The nurse has received shift report on the postpartum unit. Which patient should the nurse see first?
First baby, day of delivery, fundus 2 cm above umbilicus deviated to left.
Second baby, first postpartum day, hypoactive bowel sounds all quadrants.
Third baby, first postpartum day, 3 cm diastasis recti abdominis
Second baby, third day post-cesarean, moderate lochia serosa.
The Correct Answer is A
A) First baby, day of delivery, fundus 2 cm above umbilicus deviated to left:
This is the most urgent situation. The fundus should typically be at the level of the umbilicus on the first postpartum day. A fundus that is 2 cm above the umbilicus and deviated to the left may indicate that the bladder is full, which can cause uterine displacement. This is a priority because if the bladder is not emptied, it could lead to uterine atony or hemorrhage. The nurse should first assess the bladder and encourage the client to void, or catheterize if needed, to correct the deviation.
B) Second baby, first postpartum day, hypoactive bowel sounds all quadrants:
Hypoactive bowel sounds on the first postpartum day can be expected, particularly after a cesarean section or due to the effects of medications such as opioids. While this finding should be monitored, it is not as urgent as a potential issue with uterine positioning that could affect bleeding or uterine tone.
C) Third baby, first postpartum day, 3 cm diastasis recti abdominis:
Diastasis recti abdominis, where the abdominal muscles separate, is a common finding postpartum, especially after multiple pregnancies. While it may cause discomfort, it is generally not an immediate concern unless there is significant pain or other complications. It can be addressed with physical therapy over time.
D) Second baby, third day post-cesarean, moderate lochia serosa:
Lochia serosa is the expected discharge 3 days postpartum after a cesarean. Moderate lochia serosa is normal at this stage and does not indicate an immediate problem. The nurse should continue to monitor the lochia, but this is not as urgent as addressing the possible uterine displacement and bladder issue in Option A.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Postpartum blues are transient and usually occur within the first week after delivery:
Postpartum blues, also known as "baby blues," are common and generally transient. They typically occur within the first few days to a week after delivery and can last for a few days to a week or two. Symptoms may include mood swings, irritability, crying, anxiety, and difficulty sleeping. These feelings are normal and typically resolve without the need for medical intervention. It's important for the nurse to provide reassurance that this is a common experience for many new mothers and that it is usually temporary.
B) Medications are available to relieve the symptoms:
While medications may be necessary for more severe postpartum mood disorders, such as postpartum depression, they are not typically required for postpartum blues. Since postpartum blues are mild and transient, most women do not need medications. Psychosocial support and rest are usually sufficient. Medications, especially antidepressants, are considered for women who develop postpartum depression, which is more persistent and severe than postpartum blues.
C) The father may become sad and weepy:
While fathers can experience emotional changes during the postpartum period, the phenomenon of postpartum blues is specific to the mother due to the hormonal and physiological changes related to childbirth and breastfeeding. Fathers may experience mood changes due to the stresses of parenthood, but postpartum blues is typically not recognized as a condition affecting men. However, men can experience postpartum depression or anxiety, which warrants different attention and support.
D) Very few women experience postpartum blues:
On the contrary, postpartum blues is very common, affecting a large percentage of women after childbirth. Studies show that 50-80% of women experience some form of postpartum blues. This makes the statement incorrect. It's important to normalize the experience and emphasize that it is a common and temporary reaction to the changes associated with childbirth.
Correct Answer is A
Explanation
A) Mother Rh-, baby Rh+:
RhoGAM (Rh immune globulin) is administered to a mother who is Rh-negative and has delivered a baby who is Rh-positive. If the Rh-negative mother is exposed to Rh-positive blood (via the baby’s blood during delivery), her immune system may start producing antibodies against Rh-positive cells, which could affect future pregnancies. The RhoGAM injection works by preventing the mother from developing these antibodies, thereby protecting any subsequent pregnancies from hemolytic disease of the newborn (HDN) in which the mother’s antibodies attack the baby’s red blood cells. This is a crucial preventive measure to avoid sensitization to Rh-positive blood.
B) Mother Rh-, baby Rh-:
If both the mother and baby are Rh-negative, there is no concern about the development of antibodies because there is no exposure to Rh-positive blood. Therefore, RhoGAM is not necessary in this situation.
C) Mother Rh+, baby Rh+:
In this scenario, the mother is Rh-positive, so she cannot develop antibodies against Rh-positive blood, regardless of the baby's Rh status. Hence, RhoGAM is not required because there is no risk of Rh incompatibility.
D) Mother Rh+, baby Rh-:
Since the mother is Rh-positive, there is no risk of her immune system attacking an Rh-negative baby’s red blood cells. Thus, RhoGAM is not needed in this case either.
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