding should the nurse prioritize? You Selected: proteinuria of 200 mg/24 hours Correct response: urine output of less than 15 ml/hr
xplanation: Severe preeclampsia may develop suddenly and bring with it high blood pressure of more than 160/110 mm Hg, proteinuria of more than 500 mg in 24 hours, oliguria of less than 15 ml/hr, cerebral and visual symptoms, and rapid weight gain. Mild facial edema or hand edema occurs with mild preeclampsia. A urinary output of 15 ml/hr would result in an output of 360 ml/24 hours, which would be below the recommended range and should be reported. Ankle edema of 1+ could be related to regular pregnancy and not necessarily just severe preeclampsia. A finding of 3+ to 4+ pitting edema would be more alarming and require intervention.
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? You Selected: Postpartum depression Correct response: Postpartum psychosis
Explanation: Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.
A woman in labor who is receiving an opioid for pain relief is to receive promethazine. The nurse determines that this drug is effective when the woman demonstrates which finding? You Selected: increased feelings of control Correct response: less anxiety
Explanation: Promethazine is used in combination with an opioid to decrease nausea and vomiting and lessen anxiety. It may also be used to increase sedation. It does not affect the progress of labor. Benzodiazepines are used to calm a woman who is out of control, allowing her to relax enough to participate effectively during labor.
An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate? You Selected: Continue to monitor the client's hyperemesis gravidarum. Correct response: Contact the health care provider to report the client's feelings.
Explanation: The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family. Reference:
The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner? You Selected: Ambulate within 15 minutes to prevent spinal headache. Correct response: Ambulate only with assistance from the nurse or caregiver.
Explanation: The client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.
Which nursing action is essential if the laboring client has the urge to push but she is not fully dilated? You Selected: Have the client lightly push to meet the need. Correct response: Have the client pant and blow through the contraction.
Explanation: The essential nursing action does not allow the client to push. The action is to have the client pant at the beginning of the contraction and then have the client blow through the peak of the contraction. Pushing efforts before the cervix is fully dilated may result in cervical lacerations or cause edema of the cervix, slowing delivery of the fetus. No pushing should be accomplished at this time. It is difficult to divert energy but not push. Assuming a Fowler position places weight on the perineum.
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture? You Selected: Cloudy white fluid Correct response: Clear to straw-colored fluid
Explanation: The infant is in the correct position, and the client has been in labor. Expectation would be for normal amniotic fluid presentation of clear to straw-colored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? You Selected: Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Correct response: Finish all antibiotics to decrease a genital tract infection.
Explanation: A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.
A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure? You Selected: Nonstress test Correct response: Amniocentesis
Explanation: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.
A woman's husband expresses concern about risk of paralysis from an epidural block being given to his wife. Which would be the most appropriate response by the nurse? You Selected: "An injury is unlikely because of expert professional care given." Correct response: "The injection is given in the space outside the spinal cord."
Explanation: An epidural block, as the name implies, does not enter the spinal cord but only the epidural space outside the cord.
A nurse is assessing a pregnant client for the possibility of preexisting conditions that could lead to complications during pregnancy. The nurse suspects that the woman is at risk for hydramnios based on which preexisting condition? You Selected: late maternal age Correct response: diabetes
Explanation: Approximately 18% of all women with diabetes will develop hydramnios during their pregnancy. Hydramnios occurs in approximately 2% of all pregnancies and is associated with fetal anomalies of development.
A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out? You Selected: prevent fetal Rh blood formation. Correct response: prevent maternal D antibody formation.
Explanation: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.
A pregnant client diagnosed with hyperemesis gravidarum is prescribed intravenous fluids for rehydration. When preparing to administer this therapy, which solution would the nurse anticipate being prescribed initially? You Selected: dextrose 5% and water Correct response: normal saline
Explanation: For the client with hyperemesis gravidarum, parenteral fluids and drugs are prescribed to rehydrate the client and reduce the symptoms. The first choice for fluid replacement is generally isotonic, such as normal saline, which aids in preventing hyponatremia, with vitamins (pyridoxine, or vitamin B6) and electrolytes added. Dextrose 5% and water and 0.45% sodium chloride are hypotonic solutions that would cause the cells to swell and possibly burst. Albumin could lead to fluid overload.
The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. The nurse will stress the importance of frequent and continuous office visits to the client with: You Selected: Rh negative blood. Correct response: a molar pregnancy.
Explanation: Molar pregnancies can indicate the possibility of developing malignancy. The woman will need close observation and follow-up for a year, every 1 to 2 weeks for hCG levels to detect cancer. A follow-up visit after an ectopic pregnancy or a complete spontaneous abortion (miscarriage) are typically scheduled at 6 weeks, not monthly. A woman who is Rh negative does not need a follow-up visit because of her Rh status, but would be scheduled as per routine postpartum visits. Reference:
A woman who is 10 weeks' pregnant calls the physician's office reporting "morning sickness" but, when asked about it, tells the nurse that she is nauseated and vomiting all the time and has lost 5 pounds. What interventions would the nurse anticipate for this client? You Selected: Since morning sickness is a common problem for pregnant women, the nurse will suggest the woman drink more fluids and eat crackers. Correct response: Lab work will be drawn to rule out acid-base imbalances.
Explanation: Morning sickness that lasts all day and is severe is called hyperemesis gravidarum. It is much more serious than "morning sickness" and can lead to significant weight loss and electrolyte imbalance. Lab work needs to be drawn to determine the extent of electrolyte loss and acid-base balance. An ultrasound is performed but it is done to determine if the mother is experiencing a molar pregnancy. Treatment for hyperemesis gravidarum requires much more care than just rest, drinking fluids and eating crackers.
A client who is in the active phase of labor reports the pain medication last given 3 hours ago has worn off. The client asks if they can have another dose of the opioid. How should the nurse respond to the request? You Selected: "I will get permission from your health care provider." Correct response: "Your phase of labor makes giving another dose unsafe."
Explanation: Opioids may cause central nervous system depression in the neonate if given too close to birth. This client is in the active phase of labor, thus, is within 30 minutes to 2 hours of birth. Whether it has been 3 or 4 hours since the last dose is not the determining factor; safety is the determining factor. There is no need to ask the health care provider.
A woman at 34 weeks' gestation presents to labor and delivery with vaginal bleeding. Which finding from the obstetric examination would lead to a diagnosis of placental abruption (abruptio placentae)? You Selected: Fetus is in a breech position Correct response: Onset of vaginal bleeding was sudden and painful
Explanation: Sudden onset of abdominal pain and vaginal bleeding with a rigid uterus that does not relax are signs of a placental abruption (abruptio placentae). The other findings are consistent with a diagnosis of placenta previa.
A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize? You Selected: Pedal edema Correct response: A dipstick value of 2+ for protein
Explanation: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was. Reference:
A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia? You Selected: passage of the drug to the fetus Correct response: headache following anesthesia
Explanation: The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition. Reference:
The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client? You Selected: Place the client in a supine position. Correct response: Keep the suction equipment readily available.
Explanation: The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.
A nurse is taking a history of a client at 5 weeks' gestation in the prenatal clinic; however, the client is reporting dark brown vaginal discharge, nausea, and vomiting. Which diagnosis should the nurse suspect? You Selected: placenta previa Correct response: gestational trophoblastic disease
Explanation: This client has risk factors of a "molar" pregnancy: nausea and vomiting at an early gestational week and dark brown vaginal discharge. The early nausea/vomiting can be due to a high hCG level, which is a sign of gestational trophoblastic disease. There is only one sign/symptom of hyperemesis gravidarum. Placenta previa is marked by bright red bleeding and tends to happen later in gestation. There are no data to support any psychosis at this stage
The nurse is required to assess a pregnant client who is reporting vaginal bleeding. Which nursing action is the priority? You Selected: assessing signs of shock Correct response: assessing the amount and color of the bleeding
Explanation: When the woman arrives and is admitted, assessing her vital signs, the amount and color of the bleeding, and current pain rating on a scale of 1 to 10 are the priorities. Assessing the signs of shock, monitoring uterine contractility, and determining the amount of funneling are not priority assessments when a pregnant woman complaining of vaginal bleeding is admitted to the hospital. Reference:
The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed? You Selected: "I will take frequent walks around my home to promote drainage." Correct response: "When I am sleeping or lying in bed, I should lie flat on my back."
Explanation: With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.
Six hours after birth, a client's first void is 70 ml. What is the nurse's next action? Assess for residual urine
Given the small volume voided, the nurse would assess for residual urine. Clients experience diuresis after birth; therefore, a large volume of urine is expected. A urinary tract infection is characterized by burning, frequency, and dysuria. A perineal hematoma, if large, may obstruct the urethra and cause an inability to void, but it will not impact the quantity voided.
