The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?

Correct Answer: C

Rationale: The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38°C (100.4°F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

Correct Answer: C

Rationale: Excessive fatigue can impact the level of interaction between parent and child, leading to impaired parenting. En face behavior and feeling exhilarated post-birth are normal aspects of parental adaptation. Finger tipping behavior indicates a sense of identification or claiming behavior, which is not necessarily indicative of impaired parenting. Therefore, the correct answer is C.

Correct Answer: D

Rationale: In the context of pediatric nursing care, understanding the signs of thrombophlebitis is crucial for early detection and intervention. The correct answer, option D, "local tenderness, heat, and swelling," is indicative of thrombophlebitis. Localized tenderness, heat, and swelling are classic signs of inflammation in the affected vein, which can be caused by a blood clot. Option A, "visible varicose veins," is incorrect because varicose veins are dilated, superficial veins typically seen in conditions like chronic venous insufficiency, but they are not specific to thrombophlebitis. Option B, "positive Homans sign," refers to calf pain upon dorsiflexion of the foot, which used to be considered a sign of deep vein thrombosis. However, this sign is no longer reliable and can actually dislodge a clot, making it an outdated and potentially harmful assessment. Option C, "pedal edema in the affected leg," is a common symptom in many lower extremity conditions, including venous insufficiency and heart failure, but it is not a specific indicator of thrombophlebitis. Educationally, nurses must be able to differentiate between various signs and symptoms to provide accurate assessments and interventions. Understanding the unique manifestations of thrombophlebitis in pediatric patients is essential for delivering safe and effective care.

Correct Answer: B

Rationale: The correct answer is B because an abnormal odor of the lochia indicates a uterine infection in a postpartum patient. This is an early and specific sign of infection compared to assessing other areas such as the episiotomy site, abdomen, or vital signs. Monitoring the odor of the lochia can help in early detection and appropriate management of uterine infections in postpartum patients.

Correct Answer: B

Rationale: In pediatric respiratory disorders, methylergonovine (Methergine) is not a commonly used medication. However, understanding the rationale behind checking blood pressure before administering it is crucial in nursing care. Methylergonovine is a medication primarily used to prevent or control excessive bleeding after childbirth. One of its potential side effects is hypertension, which can lead to severe complications if not monitored closely. Checking the blood pressure before giving methylergonovine is crucial to ensure that the patient's blood pressure is within the safe range. If the blood pressure is already elevated, administering methylergonovine could further exacerbate this condition, putting the patient at risk for adverse effects such as hypertensive crisis or stroke. Therefore, monitoring blood pressure allows the nurse to make an informed decision about the safety of administering the medication. The other options - color of the lochia, location of the fundus, and last administration of analgesics - are not directly related to the administration of methylergonovine. While monitoring lochia color and fundal height are essential postpartum assessments, they are not specifically relevant to the administration of this medication. Similarly, the timing of analgesic administration is important for pain management but does not impact the safety or effectiveness of methylergonovine. In an educational context, understanding the rationale behind checking blood pressure before administering medications is a fundamental nursing skill. It demonstrates the importance of thorough assessment and critical thinking in ensuring patient safety. By grasping the specific considerations for each medication, nurses can provide optimal care and prevent potential complications. This knowledge is essential for nursing students to develop their clinical judgment and decision-making abilities in various patient care scenarios.