The following are nursing interventions to relieve episiotomy wound pain EXCEPT
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Solution
Perineal care
Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not.
The following are interventions to make the fundus contract postpartally EXCEPT
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Solution
Massage the fundus vigorously for 15 minutes until contracted
Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feels firm and contracted. If the massage is vigorous and prolonged, the uterus will relax due to over stimulation.
When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse should suspect
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Solution
Laceration of soft tissues of the cervix and vagina
When the uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina.
The following are nursing measures to stimulate lactation EXCEPT
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Solution
Application of cold compress on the breast
To stimulate lactation, a warm compress is applied to the breast. A cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk.
In a woman who is not breastfeeding, menstruation usually occurs after how many weeks?
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Solution
6-8 weeks
When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery, the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Follicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a Graafian follicle and the menstrual cycle post pregnancy resumes.
A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has a saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:
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Solution
Heavy
Heavy lochial discharge is a saturated menstrual pad in 1 hour.
Option A: Excessive = menstrual pad saturated in 15 minutes.
Option C: Light = less than 10 cm on a menstrual pad in 1 hour.
Option D: Scanty = less than 2.5 cm on a menstrual pad in 1 hour.16.
The uterine fundus right after delivery of placenta is palpable at
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Solution
Level of umbilicus
Immediately after the delivery of the placenta, the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) every day until it becomes no longer palpable above the symphysis pubis.
Which of the following is an abnormal vital sign in postpartum?
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Solution
BP diastolic increase from 80 to 95mm Hg
All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy.
The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because:
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Solution
There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin
If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother, it no longer receives a high dose of glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can lead to hypoglycemia.
According to Rubin’s theory of maternal role adaptation, the mother will go through 3 stages during the postpartum perioD. These stages are:
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Solution
Taking-in, taking-hold and letting-go
Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in, taking-hold and letting-go. In the taking-in stage, the mother is more passive and dependent on others for care. In taking-hold, the mother begins to assume a more active role in the care of the child and in letting-go, the mother has become adapted to her maternal role.