Why does the nurse encourage ambulation in a patient who has experienced a cesarean birth?

Correct Answer: A

Rationale: In the postpartum period, especially after a cesarean birth, encouraging ambulation is essential for several reasons. The correct answer is A) Ambulation helps to prevent DVT (Deep Vein Thrombosis). After surgery, immobility can lead to blood pooling in the lower extremities, increasing the risk of DVT. Ambulation promotes blood circulation, reducing the likelihood of clot formation. Option B) Ambulation causes the person to lose weight in the hospital is incorrect as ambulation primarily serves therapeutic purposes related to postpartum recovery, not weight loss. Option C) Ambulation helps with breastfeeding is incorrect as while ambulation may indirectly support breastfeeding by promoting overall well-being, its primary benefit in this context is preventing complications like DVT. Option D) Ambulation decreases peristalsis is incorrect as ambulation actually helps to stimulate peristalsis and prevent complications like constipation post-surgery. Understanding the rationale behind encouraging ambulation after a cesarean birth is crucial for nurses to provide optimal care and prevent potential complications in postpartum patients.

Correct Answer: B

Rationale: The correct answer is B) encouraging the family to have support available for the person and partner. Postpartum depression (PPD) is a serious issue that affects many new mothers, and having a strong support system in place can significantly help in managing and recovering from PPD. Family support can provide emotional comfort, practical assistance with daily tasks, and create a nurturing environment for the new parent and baby. Option A is incorrect because while it is important for the postpartum person to learn self-care, encouraging the partner to let them do it alone may not be the most beneficial approach when dealing with PPD. Option C is incorrect as it is essential to consult a healthcare provider before making any decisions regarding medication and breastfeeding. Option D is also incorrect as keeping the newborn in the nursery most of the time can hinder the bonding process between the parent and baby, which is crucial for both their well-being. In an educational context, it is vital for nurses to understand the complexities of postpartum complications, particularly PPD, and the role of support systems in aiding recovery. Nurses play a crucial role in assessing, educating, and providing resources for new parents experiencing PPD, emphasizing the importance of a supportive environment for optimal outcomes.

Correct Answer: A

Rationale: The correct answer is A) The woman should not become pregnant for at least 4 weeks. This is because the rubella vaccine is a live attenuated vaccine, which means there is a risk of transmitting the virus to a developing fetus if the woman were to become pregnant shortly after receiving the vaccine. This precaution is crucial to prevent potential harm to the fetus. Option B) stating that the woman should pump and dump her breast milk for 1 week is incorrect because the rubella vaccine is not excreted in breast milk, so there is no need to stop breastfeeding or discard breast milk. Option C) suggesting that the mother should wear a surgical mask when holding the baby is unnecessary in this context, as the rubella vaccine does not pose a risk of transmission through respiratory droplets. Option D) claiming that antibodies transported through breast milk will protect the baby is inaccurate because the rubella vaccine works by stimulating the mother's immune system to produce antibodies, which then protect her and potentially future pregnancies, but it does not directly provide protection to the baby through breast milk. In an educational context, it is essential for nurses to understand the rationale behind vaccination recommendations, especially in the postpartum period when the health of both the mother and the newborn is at stake. By providing accurate information, nurses can empower mothers to make informed decisions about their health and the health of their babies.

Correct Answer: D

Rationale: In this scenario, the appropriate nursing intervention at this time is option D) Encourage intake of water and other fluids. Postpartum fever, defined as a temperature of 100.4°F or higher after the first 24 hours and during the first 10 days following delivery, is a common complication. It is often caused by dehydration due to the physiological stress of labor and delivery, as well as inadequate fluid intake postpartum. Encouraging the intake of water and other fluids is crucial in this situation as it helps to rehydrate the patient, which can aid in reducing her temperature and preventing further complications. Dehydration can also affect milk production and delay the recovery process postpartum. The other options are less appropriate in this scenario: A) Notify the doctor to get an order for acetaminophen: While acetaminophen can help reduce fever, addressing the underlying cause of the fever, which in this case is likely dehydration, is more important. B) Request an infectious disease consult from the doctor: There is no indication in the scenario to suggest that the fever is due to an infectious disease, so this option is not warranted. C) Provide the woman with cool compresses: While this can provide symptomatic relief, addressing the dehydration with fluid intake is more important in this situation. In an educational context, understanding the importance of monitoring postpartum patients for signs of complications, such as fever, and knowing appropriate nursing interventions can help prevent further health issues and promote better outcomes for both the mother and the newborn. It highlights the significance of holistic care in the postpartum period, focusing on hydration and physiological well-being.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Encourage the woman exclusively to breastfeed her baby. This is the right action because the woman's breasts being firm and warm indicate engorgement due to missed feedings. Encouraging exclusive breastfeeding will help relieve the engorgement and establish proper milk supply. Option B) having the woman massage her breasts hourly is not the best choice as it may provide temporary relief but does not address the root cause of engorgement. Option C) obtaining an order to culture her expressed breast milk is unnecessary at this point as the issue is engorgement, not infection. Option D) taking the temperature and pulse rate of the woman is not directly related to addressing the breastfeeding issue. Educationally, it is important to understand the significance of exclusive breastfeeding in the early postpartum period to establish milk supply and prevent complications like engorgement. Nurses should provide education and support to ensure successful breastfeeding initiation and maintenance.