A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following?

Correct Answer: B

Rationale: In the immediate postpartum period, the correct answer is B) Excess blood volume from pregnancy is circulating in the woman's periphery. During pregnancy, a woman's blood volume increases significantly to support the needs of the developing fetus. After delivery, this excess blood volume is suddenly no longer needed, leading to a rapid shift of blood from the uterus to the maternal circulation. This sudden increase in circulating blood volume can overwhelm the cardiovascular system, potentially leading to cardiovascular compromise. Option A is incorrect because the weight of the uterine body being reduced does not directly impact cardiovascular compromise. Option C is incorrect as the dilation of the cervix and the flow of lochia are related to the stages of labor and not specifically to cardiovascular compromise post-delivery. Option D is incorrect as maternal blood pressure typically drops after the baby is delivered due to the sudden decrease in intra-abdominal pressure, not when the baby's head emerges. Understanding the physiological changes that occur in the postpartum period is crucial for maternity nurses to provide appropriate care and anticipate potential complications. By recognizing the risk of cardiovascular compromise due to the sudden shift in blood volume, nurses can closely monitor vital signs and intervene promptly if needed to ensure the well-being of the mother.

Correct Answer: B

Rationale: In this scenario, option B, "Monitor the incision for drainage," is the most appropriate action for the nurse to take after the surgeon has removed the cesarean section dressing from a post-op day 1 client. This is the correct answer because monitoring the incision for drainage is essential in assessing for signs of infection, which is a common complication postpartum. Drainage from the incision site could indicate infection, and early detection is crucial for prompt intervention and prevention of further complications. Option A, "Irrigate the incision twice daily," is incorrect because irrigating the incision without proper assessment and orders from the healthcare provider can introduce pathogens and disrupt the healing process. Option C, "Apply steristrips to the incision line," is incorrect because applying steristrips is not within the nurse's scope of practice without specific orders from the healthcare provider. Steristrips are typically applied during the initial closure of the incision by the surgeon. Option D, "Palpate the incision and assess for pain," is incorrect because palpating the incision can introduce pathogens and increase the risk of infection. Assessing for pain is important, but monitoring for drainage is a more immediate concern in this situation. In an educational context, understanding proper postoperative wound care is crucial for nursing practice. Nurses need to know how to assess incisions for signs of complications, such as infection, and follow evidence-based guidelines to provide safe and effective care to postpartum clients. Monitoring for drainage is a fundamental aspect of wound care assessment and plays a vital role in early detection and management of complications.

Correct Answer: C

Rationale: In this scenario, the correct initial nursing action is to choose option C) Assess the height of her fundus. This option is the most appropriate because the woman is only 3 hours postpartum and has just voided a small amount of urine. Assessing the height of the fundus helps determine if there is any retention of urine or if there are other underlying issues such as uterine atony, which can lead to urinary retention. Option A) Insert an indwelling catheter is not the initial action because it is invasive and should only be considered if there is a confirmed need for catheterization after assessment. Option B) Have her drink additional fluids may be beneficial in some cases of postpartum urinary retention, but it is not the most appropriate initial action in this scenario. Option D) Chart the urination amount is important for documentation purposes but does not address the immediate need to assess the woman's condition. Educationally, understanding the importance of prompt assessment in postpartum care is crucial for nursing students and healthcare providers. This scenario highlights the significance of assessing for potential complications early on to provide timely and appropriate interventions. It also emphasizes the need for critical thinking and prioritization in nursing care to ensure the best outcomes for postpartum women.

Correct Answer: A

Rationale: In the context of postpartum complications, adequate rest is crucial for the mother's physical and mental well-being. Option A, "Plan to sleep or rest any time the infant sleeps," is the best choice because it aligns with the concept of maximizing rest opportunities during the newborn's sleep cycles. This approach allows the mother to recuperate, promote healing, and manage potential postpartum complications more effectively. Option B, "Do all housecleaning while the infant sleeps," is incorrect as it neglects the importance of rest for the mother, which is essential for her recovery and overall health. Engaging in housecleaning activities during the infant's sleep time can lead to exhaustion and may exacerbate postpartum complications. Option C, "Cook several meals at once and freeze for later use," although helpful in managing time and reducing stress, does not directly address the need for rest, which is the primary concern in the postpartum period. Option D, "Tell family and friends not to visit for the first month," is also incorrect as social support is crucial for the mother's well-being postpartum. However, setting boundaries and managing visitors' expectations to ensure that the mother has ample time to rest is essential. In an educational context, it is important to emphasize to new mothers the significance of prioritizing rest and self-care in the postpartum period. By understanding and implementing strategies like sleeping or resting when the infant sleeps, mothers can better manage postpartum complications and promote a smoother recovery process.

Correct Answer: C

Rationale: In postpartum care, uterine massage is a crucial intervention to prevent postpartum hemorrhage by promoting uterine contraction. Placing one hand above the symphysis pubis during uterine massage helps prevent the uterus from inverting by providing counter-pressure as the fundus contracts. This is essential to maintain uterine position and prevent potential complications such as uterine inversion, which can lead to severe bleeding and shock. Option A is incorrect because the primary goal of uterine massage is not to make the woman more comfortable but to ensure proper uterine contraction. Option B is incorrect as the location of the hand does not necessarily increase the effectiveness of the procedure; rather, it is about providing specific support to prevent uterine inversion. Option D is also incorrect as determining the firmness of the uterus can be achieved by palpating the fundus, not by the hand's placement above the symphysis pubis. Understanding the rationale behind proper uterine massage technique is crucial for nurses and healthcare providers caring for postpartum women. By knowing the correct hand placement and its purpose, they can effectively prevent complications and ensure optimal postpartum care for their patients.