Chapter 16: Nursing Management During the Postpartum Period (Prep U)

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? 1,000 additional calories per day 250 additional calories per day 750 additional calories per day 500 additional calories per day

500 additional calories per day The breastfeeding 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 nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? hemorrhage infection atony normal involution

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day? 800 calories 650 calories 500 calories 950 calories

650 calories Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? Provide phone numbers for call centers for questions. Schedule home visits for high-risk families. Ask family members to monitor the parents' progress. Encourage frequent clinic visits for high-risk families.

Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? Ensure that the newborn's daily bath is performed by the nurses. Allow time for the numerous visitors who come to see the woman and newborn. Provide time for prayers to be performed at the bedside. Assign a female nurse to care for her.

Assign a female nurse to care for her. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply. episiotomy hemoglobin 11.0 g/100 mL white blood cell count 25,000/mm³ urinary stasis denuded endometrial arteries

urinary stasis denuded endometrial arteries episiotomy The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "I'll contact your primary care provider." "I'll check on you in a few hours." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "If you don't attempt to void, I'll need to catheterize you."

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time? Apply a glycerin-based ointment to the area. Encourage use of a sitz bath. Instruct in the use of witch hazel compresses. Apply an ice pack to the perineal area.

Apply an ice pack to the perineal area. Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

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

Instruct the client to empty her bladder before the examination. 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.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The color of the flow is red. Her uterus is soft to your touch. The flow is over 500 mL. The flow contains large clots.

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. Walk alongside the client to the bathroom. Frequently ask the client how her head feels. Elevate the head of the bed for several minutes before getting her up. Check her blood pressure after she stands up. Sit her in a chair after getting out of bed before going to the bathroom.

Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels. One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Appropriate interventions include: checking blood pressure first before ambulating the client; elevating the head of the bed for a few minutes before ambulating the client; having the client sit on the side of the bed for a few moments before getting up; helping the client to stand up, and staying with her; ambulating alongside the client and providing support if needed; and frequently asking the client how her head feels. Having her sit in the chair after getting out of bed would be inappropriate because the client's blood pressure may already have dropped.

Which postpartum client will the nurse assess first? an 18-year-old who wants to sleep until 10:00 before the nurse brings the infant for a visit. a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated a 22-year-old who has been up, showered, and packing for discharge later today a 30-year-old postpartum client who had a cesarean birth and is sleeping following pain medication administration

a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. If blood pressure is 15 to 20 mm Hg lower after raising the head of the bed upright compared with the supine reading, the woman might be susceptible to dizziness and fainting when she ambulates. Developmentally, 18-year-old teenagers may stay up late and sleep late as a normal sleep cycle. The young 22-year-old packing for discharge is not the priority. A client who had a cesarean birth with minimal blood loss should be allowed to sleep after receiving pain medication and is not the priority.

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? opioid pain medication a sitz bath a heating pad applied to the perineum an ice pack applied to the perineum

an ice pack applied to the perineum 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. Opioid pain medication would not be the first choice.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. 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: increase the flow of an IV. assess and massage the fundus. inspect the perineum for lacerations. call the primary care provider or the nurse-midwife.

assess and massage the fundus. 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 new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? bringing the newborn into the room allowing the mother to pick the best time to hold her newborn talking about how the nurse held her own newborn while on the birthing table showing a video of parents feeding their babies

bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" saturating 1 pad in 6 hours saturating 1 pad in 3 hours saturating 1 pad in 8 hours saturating 1 pad in 1 hour

saturating 1 pad in 1 hour Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour.

Which factor puts a client on her first postpartum day at risk for hemorrhage? moderate amount of lochia rubra hemoglobin level of 12 g/dl (120 g/L) thrombophlebitis uterine atony

uterine atony 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.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. head-to-toe assessment of newborn pain level vital signs of mother newborn's vital signs head-to-toe assessment

vital signs of mother pain level head-to-toe assessment Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women using street drugs women on antithyroid medications women who had difficulties with breastfeeding in the past women on antineoplastic medications women with more than one infant

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Talk to your 2-year-old about the baby when you're driving him to day care." "Ask your 2-year-old to pick out a special toy for his sister." "Have your 2-year-old stay at home while you're here in the hospital." "Expect to see your 2-year-old become more independent when the baby gets home."

"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "Sitz baths worked the last time." "My mom always used dibucaine." "I already have some pads with witch hazel at home." "I only eat a low-fiber diet."

"I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "Let me call your health care provider about this problem." "It might take up to a week for your bowels to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?"

"It might take up to a week for your bowels to return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? "Breastfeeding takes time and practice." "Some women just can't breastfeed. Maybe I'm one of these women." "Some babies latch on and catch on quickly; others take a little more time." "Maybe a lactation specialist can help me work through this."

"Some women just can't breastfeed. Maybe I'm one of these women." The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 3 weeks 1 week 4 weeks 2 weeks

2 weeks Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum? Ask her if she feels any warmth in her legs. Palpate her feet for tingling or numbness. Assess for calf redness and edema. Take her temperature every 4 hours.

Assess for calf redness and edema. Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy. Determine if this is the client's first baby. Determine the newborn's blood type and rhesus.

Determine the newborn's blood type and rhesus. 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.

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? Use ice packs for a week after birth. Ensure ice pack is changed frequently. Apply ice packs for 40 minutes continuously. Apply ice packs directly to the perineal area.

Ensure ice pack is changed frequently. 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.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Help the mother initiate breastfeeding within 30 minutes of birth. Give newborns water and other foods to balance nutritional needs. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Provide breastfeeding newborns with pacifiers.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? Percussion reveals dullness. Bladder is nonpalpable. Lochia is less than usual. Uterus is firm.

Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? Avoid elevating her feet when she rests in a chair. Avoid getting out of bed for another 2 days. Walk the length of the hallway to regain her strength. Walk with the nurse the length of her room.

Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? Percussion reveals tympany. Bladder is nonpalpable. Lochia is less than usual. Uterus is boggy.

Uterus is boggy. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. abdominal pain active bowel sounds nondistended abdomen passing gas tender abdomen

active bowel sounds nondistended abdomen passing gas Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? lochia appearing pinkish-brown on the fourth day lochia that is the color of menstrual blood an absence of lochia red-colored lochia for the first 24 hours

an absence of lochia Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: using a breast pump to facilitate removal of stagnant breast milk. having the client stand facing in a warm shower. encouraging the client to wear a supportive bra. informing the primary care provider that the client is showing early signs of breast infection.

encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? screening for bacteriuria in the urine increasing oral fluid intake increasing intravenous fluids encouraging the woman to empty her bladder completely every 2 to 4 hours

encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? first 6 months first month first 3 to 5 days first 30 to 60 minutes

first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? third degree fourth degree second degree first degree

fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

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? generally after 12 weeks generally within 3 to 6 weeks usually within a couple weeks whenever the couple wishes

generally within 3 to 6 weeks 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 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? infection depression hemorrhage pulmonary emboli

infection 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.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition? long-term obesity feelings of increased self-esteem increased sex drive diabetes

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

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? mastitis normal findings in breastfeeding mothers an improperly positioned baby during feedings too much milk being retained

mastitis 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 nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: light. moderate. heavy. scant.

moderate. Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? positive bonding negative bonding positive attachment negative attachment

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

When palpating for fundal height on a postpartum woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus palpating the fundus with only fingertip pressure placing one hand on the fundus, one on the perineum resting both hands on the fundus

placing one hand at the base of the uterus, one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that allow visitors policies that allow rooming the infant and mother together policies that discourage unwrapping and exploring the infant policies that allow flexibility for cultural differences

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: the level of the umbilicus. between the umbilicus and symphysis pubis. 1 cm below the umbilicus. 2 cm below the umbilicus.

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities infection normal response to the body converting back to prepregnancy state

thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.