An Asian client 's temperature 10 hours after delivery is 100.2°F, but when encouraged she refuses to drink her ice water. Which of the following nursing actions is most appropriate?

Correct Answer: A

Rationale: In the context of postpartum complications, the correct answer is A) Replace the ice water with hot water. This choice is appropriate because an Asian client's refusal to drink ice water despite having a slightly elevated temperature may indicate a cultural preference for warm beverages. By offering hot water instead, the nurse respects the client's cultural norms and helps promote hydration, which is crucial for postpartum recovery. Option B) Notify the client's health care provider is not the most appropriate action at this time because the situation does not warrant immediate medical intervention. The client's temperature is only slightly elevated, and addressing hydration can be managed by the nurse without involving the healthcare provider. Option C) Reassess the temperature in one half hour is not the best choice as it does not address the underlying issue of the client's refusal to drink ice water. Simply waiting and reassessing the temperature does not actively promote hydration or address the client's needs. Option D) Remind the client that drinking is very important is not the most appropriate action because it does not take into account the client's cultural preferences. Simply reminding the client without offering a suitable alternative may not effectively address the situation at hand. In an educational context, understanding cultural considerations in patient care is essential for providing culturally competent and patient-centered nursing care. Nurses should be aware of and respect cultural differences in preferences and practices related to health and wellness. In this scenario, offering hot water demonstrates cultural sensitivity and promotes effective communication and collaboration with the client.

Correct Answer: B

Rationale: In the postpartum period, the hormone that increases sharply following the third stage of labor in a mother who decides to bottle feed her baby is Prolactin. Prolactin is responsible for milk production in the mammary glands. When a mother chooses not to breastfeed, the prolactin levels will still rise initially due to the physiological response of the body to the delivery of the placenta, but they will eventually decrease since ongoing milk production is not necessary. Estrogen (Option A) levels decrease after childbirth to allow for milk production and to prevent uterine contractions that could impede the healing process. Human placental lactogen (Option C) is produced by the placenta during pregnancy to help prepare the breasts for lactation and regulate glucose levels. Its levels decrease postpartum. Human chorionic gonadotropin (Option D) is a hormone produced during pregnancy that is no longer present in significant amounts after childbirth. Understanding these hormonal changes in the postpartum period is crucial for healthcare providers to provide appropriate care and support to new mothers, whether they choose to breastfeed or bottle feed their infants.

Correct Answer: C

Rationale: In the postpartum period, the highest priority nursing care goal for a client transferred from labor and delivery is to ensure a moderate lochial flow (Option C). Lochia is the vaginal discharge after childbirth, and monitoring its flow is crucial as excessive bleeding can indicate postpartum hemorrhage, a life-threatening complication. By ensuring a moderate lochial flow, the nurse can assess and intervene promptly if there are signs of hemorrhage, thereby safeguarding the client's well-being. Option A, breastfeeding every 2 hours, is important for infant nutrition but does not take precedence over the immediate maternal health concern of monitoring postpartum bleeding. Option B, consuming a normal diet, is important for maternal recovery but is not as urgent as assessing for postpartum hemorrhage. Option D, ambulating to the bathroom, is essential for preventing complications like blood clots, but in this case, monitoring the lochial flow is more critical for early detection of hemorrhage. Educationally, this scenario highlights the importance of prioritizing nursing care based on the client's immediate needs to ensure optimal outcomes. Understanding the significance of monitoring postpartum complications empowers nurses to provide safe and effective care during this critical period of maternal recovery.

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to perform is to assess the client's feet and ankles for pitting edema (Option A). This is crucial in the postpartum period to monitor for signs of potential complications such as deep vein thrombosis (DVT) or preeclampsia. Assessing for edema helps in early identification of any circulatory issues or fluid retention that could lead to serious complications. Option B is incorrect because lowering both legs simultaneously can increase the risk of postpartum hemorrhage by reducing uterine contraction and increasing blood flow to the pelvic area. Option C is incorrect as breastfeeding helps with uterine contractions, reducing the risk of postpartum hemorrhage. Stopping breastfeeding abruptly is unnecessary and can impact the bonding between the mother and her baby. Option D is incorrect as measuring the length of the episiotomy and documenting it is important but not an immediate priority in this situation. Assessing for edema takes precedence due to its significance in early detection of potential complications. Educationally, this question highlights the importance of immediate postpartum assessment and monitoring for complications. It emphasizes the nurse's role in ensuring the well-being of the mother and promoting a safe postpartum recovery. Understanding the rationale behind each option enhances critical thinking skills in assessing and prioritizing care in postpartum situations.

Correct Answer: D

Rationale: In this scenario, option D is the most appropriate response because discussing the need for an infant car seat the day before discharge allows adequate time for the couple to prepare for the baby's safe transport home. This timing ensures that the family has sufficient time to acquire a car seat if they do not already have one and to properly install and become familiar with its use. Option A is incorrect because discussing the car seat need upon admission to the labor room may be premature and overwhelming for the couple. Option B, discussing it after delivery, may be too late as it leaves little time for the family to make necessary arrangements. Option C, during the first breastfeeding session, may not be the most appropriate time as the focus should be on establishing breastfeeding and bonding with the baby. In an educational context, this question highlights the importance of effective discharge teaching in postpartum care. Providing education at the right time ensures that families are well-prepared to care for their newborn and promotes a safe transition home. It emphasizes the nurse's role in promoting infant safety and supporting families in their new role as parents.