Chapter 16 (easy)

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks R: The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 R:The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? A. mastitis B. too much milk being retained C. normal findings in breastfeeding mothers D. an improperly positioned baby during feedings

A R:Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening? A. pulmonary emboli B. hemorrhage C. fluid volume overload D. infection

B R:Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: A. increase the flow of an IV. B. assess and massage the fundus. C. inspect the perineum for lacerations. D. call the primary care provider or the nurse-midwife.

B R: This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? A. Apply ice packs directly to the perineal area. B. Ensure ice pack is changed frequently. C. Apply ice packs for 40 minutes continuously. D. Use ice packs for a week after birth.

B R: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

Moderate R: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

Pulmonary embolism R: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus R:After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg R: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A. infection B. pulmonary emboli C. hemorrhage D. depression

A R: There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: A. consistency. B. odor. C. pH. D. specific gravity.

B R:The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A. looking B. feeding C. touching D. talking

C R:Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? A. "I'll need to take medication to treat the anxiety and sadness." B. "If the symptoms last more than a few days, I need to call my doctor." C. "I might feel like laughing one minute and crying the next." D. "I should call this support line only if I hear voices."

C R: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A. whenever the couple wishes B. usually within a couple weeks C. generally within 3 to 6 weeks D. generally after 12 weeks

C R:There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. A. Inverted nipples following breastfeeding B. Moderate saturation of peripad every 3 hours C. Fundus one fingerbreadth below the umbilicus D. Urination of 100 mL every 4 hours E. Hypotonic bowel sounds

C,B R:A fundus should be one fingerbreadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of100 mL every 4 hours is inadequate given the occurrence of diuresis.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? A. pulse rate 75 beats per minute B. respiratory rate 16 breaths/minute C. uterine fundus 1 cm below umbilicus D. oral temperature 100.8° F (38.2° C)

D R:A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

A nurse is assessing a postpartum client. Which measure is appropriate? A. Wear sterile gloves when assessing the pad and perineum. B. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. C. Perform the examination as quickly as possible. D. Instruct the client to empty her bladder before the examination.

D R:An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

Which factor puts a client on her first postpartum day at risk for hemorrhage? A. thrombophlebitis B. moderate amount of lochia rubra C. hemoglobin level of 12 g/dl D. uterine atony

D R:Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? A. Advise that the woman not get out of bed until the nurse returns with assistance. B. Do nothing, this is normal. C. Ask the woman what she has had to eat today. D. Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

D R:During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A. pulmonary emboli B. depression C. hemorrhage D. infection

D R:There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? A. presence of lochia rubra B. fundus is above the umbilicus C. fundus is firm D. fever more than 100.4° F (38° C)

D R:A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

Dehydration R: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? A. an ice pack applied to the perineum B. narcotic pain medication C. a heating pad applied to the perineum D. a sitz bath

A R:Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine newborn's blood type R:The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.