The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal?

Correct Answer: C

Rationale: In postpartum care, evaluating the involution of the uterus is crucial to monitor the woman's recovery. Three days postpartum, the fundus should be around 2 cm below the umbilicus, as indicated by option C, with lochia rubra being the expected discharge color at this stage. This finding suggests that the uterus is contracting effectively to return to its pre-pregnancy size. Option A is incorrect because the fundus should be descending rather than ascending, and lochia rosa is not the expected color at this point. Option B is incorrect as the fundus should be lower, and lochia alba is not seen until later in the postpartum period. Option D is incorrect because the fundus being 3 cm below the umbilicus is beyond the expected level of involution at this stage, and lochia serosa is also not the typical discharge for day 3 postpartum. Understanding these normal postpartum findings is essential for nurses to provide appropriate care, identify deviations from the expected progression, and intervene promptly if needed to prevent complications. This knowledge ensures optimal recovery and well-being for postpartum women.

Correct Answer: C

Rationale: In this scenario, the appropriate nursing action is to have the client turn and deep breathe every 2 hours (Option C). This is crucial post-cesarean section under spinal anesthesia to prevent complications such as atelectasis and promote optimal lung expansion, preventing respiratory issues. Option A, elevating the head of the bed 60 degrees, is incorrect as it could increase the risk of hypotension due to the decreased venous return. Reporting the absence of bowel sounds to the physician (Option B) is not a priority at this early postoperative stage. Assessing for patellar hyperreflexia bilaterally (Option D) is not relevant in this immediate postoperative period and does not address the client's current needs. Educationally, it is essential for nurses to understand the specific postoperative care requirements for clients who have undergone cesarean sections under spinal anesthesia to promote optimal recovery and prevent complications. Encouraging turning and deep breathing helps maintain respiratory function and prevent postoperative respiratory issues.

Correct Answer: D

Rationale: In this scenario, option D is the best response for the nurse to provide to the woman who had a cesarean section and needs to cough but is afraid to. Supporting the incision with a pillow while coughing can help reduce the pain and discomfort associated with coughing post-surgery. This response shows empathy and provides practical guidance to alleviate the woman's fear and discomfort. Option A is incorrect because simply acknowledging the pain without providing a solution does not address the woman's fear of coughing post-surgery. Option B is incorrect as checking lung fields may not directly address the woman's fear of coughing. Option C is incorrect as deep breathing, although beneficial, may not be as effective as coughing in clearing secretions and preventing complications like pneumonia. Educationally, this scenario highlights the importance of providing practical and patient-centered care to individuals post-surgery. Nurses need to not only address physical discomfort but also provide emotional support and guidance to help patients manage their fears and concerns effectively. Encouraging patients to cough while supporting their incision can be a simple yet effective intervention to promote healing and prevent complications.

Correct Answer: B

Rationale: The correct answer is B) "With all of your preparations, it must have been disappointing for you to have had a cesarean." This response demonstrates empathy and acknowledges the woman's feelings of disappointment and possibly loss of control over her birth experience. It validates her emotions and shows understanding of the situation she is facing. Option A) is inappropriate because it dismisses the woman's feelings and experience by implying that unexpected outcomes are normal and should be accepted without acknowledging her emotions. Option C) while acknowledging the baby's health, fails to address the woman's emotional state and could come across as minimizing her feelings about the birth experience. Option D) focuses on the presence of the husband but does not address the woman's feelings about the birth experience or her disappointment in not having the birth she had planned for. In an educational context, it is crucial for healthcare providers to practice empathy and active listening when communicating with patients, especially in sensitive situations like childbirth. Acknowledging and validating a patient's feelings can help build trust and improve the overall quality of care provided.

Correct Answer: A

Rationale: In this scenario, the appropriate action for the nurse to take is option A) Discard the remaining medication in the presence of another nurse. This choice is correct because it ensures proper disposal of the controlled substance, preventing misuse or diversion. Patient-controlled analgesia (PCA) should be discontinued as per the physician's orders to prevent overmedication or potential side effects. Option B) Recommend waiting until her pain level is zero to discontinue the medicine is incorrect as it does not align with best practice. Pain management should be individualized and based on the patient's needs, not solely on achieving a pain level of zero. Option C) Discontinuing the medication only after the analgesia is completely absorbed is incorrect as it does not address the need for immediate discontinuation as per the physician's order. Option D) Returning the unused portion of medication to the narcotics cabinet is incorrect as controlled substances should never be returned to the cabinet once dispensed to a patient, to prevent diversion and ensure accurate tracking of medication administration. Educationally, this question highlights the importance of following physician's orders accurately, proper disposal of controlled substances, and individualized pain management strategies in postpartum care. Nurses need to be vigilant in medication management to ensure patient safety and prevent medication errors.