A postpartum cesarean patient comes into the rural health clinic at 1 week postdelivery for an incision check by the nurse. The vital signs reveal a temperature of 100.5°F, and the patient reports moderate foul-smelling lochia. The nurse determines that the skin incision is healing normally, but when palpating the uterus, she discovers the patient to have uterine and pelvic tenderness. What are the most appropriate nursing actions?

Correct Answer: D

Rationale: Step 1: The nurse's assessment reveals signs of infection (fever, foul-smelling lochia, uterine, and pelvic tenderness). Step 2: The nurse should address the immediate concerns - fever and pain. Tylenol helps reduce fever and pain. Step 3: The incision healing well indicates no immediate surgical intervention required. Step 4: Continuing pain medication ensures comfort until next visit. Step 5: Blood tests for infection are not urgent; they can be done at the next visit if symptoms persist. Summary: A: Immediate blood draw is not necessary without a clear indication of sepsis. B: Resting more won't address the infection; waiting a few days can worsen the condition. C: Normal postoperative pain doesn't include fever and foul-smelling lochia; waiting for the 6-week checkup is risky.

Correct Answer: B

Rationale: Performing fundal massage is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony. Uterine atony is a common cause of postpartum hemorrhage, where the uterus fails to contract and retract after childbirth, leading to excessive bleeding. Fundal massage helps stimulate uterine contractions and assists in controlling the bleeding. Establishing venous access, preparing the woman for surgical intervention, and catheterizing the bladder are important interventions as well, but fundal massage takes priority in managing uterine atony and preventing further blood loss.

Correct Answer: B

Rationale: Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. A primiparous woman being prepared for an emergency cesarean birth for fetal distress, a multiparous woman with an 8-hour labor, and a primigravida in spontaneous labor with preterm twins do not indicate risk factors or causes of early PPH

Correct Answer: C

Rationale: The most important strategy for the nurse to adopt in preventing puerperal infection is option C, which is the strict aseptic technique, including hand washing, by all health care personnel. Puerperal infection, also known as postpartum infection, is a serious complication following childbirth that can lead to severe consequences if not prevented. Maintaining proper hygiene practices, such as hand washing and using aseptic techniques, is crucial in preventing the spread of pathogens that can cause infections. This simple yet effective measure can significantly reduce the risk of puerperal infections among postpartum women. Large doses of vitamin C during pregnancy (option A) may have benefits for overall health but are not specifically proven to prevent puerperal infections. Prophylactic antibiotics (option B) may be used in certain cases but are not the primary strategy for prevention in all cases. Limiting protein and fat intake (option D) is not a recommended approach

Correct Answer: B

Rationale: The most accurate statement regarding the basic definitions and incidence data of postpartum hemorrhage (PPH) is statement B. Traditionally, PPH is defined as losing more than 1000 ml of blood after vaginal birth and more than 2500 ml after cesarean birth. This definition helps healthcare providers recognize and diagnose PPH based on the amount of blood loss, which is crucial for prompt intervention and management.