OB Midterm review

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation?

* Normal (Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots.)

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis?

Ambulate frequently.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss

An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan?

Holding the infant close and allowing the infant to feel the mother's warmth will initiate a positive experience for the mother and will console the infant

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein.

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?

Peanut butter and jelly sandwich and glass of 2% milk (calorie needs increase by approximately 500 calories/day.)

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal

Saturation of more than 1 peripad per hour is considered excessive even in the early postpartum period.

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

Signs and symptoms of infection include pain, redness, heat, and swelling of a localized area of the breast. If these signs or symptoms occur, the client needs to contact the health care provider.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?

A fever in the postpartum period is not expected and if this occurs the client should contact the health care provider because fever is an indication of infection.

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?

Assess for hypovolemia and notify the health care provider (HCP) (cool, clammy, pale skin; sensations of anxiety or impending doom; restlessness; and thirst)

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client?

Assess her blood glucose before administering any glucose-lowering medications.

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action?

provide comfort, promote healing, and reduce the incidence of infection.

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs?

Every 4 hours

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.

Massaging the uterus Assisting the woman to urinate Checking for a distended bladder

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?

*Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures (prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor)

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which clients would be at most risk for development of postpartum thromboembolic disorders? Select all that apply.

*A 39-year-old woman who reports that she smokes *A 37-year-old woman in her fourth pregnancy who is overweight *A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply.

*A mother who had 10 vaginal exams during labor *A mother with a history of previous puerperal infections *A mother who experienced prolonged rupture of the membranes

A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection? Select all that apply.

*Urinate frequently throughout the day. *Increase fluid intake to at least 3000 mL/day. *Wipe the perineal area from front to back after urinating. *Consume foods and fluids that will increase urine acidity.

At 10 days postpartum, a breast-feeding mother develops mastitis in her right breast. The nurse plans to instruct the client on which interventions? Select all that apply.

*Using ice packs *Using analgesics *Wearing proper breast support *Completing the full course of prescribed antibiotics.

The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.

*Wear a supportive bra between feedings. *Apply moist heat to both breasts for about 20 minutes before a feeding *Feed the infant at least every 2 hours for 15 to 20 minutes on each side. *Massage the breasts gently during a feeding, from the outer areas to the nipples.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression?

The mother constantly complains of tiredness and fatigue.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.

12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR). A 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time?

Concern about the loss of the baby and personal health

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake (The client should consume 3000 mL of fluids per day if not contraindicated.)

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

Gently massage the uterine fundus.

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply.

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response?

Mastitis can occur at any time during breast-feeding."(most often during the 2nd and 3rd after birth)

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2°F (37.8°C). What is the priority nursing action?

* increase Fluid intake (Temperatures up to 100.4°F (38°C) in the first 24 hours after birth often are related to the dehydrating effects of labor.)

The client delivered a newborn baby 3 hours ago. The assigned nurse is reviewing the electronic health record to determine if the new mother is a candidate for Rh immune globulin administration. Which criteria must be present in order to administer this medication correctly? Select all that apply.

*The mother must be Rh negative. *The newborn must be Rh positive. *The indirect Coombs' test must be negative.

Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly.

Support the mother in her reaction to the newborn infant

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

*Wear a supportive bra. *Rest during the acute phase. *Maintain a fluid intake of at least 3000 mL/day. *Continue to breast-feed if the breasts are not too sore.

Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104°F (37.9°C). This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Increased diuresis and appetite, slight elevation in temperature, and firm fundus, midline below the umbilicus represent normal maternal physiological responses in the immediate postpartum period

Abdominal tenderness and chills

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking.

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

BP cuff (oxytocic agent used to prevent or control postpartum hemorrhage by contracting the uterus. It causes constant uterine contractions and may cause the blood pressure to elevate. A priority assessment before administering this medication is obtaining a baseline blood pressure. )

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure

Breast-feed from the left breast and gently pump the right breast.

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs?

15 minutes during the first hour and then every 30 minutes for the next 2 hours

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction?

I need to stop breast-feeding until this condition resolves.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?

I should apply my antiembolism stockings after breakfast."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

I should wash my nipples daily with soap and water."

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

I will begin abdominal exercises immediately." ( the client should wait at least 3 to 4 weeks)

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?

If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately."

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor?

Postpartum infection

A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common.

Prepare an ice pack for application to the area.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider (HCP), what is the nurse's next action?

Prepare the client for surgery

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply.

Report a foul-smelling discharge. Take a warm sitz baths 3 times a day. Use warm water to rinse the perineum after elimination. Wipe the perineum from front to back after voiding and defecation.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?

Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply.

nfections and retained placental fragments are the primary causes of subinvolution.

A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used.

*Ketorolac 30 mg by intravenous (IV) push over 3 minutes *Ampicillin sodium 1 g IV piggyback over 60 minutes *Docusate sodium 100 mg orally daily *Prenatal vitamin 1 tablet orally daily

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

They want to attend a support group

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed?

Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the clien

You should not become pregnant for 2 to 3 months after administration of the vaccine

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle-feed your newborn."

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

* Notify HCP (Clots larger than 1 cm are considered abnormal)

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instruction?

"Foods and fluids that will increase urine alkalinity should be consumed."

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates a need for further teaching?

"I need to stop breast-feeding until this condition resolves

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?

500

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

Ask the client about pain in the calf area.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul-smelling odor

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement?

The only medications I will take are prenatal vitamins and stool softeners

The nurse is assessing a client in the postpartum period and suspects the presence of uterine atony. Which is the initial nursing action?

When uterine atony occurs, the initial nursing action should be to massage the uterus until it is firm. If this does not assist in controlling blood loss, the nurse should contact the HCP.

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply.

*Accepting the client's feelings *Acknowledging the client's apprehension *Assisting the client with giving the baths to allow her to become more at ease

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

*I need to breast-feed, especially for the first 6 weeks postpartum *My baby has no symptoms so it is not likely that he has gotten the infection from me."

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should take action in which priority order?

*Massage the uterus attempting to achieve firmness. *Contact the health care provider. *Monitor vital signs. *Check the amount of drainage on the peripad.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

*Pregnancy needs to be avoided for 1 to 3 months. *The vaccine is administered by the subcutaneous route. *Exposure to immunosuppressed individuals needs to be avoided. *A hypersensitivity reaction can occur if the client has an allergy to eggs.

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply.

*The client may complain of lack of sleep and fatigue. *The client is self-focused and talks to others about labor.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply.

I am going to need to bottle-feed my baby." "I need to wash my hands before and after bathroom use. "I can transmit the infection to my baby when I breast-feed. "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client?

The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. (Maternal overexertion)

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?

The mother requests that the nurse feed the newborn because she is feeling fatigued.

he nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

You need this vaccine because you are not immune to the rubella virus. "You should not become pregnant for 1 to 3 months after the administration of the vaccine." provides immunity for 15 years. A second vaccination is not required to attain immunity. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. If not immune (titer less than 1:8) then the client should be vaccinated in the postpartum period