Question 1:
A nurse is collecting data from a client who is postpartum. Which of the
following findings should alert the nurse to the possibility of a
... [Show More] postpartum
complication?
A. Urinary output 2,000 mL/12 hr
B. Temperature 100.4 F for two days
C. Chills shortly following delivery
D. Fundus at umbilicus level
Show correct answer and explanation
Explanation
Choice A reason:
A urinary output of 2,000 mL/12 hr is normal for a postpartum client, as the body
eliminates excess fluid accumulated during pregnancy.
Choice B reason:
A temperature of 100.4 F for two days indicates a possible infection, such as
endometritis or mastitis, and requires further evaluation and treatment.
Choice C reason:
Chills shortly following delivery are common and benign and are caused by
hormonal changes and fluid shifts.
Choice D reason:
A fundus at the umbilicus level is expected for a postpartum client and indicates
that the uterus is involuting properly.
Question 2:
A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following
delivery. Which of the following actions should the nurse take?
A. Prepare a warm sitz bath.
B. Apply an ice pack to the perineum.
C. Place a soft pillow under the client's butocks.
D. Position a heating lamp toward the episiotomy.
Show correct answer and explanation
Explanation
Choice A reason:
A warm sitz bath can promote healing and comfort, but it is not recommended
until 24 hr after delivery, as it can increase swelling and bleeding.
Choice B reason:
An ice pack can reduce inflammation and pain by causing vasoconstriction and
numbing the area. It should be applied for 20 minutes at a time, with a cloth
barrier between the skin and the ice.
Choice C reason:
A soft pillow under the client's butocks can increase pressure on the perineum
and worsen the pain. The client should be encouraged to lie on her side or sit in a
semi-Fowler's position.
Choice D reason:
A heating lamp can dry out the wound and delay healing. It can also cause burns
and discomfort. It should be avoided for episiotomy care. [Show Less]