The nurse is caring for a woman who is 6 hours postpartum after a vaginal delivery. She has a history of labial varicose veins and is reporting perineal pain of 8 on a 10-point scale. What interventions should the nurse include in the plan of care?

Correct Answer: C

Rationale: The correct answer is C: Assess the perineum for a hematoma or inflamed varicosities, and administer oral pain medication. This option is the most appropriate because it addresses the immediate concern of the patient's perineal pain after delivery and acknowledges her history of labial varicose veins. By assessing the perineum for potential complications like hematoma or inflamed varicosities, the nurse can identify any underlying issues contributing to the pain and provide targeted interventions. Administering oral pain medication will help alleviate the discomfort and improve the patient's postpartum experience. Option A is incorrect because while providing an inflatable donut ring may offer some relief, it does not address the need for a thorough assessment of potential complications. Option B is incorrect as it dismisses the patient's pain as normal without further evaluation, potentially overlooking a treatable issue. Option D is also incorrect as it focuses on bowel management rather than addressing the immediate perineal pain concern. In an educational context, it is essential for nurses to understand the importance of thorough assessment and individualized care in postpartum patients, especially when managing pain and potential complications related to delivery. By prioritizing assessment and targeted interventions, nurses can provide optimal care and support for women during the postpartum period.

Correct Answer: A

Rationale: The correct answer is A) You need to come to the clinic to be evaluated, as your symptoms indicate a possible breast infection. This response is the best choice because the patient's symptoms of achiness, fever, and pain/tenderness in the breast are indicative of mastitis, a common breast infection in breastfeeding women. Prompt evaluation and treatment are crucial to prevent complications and ensure the mother's well-being. Option B) is incorrect because engorgement typically presents with breast fullness and discomfort, not generalized achiness and fever. While more frequent breastfeeding can help with engorgement, it is not the appropriate response to the symptoms described. Option C) is also incorrect as advising a mother to stop breastfeeding without proper evaluation can lead to decreased milk supply and potential complications for both the mother and baby. Breastfeeding can usually continue with proper management of mastitis. Option D) is incorrect as sleep deprivation may contribute to overall feelings of achiness and soreness but does not explain the localized symptoms in the right breast. It is essential to address the specific breast symptoms promptly in this scenario. In an educational context, this question highlights the importance of recognizing and managing common postpartum complications like mastitis in breastfeeding women. Nurses and healthcare providers must have a thorough understanding of postpartum care to provide appropriate guidance and support to new mothers. Early identification and intervention can improve outcomes and promote successful breastfeeding.

Correct Answer: C

Rationale: In this scenario, option C, which is to remove the IV, restart it in a new location, and complete the antibiotic administration, is the correct course of action for the nurse. The red, inflamed, and swollen IV site, along with tenderness and soreness reported by the patient, indicate phlebitis, an inflammation of the vein. Continuing the IV in the same location poses risks of infection and further complications. Option A is incorrect as flushing the IV with normal saline will not address the underlying issue of phlebitis. Option B is not the priority in this situation as the main concern is the compromised IV site. Option D is dangerous as allowing the IV to continue dripping slowly can lead to further complications. Educationally, this scenario highlights the importance of recognizing signs of IV complications such as phlebitis and the appropriate nursing interventions to ensure patient safety and optimal treatment delivery. Nurses must be vigilant in assessing IV sites and be prepared to take prompt action to prevent complications and provide effective care.

Correct Answer: A

Rationale: In postpartum hemorrhage leading to hematoma, rectal pain accompanied by a rising pulse (Option A) is a significant sign. This is because a hematoma is a localized collection of blood outside blood vessels, often causing pain in the affected area. The rising pulse indicates the body's response to increased blood loss, which is a critical sign of postpartum hemorrhage. Option B, cramping accompanied by a steady trickle of blood, is more indicative of normal postpartum contractions and bleeding. Option C, a soft uterine fundus and falling blood pressure, suggests uterine atony leading to hemorrhage but not specifically related to hematoma formation. Option D, heavy lochia accompanied by tachypnea and dyspnea, may indicate other complications like pulmonary embolism but does not directly point towards hematoma formation. Educationally, understanding the specific signs and symptoms of postpartum complications like hematoma is crucial for healthcare providers to provide timely and appropriate interventions to prevent further complications and ensure maternal well-being post-delivery. It is essential to differentiate between various postpartum complications to provide effective care and prevent adverse outcomes.

Correct Answer: D

Rationale: In the context of postpartum care, when a woman is receiving heparin therapy, it is crucial to have protamine sulfate readily available. Protamine sulfate is the antidote for heparin, a common anticoagulant used to prevent blood clots. If a woman on heparin therapy experiences excessive bleeding or needs urgent reversal of the anticoagulant effects, protamine sulfate can quickly neutralize the effects of heparin, thereby preventing serious complications like hemorrhage. Option A, Vitamin K, is not directly related to reversing the effects of heparin. Vitamin K is commonly used to treat coagulation disorders related to deficiencies in clotting factors, particularly in newborns. Option B, Methylergonovine, is a medication used to prevent or control postpartum hemorrhage by inducing uterine contractions. It is not indicated for reversing the effects of heparin therapy. Option C, Ferrous sulfate, is an iron supplement used to treat or prevent iron deficiency anemia. It is not relevant to the scenario of a woman on heparin therapy requiring an antidote. Understanding the appropriate antidotes and reversal agents for medications is essential in clinical practice, especially in situations where prompt intervention is necessary to ensure patient safety and optimal outcomes. Healthcare providers should be knowledgeable about the specific antidotes for commonly used medications to address potential complications effectively.