The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding?

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Respiratory Pediatric Nursing Questions

Question 1 of 5

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding?

Correct Answer: C

Rationale: Saturated peripad with lochia rubra after cesarean birth indicates abnormal bleeding and potential hemorrhage. The nurse's priority action should be to contact the health care provider immediately for further assessment and intervention. Weighing the peripad can provide an estimation of blood loss but may cause a delay in care. Replacing the peripad and documenting the finding are appropriate actions but not the priority when facing potential hemorrhage.

Question 2 of 5

Nursing measures that help prevent postpartum urinary tract infection include

Correct Answer: A

Rationale: Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products, reducing the risk of urinary tract infections. Early ambulation, not bed rest, is encouraged postpartum. Acidifying drinks like cranberry juice can also help prevent infections. Delaying voiding can lead to urinary stasis and increase the risk of infection.

Question 3 of 5

If the nurse suspects a complication of a low forceps birth labor, she should immediately

Correct Answer: B

Rationale: A low forceps birth can result in significant vaginal trauma. Therefore, the nurse should immediately assess the perineal and vaginal areas to determine the extent of trauma and provide appropriate care. Administering analgesics, assessing the uterine fundus position, or reviewing the labor record will not provide immediate information on the extent of vaginal trauma and may delay necessary interventions.

Question 4 of 5

If the nurse suspects a pulmonary embolism in the patient who suddenly complains of chest pain, she or he should immediately

Correct Answer: B

Rationale: The immediate action for a suspected pulmonary embolism is to apply oxygen via a tight face mask to increase oxygen saturation and decrease hypoxia. Assessing breath sounds and monitoring pulse oximetry provide assessment data but do not address the immediate problem. A supine position with the head of the bed flat is incorrect as the head of the bed should be elevated to facilitate respiratory function.

Question 5 of 5

The nurse is explaining the risk of hypothermia in the newborn to a group of nursing students. Which statement best describes the manifestations of hypothermia in the newborn?

Correct Answer: C

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

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