A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication?

Correct Answer: C

Rationale: In the context of postpartum care, the correct assessment to be made before administering Methergine (ergonovine) is blood pressure (Option C). Methergine is a uterotonic medication commonly used to prevent or treat postpartum hemorrhage by causing uterine contractions. Monitoring blood pressure is crucial because Methergine can cause hypertension as a side effect. By assessing blood pressure before administration, healthcare providers can ensure that the patient's blood pressure is within safe limits to receive the medication. Option A (Apical pulse) is not the primary assessment needed before administering Methergine because the medication's effect on blood pressure is more critical in this context. Option B (Lochia flow) and Option D (Episiotomy) are not directly related to the administration of Methergine and do not impact the safety or efficacy of the medication. In an educational context, understanding the rationale behind assessing blood pressure before administering specific medications is essential for providing safe and effective patient care. By emphasizing the importance of monitoring vital signs and understanding the potential side effects of medications like Methergine, healthcare professionals can ensure they are administering treatments responsibly and minimizing risks to their patients during the postpartum period.

Correct Answer: D

Rationale: The correct answer is D) The woman understands that her urine may turn orange. Rationale: Docusate sodium (Colace) is a stool softener commonly prescribed postpartum to prevent constipation, a common issue after cesarean delivery. One of the side effects of docusate sodium is that it may cause the urine to turn a pinkish or reddish color, which is a harmless and expected outcome. Understanding this side effect is crucial for the client to prevent unnecessary anxiety or concern. Option A is incorrect because swallowing the tablets whole does not impact the effectiveness of the medication. Option B is incorrect as there is no specific requirement to take docusate sodium between meals. Option C is incorrect as developing a headache is not typically associated with taking Colace and does not require immediate physician notification. In an educational context, this question emphasizes the importance of teaching clients about medication side effects to promote informed decision-making and reduce anxiety related to potential unexpected outcomes. Understanding common side effects empowers clients to manage their health effectively and seek appropriate care when needed.

Correct Answer: C

Rationale: In this scenario, the correct task to delegate to the nursing care assistant is taking the client's vital signs (Option C). This is appropriate because measuring vital signs is a routine and non-invasive task that does not require specialized nursing knowledge or assessment skills. Nursing care assistants are trained to perform basic tasks like measuring blood pressure, pulse, temperature, and respiratory rate under the supervision of a registered nurse. Option A, assessing the client's fundal height, requires a higher level of assessment and interpretation of findings, which is more appropriate for a registered nurse. Option B, teaching the client how to massage her fundus, involves patient education and requires knowledge of proper technique and patient-specific considerations, making it a task better suited for a nurse. Option D, documenting the quantity of lochia in the chart, involves recording and interpreting clinical data, which falls within the scope of a registered nurse's responsibilities. This question provides a valuable teaching opportunity by highlighting the importance of appropriate delegation based on the complexity and skill level required for each task. Understanding delegation principles is crucial for efficient and safe patient care delivery in healthcare settings.

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 the postpartum period, it is crucial for the nurse to provide accurate and evidence-based information to support the client's recovery and well-being. Option B, advising the client that for the first two days she will be bleeding too heavily for a tampon, is the correct answer. This is because immediately after childbirth, the woman will experience lochia, which is a postpartum vaginal discharge containing blood, mucus, and placental tissue. Using tampons during this time can increase the risk of infection and hinder the natural healing process. Option A is incorrect as inserting a tampon immediately after childbirth can introduce bacteria into the vagina, leading to infections. Option C is incorrect because it is not necessarily unsafe to place anything into the vagina until involution is complete, but rather tampons specifically should be avoided in the immediate postpartum period. Option D is incorrect as the discomfort from using a tampon is not the primary concern; the risk of infection and interference with healing are more significant issues to address. Educationally, this scenario highlights the importance of providing appropriate postpartum care and education to women. Nurses must be knowledgeable about the physiological changes that occur after childbirth and be able to communicate effectively with clients to promote their health and well-being. By choosing the correct action, the nurse can help prevent complications and support the client in her recovery process.