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Difficulty: MediumAnte/Intra/Postpartum and Newborn Care

A practical nurse is assigned to care for a client who is 18 hours postpartum following a forceps-assisted vaginal delivery at 40 weeks of gestation, along with her newborn. Which of the following actions by the practical nurse are appropriate? Select all that apply.

  1. Initiating gentle fundal massage immediately upon palpating a soft, boggy uterusAnswer
  2. Reinforcing previous teaching regarding expected lochia rubra characteristics and perineal careAnswer
  3. Swaddling the newborn and providing a pacifier for comfort during a routine heel stick for blood glucose monitoringAnswer
  4. D
    Instructing the client that saturating one perineal pad over a 3-hour period is a danger sign requiring immediate evaluation
  5. E
    Administering a prescribed intravenous push opioid analgesic to relieve the client's severe perineal discomfort
  6. F
    Reporting a positive Babinski reflex in the 18-hour-old newborn to the registered nurse as a sign of neurological deficit

Answer

The appropriate actions are initiating gentle fundal massage for a boggy uterus, reinforcing previous teaching regarding lochia and perineal care, and swaddling the newborn with a pacifier during a heel stick.
The practical nurse operates safely within their scope of practice by performing independent interventions like fundal massage for a boggy uterus, which is the immediate first-line response to prevent hemorrhage. Furthermore, the practical nurse correctly reinforces existing educational plans regarding lochia and perineal care, and utilizes standard non-pharmacological comfort measures such as swaddling and offering a pacifier during minor neonatal procedures.

Step-by-Step Solution

1
Evaluate the clinical findings and the practical nurse scope of practice for each option.
Identified that fundal massage, teaching reinforcement, and non-pharmacological newborn pain management are correct.
These actions address safe, independent practical nurse interventions for a postpartum client and newborn dyad.
2
Identify findings that represent normal physiology versus true complications.
Determined that saturating 1 pad in 3 hours and exhibiting a positive Babinski reflex are both normal expected findings.
Recognizing normal postpartum and neonatal progression prevents inappropriate escalation of care.
3
Filter interventions that exceed the practical nurse's legal scope of practice.
Excluded the administration of intravenous push medications.
The administration of intravenous push medications is strictly reserved for the registered nurse or provider.

Key Concept

Practical Nurse Scope of Practice in Postpartum and Newborn Care
Estimated Time:1m 30s
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Topics

Ante/Intra/Postpartum and Newborn Care

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