The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate?

Correct Answer: C

Rationale: The correct answer is C) Administer an oxytocic as ordered. Rationale: In this scenario, the nurse has noted a firm uterus at the umbilicus with heavy lochial flow, indicating uterine atony, which is a common cause of postpartum hemorrhage. Administering an oxytocic medication, as ordered by the healthcare provider, helps to promote uterine contractions and prevent excessive bleeding. This intervention is crucial in managing postpartum hemorrhage and ensuring maternal safety. Why other options are wrong: A) Massaging the uterus is not appropriate in this situation because a firm uterus suggests that it is contracting well, and massaging could potentially overstimulate the uterus, leading to increased bleeding. B) Notifying the obstetrician is important but should not be the first action in this scenario. Immediate nursing interventions to address the uterine atony are necessary to prevent complications. D) Assisting the client to the bathroom is not a priority when the client is at risk of postpartum hemorrhage. Addressing the uterine atony and managing bleeding take precedence over assisting the client with basic activities. Educational context: Understanding postpartum assessments and interventions is crucial for nurses caring for postpartum clients. Recognizing signs of uterine atony and knowing the appropriate interventions, such as administering oxytocics, can prevent serious complications like postpartum hemorrhage. Nurses should be knowledgeable about postpartum body changes and be prepared to take swift and appropriate actions to ensure the well-being of both the mother and the newborn.

Correct Answer: B

Rationale: In the postpartum period, it is crucial for the nurse to prioritize the safety and well-being of the mother and newborn. In this scenario, the correct action for the nurse to take following the administration of Benadryl to a post-cesarean client experiencing side effects from morphine is to supervise while the woman holds her newborn (Option B). This is the correct answer because it ensures that the mother and newborn have a bonding opportunity, which is essential for establishing a strong maternal-infant relationship and promoting breastfeeding initiation. Option A, monitoring urinary output hourly, is not the priority in this situation as it does not address the immediate need for maternal-newborn bonding or the management of side effects. Option C, positioning the woman slightly elevated on her left side, is not relevant in this context and does not address the specific issue at hand. Option D, asking visitors to leave the room, is not as important as ensuring the mother has the opportunity to bond with her newborn after experiencing side effects. Educationally, it is important for nurses to understand the significance of promoting maternal-newborn bonding in the immediate postpartum period. This bonding time is crucial for psychological well-being, breastfeeding success, and the establishment of a nurturing relationship between mother and baby. Nurses play a key role in facilitating these early bonding experiences, which can have long-lasting positive effects on both the mother and infant.

Correct Answer: D

Rationale: The correct answer is D) The mother's joints may become painful and stiff. This side effect is associated with rubella vaccination and is known as arthralgia or joint pain. It is important for the nurse to warn the client about this potential side effect to ensure the client is informed and prepared. Option A) The baby may develop a rash a week after the shot is incorrect because rubella vaccination does not typically cause a rash in babies. Option B) The baby may temporarily reject the breast milk is incorrect as rubella vaccination in the mother does not directly impact the baby's acceptance of breast milk. Option C) The mother's milk supply may decrease precipitously is incorrect because rubella vaccination is not known to affect milk supply. Educational Context: It is crucial for nurses to educate postpartum clients about common side effects of vaccinations, especially when they are breastfeeding. By providing accurate information, nurses empower clients to make informed decisions about their health and the health of their baby. Understanding the potential side effects of vaccinations can alleviate anxiety and promote trust in the healthcare provider's guidance.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Pain. Vaginal hematoma is a serious postpartum complication characterized by the accumulation of blood in the vaginal tissues. Pain is a common and significant symptom associated with a vaginal hematoma. The presence of a hematoma can cause severe localized pain due to the pressure exerted on surrounding tissues and nerves. Option B) Bleeding is not typically associated with vaginal hematoma. While bleeding may occur if the hematoma ruptures, it is not a primary symptom of a vaginal hematoma. Option C) Warmth is not a specific symptom of a vaginal hematoma. Warmth may be a sign of infection, but it is not a typical finding in a vaginal hematoma. Option D) Redness is also not a typical symptom of a vaginal hematoma. Redness may indicate inflammation or infection but is not a characteristic feature of a hematoma. Educational Context: Understanding the symptoms of postpartum complications like vaginal hematoma is crucial for nurses caring for postpartum clients. Recognizing these symptoms promptly can lead to early intervention and prevention of serious complications. Pain in the presence of a vaginal hematoma should never be ignored and requires immediate assessment and management to ensure the well-being of the mother. Nurses should be vigilant in monitoring postpartum clients for any signs of complications to provide timely and appropriate care.

Correct Answer: C

Rationale: The correct answer to the question is option C: "Monitor the baby's daily weights for excessive weight loss." This response is appropriate because it focuses on proactive monitoring of the baby's weight to ensure adequate nutrition intake, which is a crucial aspect of breastfeeding support, especially in cases where there may be challenges such as a history of breast reduction surgery. Option A is incorrect because it provides a definitive and discouraging statement without exploring potential solutions or supportive measures. It is essential in nursing practice to offer guidance and support rather than shutting down options for the patient. Option B is incorrect as examining the incision site does not directly address the immediate concern of breastfeeding success. While understanding the anatomy may be helpful, it is not the most pressing issue at hand. Option D is incorrect as it downplays the potential impact of breast reduction surgery on milk transfer. While it is true that surgery may not always prevent breastfeeding, it is important to acknowledge the potential challenges and take proactive measures to support successful breastfeeding. In an educational context, it is crucial for nurses to approach breastfeeding support holistically, considering individual circumstances and potential barriers. By emphasizing monitoring the baby's weight, the nurse can ensure early detection of any issues and provide timely interventions to support successful breastfeeding despite the woman's history of breast reduction surgery.