Which of the following best reflects the frequency of reported postpartum “blues”?
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Solution
Between 50% and 80% of all new mothers report some form of postpartum blues
According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.
Which of the following are the most commonly assessed findings in cystitis?
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Solution
Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, Hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pyelonephritis.
Which of the following assessment findings would the nurse expect if the client develops DVT?
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Solution
Muscle pain the presence of Homans sign, and swelling in the affected limb
Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb.
Option A: Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis.
Option B: Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis.
Option D: Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.
Which of the following best describes thrombophlebitis?
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Solution
Inflammation of the vascular endothelium with clot formation on the vessel wall
Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel.
Option A: Blood components combining to form an aggregate body describe a thrombus or thrombosis
Options B and C: Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis.
Which of the following is the primary predisposing factor related to mastitis?
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Solution
Breast injury caused by overdistention, stasis, and cracking of the nipples
With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor.
Options A and B: Epidemic and endemic infections are probable sources of infection for mastitis.
Option D: Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.
Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
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Solution
More than 500 ml
Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.
Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
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Solution
Place the client in a knee-chest position in bed
The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed and elevating the maternal hips on a pillow to minimize the pressure on the cord.
Options A, C, and D: Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.
When uterine rupture occurs, which of the following would be the priority?
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Solution
Limiting hypovolemic shock
With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery.
Options B, C, and D: Obtaining blood specimens, instituting complete bed rest and inserting a urinary catheter are necessary for preparation for surgery to remedy the rupture.
Which of the following factors is the underlying cause of dystocia?
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Solution
Mechanical
Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche.
Options A, C, and D: Nutritional, environment, and medical factors may contribute to the mechanical factors that cause dystocia.
When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
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Solution
PROM removes the fetus most effective defense against infection
PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time.
Option A: Typically, PROM occurs about 1 hour, not 4 hours, before labor begins.
Option C: Fetal viability and gestational age are less immediate considerations that affect the plan of care.
Option D: Malpresentation and an incompetent cervix may be causes of PROM.