A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?

Correct Answer: B

Rationale: In the postpartum period, the most critical assessment for a recently delivered breastfeeding client, like G10 P6408, is the assessment of the fundus (Option B). The fundus assessment helps in evaluating the uterine tone and detecting any excessive bleeding or potential uterine atony, a common complication after childbirth. A firm fundus indicates proper involution of the uterus, which is crucial for preventing postpartum hemorrhage. Pulse (Option A) is important but not as immediate as assessing the fundus in the early postpartum period. Monitoring the bladder (Option C) is essential to prevent urinary retention, but it is not as urgent as assessing the fundus. Breast assessment (Option D) is important for breastfeeding success but is not the priority immediately after delivery in terms of preventing complications like postpartum hemorrhage. Educationally, understanding the significance of timely fundus assessment postpartum is crucial for nurses and healthcare providers caring for postpartum clients. It highlights the importance of early detection and intervention in preventing life-threatening complications. This knowledge equips nurses to provide safe and effective care to postpartum clients and promotes positive maternal outcomes.

Correct Answer: B

Rationale: In the context of postpartum care following a cesarean section, it is crucial to educate the patient on the proper use of patient-controlled analgesia (PCA). Option B, which states that the client should report any feelings of nausea or itching to the nurse, is the correct answer. This is important because nausea and itching can be side effects of the pain medication administered through PCA, and timely reporting can help prevent complications or the need for additional interventions. Option A is incorrect because monitoring how often the button is pressed is not as critical as recognizing and reporting side effects. Option C is incorrect as only the patient should control the PCA administration to ensure safe dosing. Option D is incorrect because it is the responsibility of the patient, not the family, to communicate any changes in symptoms or condition to the healthcare team. Educationally, this question highlights the importance of patient education in managing postoperative pain and the role of the healthcare team in supporting patients through effective communication and monitoring for potential complications in the postpartum period.

Correct Answer: B

Rationale: The correct answer is B) 0.6 mL. To calculate the wastage, we first determine the total morphine used in 24 hours, which is 4 mg every 3-4 hours. If we assume the maximum frequency (every 3 hours), the patient would receive 6 doses in 24 hours (24 hours ÷ 3 hours = 8 doses, but the last dose is not fully utilized). Therefore, the total morphine used in 24 hours is 24 mg (4 mg/dose x 6 doses). Given that each syringe contains 10 mg/1 mL, the total volume of morphine needed in 24 hours is 2.4 mL (24 mg ÷ 10 mg/mL = 2.4 mL). However, since the syringes are premeasured and contain 1 mL each, there will be a wastage of 0.4 mL per dose. Therefore, for 6 doses in 24 hours, the total wastage will be 2.4 mL (0.4 mL/dose x 6 doses), which is equivalent to 0.6 mL when rounded to the nearest tenth. Educationally, understanding medication calculations is crucial for safe and effective nursing practice. Nurses must be able to accurately calculate dosages to prevent medication errors and ensure patient safety. This question highlights the importance of precise calculations in medication administration to minimize wastage and optimize patient care.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Respiratory rate 8 rpm. This is the most critical assessment finding that would require immediate reporting to the anesthesiologist. The administration of a narcotic via epidural infusion can lead to respiratory depression as a side effect, especially when higher doses are used. A respiratory rate of 8 rpm is dangerously low and could indicate impending respiratory failure, a potentially life-threatening complication that requires immediate intervention. Complaint of thirst (option B) is a common side effect of narcotic medications but is not as urgent or concerning as respiratory depression. Urinary output of 250 mL/hr (option C) is within normal limits and not directly related to the administration of a narcotic. Numbness of feet and ankles (option D) is a common side effect of epidural anesthesia and does not indicate a critical issue requiring immediate attention. Educationally, this question highlights the importance of monitoring patients receiving epidural narcotic infusions postpartum for potential complications, particularly respiratory depression. Nurses must be vigilant in assessing vital signs and responding promptly to any signs of respiratory distress to ensure patient safety.

Correct Answer: C

Rationale: The correct answer is C) The woman's breast milk volume may drop while taking the medicine. This is the correct answer because narcotic analgesics can pass into breast milk and affect the infant. Opioids, like narcotics, can lead to decreased milk production and potentially drowsiness or breathing difficulties in the newborn. It is essential for the nurse to educate the mother about the potential risks associated with taking narcotics while breastfeeding. Option A is incorrect because increasing the strength of the narcotic is not necessary and may increase the risk of adverse effects for both the mother and the baby. Option B is incorrect because while constipation is a potential side effect of narcotic analgesics, it is not the most immediate concern in this scenario. Option D is incorrect because while newborns can experience withdrawal symptoms if the mother is taking narcotics consistently, the primary concern in this situation is the potential impact on breastfeeding due to the medication. Educationally, it is vital for healthcare professionals to understand the implications of prescribing medications to breastfeeding mothers and to provide thorough patient education to ensure the safety and well-being of both the mother and the newborn.