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: The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

Correct Answer: B

Rationale: The correct answer is B because a rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction, increasing the risk of postpartum hemorrhage. Delivering a 5lb, 2oz infant with outlet forceps would put the patient at risk for lacerations due to forceps use. A 7lb infant after an 8 hour labor is a normal progression, and an 8lb infant after a 12 hour labor is also a normal progression.

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.

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.

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.