The nurse is caring for a woman who is gravida 2, para 1 on her ...

[anjilletteb]

The nurse is caring for a woman who is gravida 2, para 1 on her first postpartum day.
 
  The assessment reveals: temperature 38 C (100 F), pulse 60 beats/minute, blood pressure 118/80 mm Hg, fundus firm at the level of umbilicus and displaced slightly to right, last void 6 hours earlier, moderate amount of lochia rubra, and perineum slightly edematous with episiotomy edges well approximated. The first nursing action should be to:
  a. Notify the nurse-midwife of her temperature.
  b. Apply an ice pack to her perineum.
  c. Assist her to the bathroom to void.
  d. Chart the assessment findings as normal.

Question 2

A postpartum woman's rubella titer shows that she is not protected against rubella. What instructions should she be given?
 
  a. You cannot receive the immunization until your six weeks' checkup.
  b. You will be given the vaccine the next time you get pregnant to protect that baby.
  c. After receiving the rubella vaccine, do not get pregnant for three months.
  d. If you plan to breastfeed, you cannot receive the vaccine until the baby is weaned.

[HandsomeMarc]

Answer to Question 1

ANS: C
Uterine displacement is usually associated with bladder distention. After the nurse takes her to the bathroom to void, the uterus should shift to a midline position. The other findings are normal.

Answer to Question 2

ANS: C
Exposure to rubella during pregnancy can cause birth defects. The woman should avoid pregnancy for at least 3 months. The rubella vaccine is not a contraindication for breastfeeding.