OB PrepU: Chapter 16
Postpartum bleeding must be assessed carefully during the first 24 hours after delivery. Prioritize the actions taken upon detection of increased vaginal bleeding in a patient who delivered within the last 24 hours.
1. Palpate the fundus 2. Massage the fundus if boggy 3. Notify the physician or the nurse-midwife of excessive bleeding 4. Increase IV pitocin or breastfeed the newborn 5. Assess blood pressure 6. Assist the patient to empty her bladder in the bathroom Rationale: Determining the site of bleeding is the first assessment. Palpate the fundus. If the fundus is boggy, take steps to stimulate contractions by massaging. Notify the health care provider, and continue with the assessment. Stimulate contractions. Assess blood pressure and assess for safety to ambulate. A likely reason for a boggy uterus is dislocation by a full bladder.
Which of the following would the nurse include when teaching the parents of a newborn who have a 2-year-old boy at home? a) "Ask your 2-year-old to pick out a special toy for his sister." b) "Talk to your 2-year-old about the baby when you're driving him to day care." c) "Have your 2-year-old stay at home while you're here in the hospital." d) "Expect to see your 2-year-old become more independent when the baby gets home."
a) "Ask your 2-year-old to pick out a special toy for his sister." Rationale: 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.
Which finding would the nurse describe as "light" or "small" lochia? a) 4-inch stain or a 1 to 25 ml loss b) 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss c) 4- to 6-inch stain with an estimated loss of 25 to 50 ml d) pad is saturated within 1 hour after changing it
a) 4-inch stain or a 1 to 25 ml loss Rationale: Typically the amount of lochia is described as follows: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it.
Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? a) Activity b) Infant formula selection c) Resumption of intercourse d) Signs and symptoms of infection e) Resumption of prepregnancy diet
a) Activity c) Resumption of intercourse d) Signs and symptoms of infection Rationale: The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her prepregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.
When caring for a postpartum woman who is Muslim, which of the following would be a priority? a) Assigning a female nurse to care for her b) Allowing time for the numerous visitors who come to see the woman and newborn c) Ensuring that the newborn's daily bath is performed by the nurses d) Providing time for prayers to be performed at the bedside
a) Assigning a female nurse to care for her Rationale: 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 G1 P1001 mother is just home after delivering her first child 5 days ago. Her delivery was complicated by an emergency cesarean delivery resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this patient care issue is a) At risk for postpartum depression due to inadequate rest b) At risk for interruption of tissue integrity c) At risk for safety due to low hemoglobin d) At risk for inadequate healing due to decreased nutrition
a) At risk for postpartum depression due to inadequate rest Rationale: This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.
Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT a) Maintain previous household routines to prevent infection b) The patient will show no signs of infection c) Discuss methods that the woman will use to prevent infection d) List signs of infection that she will report to her health care provider
a) Maintain previous household routines to prevent infection Rationale: The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.
A nurse assessing a postpartum patient notices excessive bleeding. What should be the nurse's first action? a) Massage the boggy fundus until it is firm. b) Document the findings. c) Call the physician. d) Nothing--excessive postpartum blood loss is normal.
a) Massage the boggy fundus until it is firm. Rationale: The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.
Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply. a) Moderate saturation of peripad every 3 hours b) Fundus one fingerbreadth above umbilicus c) Hypotonic bowel sounds d) Inverted nipples following breastfeeding e) Urination of 50 mL every hour
a) Moderate saturation of peripad every 3 hours b) Fundus one fingerbreadth above umbilicus Rationale: A fundus can rise to slightly above or below the umbilicus in the first 24 hours, and moderate saturation of 2/3 of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and 50 mL urine is inadequate given the occurrence of diuresis.
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?" a) Saturating 1 pad in 1 hour b) Saturating 1 pad in 6 hours c) Saturating 1 pad in 8 hours d) Saturating 1 pad in 3 hours
a) Saturating 1 pad in 1 hour Rationale: 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.
Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this as which of the following? a) Third-degree laceration b) Second-degree laceration c) Fourth-degree laceration d) First-degree laceration
a) Third-degree laceration Rationale: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.
The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth. a) True b) False
a) True Rationale: Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same.
Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after delivery make a woman more susceptible to infection? Select all that apply. a) Urinary stasis b) White blood cell count 25,000/mm³ c) Denuded endometrial arteries d) Episiotomy
a) Urinary stasis c) Denuded endometrial arteries d) Episiotomy Rationale: The urinary system after delivery 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. 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.
When palpating for fundal height on a postpartal woman, which technique is preferable? a) Resting both hands on the fundus b) Placing one hand at the base of the uterus, one on the fundus c) Palpating the fundus with only fingertip pressure d) Placing one hand on the fundus, one on the perineum
b) Placing one hand at the base of the uterus, one on the fundus Rationale: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.
A nursing student is studying postpartal complications. Thromboembolic conditions have which of the following risk factors? (Select all that apply.) a) cigarette smoking b) anemia c) diabetes d) irritable bowel e) obesity f) multiparity
a) cigarette smoking b) anemia c) diabetes e) obesity f) multiparity Rationale: Risk factors for developing thromboembolic conditions include anemia, diabetes, cigarette smoking, obesity, preeclampsia, hypertension, varicose veins, pregnancy, cesarean section, multiparity, inactivity, and advanced maternal age.
Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a) dehydration b) change in the temperature from the delivery room c) infection d) fluid volume overload
a) dehydration Rationale: Many women experience a slight fever (100.4 degrees F) during the first 24 hours after delivery. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.
The nurse who works on a post-partum floor is mentoring a new graduate. She informs the new nurse that a post-partum assessment of the mother includes which of the following? (check all that apply) a) head-to-toe assessment b) vital signs of mother c) head-to-toe assessment of newborn d) newborn's vital signs e) pain level
a) head-to-toe assessment b) vital signs of mother e) pain level Rationale: Post-partum 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.
Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? a) hematoma b) infection c) nothing--it is normal d) DVT
a) hematoma Rationale: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the physician immediately.
A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician 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 patient at risk for developing? a) infection b) depression c) hemorrhage d) pulmonary emboli
a) infection Rationale: There are many risk factors for developing a postpartum infection: operative procedures(eg, 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.
Hypercoagulability during pregnancy protects the mother against excessive blood loss during childbirth. It also can increase a woman's risk of developing a blood clot. It does this by which of the following ways? (Select all that apply.) a) localized vascular damage b) altered coagulation c) stasis d) decline in HGB e) decline in WBCs
a) localized vascular damage b) altered coagulation c) stasis Rationale: Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during birthing process). All these increase the risk of clot formation.
A nurse is auscultating the lungs of a postpartum patient and notices crackles and some dyspnea. The patient's respiratory rate is 12 breaths/min; she appears in some distress. What complication should the nurse suspect based on these data? a) pulmonary edema b) fluid volume deficit c) hemorrhage d) infection
a) pulmonary edema Rationale: Any change in the respiratory rate of a postpartum woman might indicate pulmonary edema, atelectasis, or pulmonary embolism and must be reported. Lungs should be clear upon auscultation.
A nurse is instructing students on how to check an episiotomy and perineum of a woman after Which of the following are normal in the early postpartum period? (Select all that apply.) a) slight bruising b) discharge c) redness d) edema
a) slight bruising d) edema Rationale: During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness or discharge.
A mother just delivered 3 hours ago. The nurse enters the room to continue hourly assessments and finds the patient on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? a) "If you plan to breastfeed, you need to calm down." b) "It sounded like you had quite a time getting here. Would you like to continue your story?" c) "You have a beautiful baby, why worry about that now?" d) "I need to assess your fundus now."
b) "It sounded like you had quite a time getting here. Would you like to continue your story?" Rationale: The mother is going through the taking-in phase of relating events during her pregnancy and delivery. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.
A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "If you don't attempt to void, I'll need to catheterize you." b) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." c) "I'll check on you in a few hours." d) "I'll contact your physician."
b) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." Rationale: After a vaginal delivery, 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 physician 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.
Which of the following findings would lead you to suspect that a woman is developing a postpartum complication? a) Lochia appearing pinkish-brown on the fourth day b) An absence of lochia c) Red-colored lochia for the first 24 hours d) Lochia that is the color of menstrual blood
b) An absence of lochia Rationale: Women should have a lochia flow following childbirth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.
Seven hours ago, a G5 P4014 woman delivered 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 physician or the nurse-midwife
b) Assess and massage the fundus Rationale: This woman is a multigravida who delivered a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100 degrees F. Which action would be most appropriate? a) Notify the health care provider about this elevation; this finding reflects infection. b) Continue to monitor the woman's temperature every 4 hours; this finding is normal. c) Obtain a urine culture; the woman most likely has a urinary tract infection. d) Inspect the perineum for hematoma formation.
b) Continue to monitor the woman's temperature every 4 hours; this finding is normal. Rationale: A temperature of 100.4 degrees F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the physician, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum), because this finding is normal.
Which of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman? a) Increasing intravenous fluids. b) Encouraging the woman to empty her bladder completely every 2 to 4 hours. c) Increasing oral fluid intake. d) Screening for bacteriuria in the urine.
b) Encouraging the woman to empty her bladder completely every 2 to 4 hours. Rationale: 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 physician's order and is not necessary as a prevention measure.
Inspection of a woman's perineal pad reveals a 5-inch stain. The nurse documents this amount as which of the following? a) Scant b) Moderate c) Heavy d) Light
b) Moderate Rationale: 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.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a) Edema b) Temperature c) Drainage d) Redness
b) Temperature Rationale: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following? a) normal involution b) atony c) hemorrhage d) infection
b) atony Rationale: The uterus in a postpartum patient should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.
A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which of the following? a) bonding b) attachment c) being spoiled d) none of the above
b) attachment Rationale: Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.
A nurse is instructing a patient who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is best described as which of the following? a) milky white b) creamy yellow c) gray liquid d) bluish white
b) creamy yellow Rationale: If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).
The nurse working on a postpartum must check lochia in terms of amount, color, change with activity and time, and: a) pH b) odor c) specific gravity d) consistency
b) odor Rationale: The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.
A nursing student learns that a certain condition in 1 in every 2,000 pregnancies is a major cause of death. What is this condition? a) infection b) pulmonary embolism c) hemorrhage d) hypertension
b) pulmonary embolism Rationale: Pulmonary embolism occurs in 1 in 2,000 pregnancies and is a major cause of maternal mortality.
When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? a) proximity b) reciprocity c) commitment d) all of the above
b) reciprocity Rationale: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (ie, the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.
After teaching a postpartum woman about postpartum blues, which statement indicates effective teaching? 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) "I might feel like laughing one minute and crying the next." Rationale: 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.
Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection? a) Multiparity b) Labor of 12 hours c) Placenta removed via manual extraction d) Hemoglobin of 11.5 mg/dL
c) Placenta removed via manual extraction Rationale: Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum hemorrhage.
A nursing instructor teaching students how to check the patient's uterus postpartum realizes that further instruction is needed when one of the students says: a) "Normally the fundus progresses downward at a rate of 1 fingerbreadth per day after birth." b) "One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis." c) "Six to twelve hours after birth the fundus is typically at the level of the umbilicus." d) "One to two hours after birth the fundus is typically at the level of the umbilicus."
c) "Six to twelve hours after birth the fundus is typically at the level of the umbilicus." Rationale: One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis. At 6ix to 12 hours after birth the fundus usually is at the level of the umbilicus. Normally the fundus progresses downward at at rate of one fingerbreadth per day after birth.
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a) Vigorously massage the fundus. b) Immediately call the primary care provider. c) Ask the client when she last changed her perineal pad. d) Have the charge nurse review the assessment.
c) Ask the client when she last changed her perineal pad. Rationale: If the morning assessment is done relatively yearly, it's possible that the client hasn't yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, wouldn't be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse wouldn't want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.
A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by a) Showing a video of parents feeding their babies b) Talking about how the nurse held her own newborn while on the delivery table c) Bringing the newborn into the room d) Allowing the mother to pick the best time to hold her newborn
c) Bringing the newborn into the room Rationale: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a) When the white blood cell count is less than 10,000/mm³ b) After any period of decreased intake c) During the first 24 hours after delivery owing to dehydration from exertion d) When the elevated temperature exceeds 100.4° F
c) During the first 24 hours after delivery owing to dehydration from exertion Rationale: Rapid breathing during labor and delivery and limited oral intake can cause a self-limited period of dehydration that is resolved after delivery by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.
A client who gave birth by cesarean delivery 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: a) Having the client stand facing in a warm shower. b) Using a breast pump to facilitate removal of stagnant breast milk. c) Encouraging the client to wear a supportive bra. d) Informing the physician that the client is showing early signs of breast infection.
c) Encouraging the client to wear a supportive bra. Rationale: 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 don't 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 of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman? a) Increasing intravenous fluids. b) Increasing oral fluid intake. c) Encouraging the woman to empty her bladder completely every 2 to 4 hours. d) Screening for bacteriuria in the urine.
c) Encouraging the woman to empty her bladder completely every 2 to 4 hours. Rationale: 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 physician's order and is not necessary as a prevention measure.
A woman yesterday delivered a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at delivery. The nurse's priority is to assist the mother to a) Visit the child in the nursery b) Review causes of a cleft palate c) Grieve for the loss of the perfect baby d) Care for herself
c) Grieve for the loss of the perfect baby Rationale: Grief is the response to loss. The process of mourning will take precedence over the mother's self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted.
A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient? a) Increased intake will increase the patient's output and therefore will provide an opportunity for more frequent perineal self-care. b) The patient needs to walk to the bathroom more often. c) Increased intake will rehydrate the patient and decrease her skin temperature. d) The patient will have to call for the nurse's help more often.
c) Increased intake will rehydrate the patient and decrease her skin temperature. Rationale: The perception of increased skin temperature a short time post delivery is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature. Information is insufficient to suggest the presence of infection. Goals of more frequent perineal care and ambulation, as well as reinforcement of patient teaching, are not appropriate in this situation.
A patient delivered 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the patient was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the physician and the nurse-midwife to her concern that the patient may be experiencing a) Upper respiratory infection b) Thrombophlebitis c) Pulmonary embolism d) Mitral valve collapse
c) Pulmonary embolism Rationale: 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.
Not all mothers express joy at seeing their newborn upon delivery and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is a) Dressing the child in old clothes b) Giving the child an uncommon name c) Referring to a facial feature as "ugly" d) Bottle feeding
c) Referring to a facial feature as "ugly" Rationale: Making negative comments about a newborn's features is a warning sign of impending attachment difficulties. The other options may be culturally rooted.
A patient who has just delivered a baby girl demonstrates behavior not indicative of bonding when she does which of the following? a) Kisses the infant on her cheek b) Strokes the infants' head c) Talks to company and ignores the baby lying next to her d) Holds and smiles at the infant
c) Talks to company and ignores the baby lying next to her Rationale: Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending to her child. Ignoring the infant while talking to visitors is not an example of proper bonding.
You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits? a) The flow contains large clots. b) The flow is over 500 mL. c) The color of the flow is red. d) Her uterus is soft to your touch.
c) The color of the flow is red. Rationale: 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 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) Transthoracic echocardiogram b) Noninvasive arterial studies of the right leg c) Venous duplex ultrasound of the right leg d) Venogram of the right leg
c) Venous duplex ultrasound of the right leg Rationale: 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 wouldn't be the first choice. Transthoracic echocardiography looks at cardiac structures and isn't indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
A woman states that she still feels exhausted on her second postpartal day. Your best advice for her would be to do which of the following? a) Avoid elevating her feet when she rests in a chair. b) Walk the length of the hallway to regain her strength. c) Walk with you the length of her room. d) Avoid getting out of bed for another 2 days.
c) Walk with you the length of her room. Rationale: Most women report feeling exhausted following childbirth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.
A postpartal woman asks you about perineal care. Which of the following recommendations would you give? a) Use an alcohol wipe to wash her suture line. b) Avoid using soap in her perineal care. c) Wash her perineum with her daily shower. d) Refrain from washing lochia from the suture line.
c) Wash her perineum with her daily shower. Rationale: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
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 of the following? a) positive bonding b) negative bonding c) negative attachment d) positive attachment
c) negative attachment Rationale: 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.
Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: a) "RhoGAM suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." b) "RhoGAM suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." c) "RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." d) "RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."
d) "RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rationale: RhoGAM is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. RhoGAM is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.
A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful? a) "Breast-feeding takes time. Let's see what's happening." b) "Let me contact our lactation specialist and together maybe we can work through this." c) "Some babies latch on and catch on quickly; others take a little more time." d) "Some women just can't breast-feed. Maybe you're one of these women."
d) "Some women just can't breast-feed. Maybe you're one of these women." Rationale: This response ignores the woman's feelings and displays a negative attitude, indicating that the woman is at fault for the current situation. The woman needs reassurance that she can breast-feed and accomplish the task. She needs to understand that although breast-feeding is a natural process, it takes time and practice. By offering to observe her breast-feeding, the nurse offers support and can provide the woman with some practical suggestions as necessary. The statement that some babies need more time would reduce her frustration and uncertainty about her ability to breast-feed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.
A postpartal woman has a history of thrombophlebitis. Which of the following would help you to determine if she is developing this postpartally? a) Palpate her feet for tingling or numbness. b) Ask her if she feels any warmth in her legs. c) Take her temperature every 4 hours. d) Assess for calf redness and edema.
d) Assess for calf redness and edema. Rationale: Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.
A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? a) Ask the woman what she has had to eat today. b) Advise that the woman not get out of bed until the nurse returns with assistance. c) Do nothing, this is normal. d) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.
d) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. Rationale: 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. 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.
When doing a health assessment, at which of the following locations would you expect to palpate the fundus in a woman on the second postpartal day and how should it feel? a) Fundus two fingerbreadths above symphysis pubis and hard b) Fundus height 4 cm below umbilicus and midline c) Fundus 4 cm above symphysis pubis and firm d) Fundus two fingerbreadths below umbilicus and firm
d) Fundus two fingerbreadths below umbilicus and firm Rationale: A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.
A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications? a) Fluid volume overload b) Ruptured bladder c) Permanent urinary incontinence d) Increased lochia drainage
d) Increased lochia drainage Rationale: If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.
A nurse is assessing a postpartum client. Which of the following measures is appropriate? a) Wear sterile gloves when assessing the pad and perineum. b) Perform the examination as quickly as possible. c) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. d) Instruct the client to empty her bladder before the examination.
d) Instruct the client to empty her bladder before the examination. Rationale: 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 delivery.
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a) At the level of the umbilicus b) Below the symphysis pubis c) One fingerbreadth above the umbilicus d) One fingerbreadth below the umbilicus
d) One fingerbreadth below the umbilicus Rationale: 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.
Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? a) Lochia is less than usual b) Bladder is nonpalpable c) Uterus is firm d) Percussion reveals dullness
d) Percussion reveals dullness Rationale: 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.
Which of the following would you emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths? a) The longer a sitz bath is continued, the more therapeutic it becomes. b) Sitz baths may lead to increased postpartal infection. c) Sitz baths cause perineal vasoconstriction and decreased bleeding. d) Sitz baths increase the blood supply to the perineal area.
d) Sitz baths increase the blood supply to the perineal area. Rationale: Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.
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: a) Between the umbilicus and symphysis pubis b) 2 cm below the umbilicus c) 1 cm below the umbilicus d) The level of the umbilicus
d) The level of the umbilicus Rationale: 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.
Which factor puts a client on her first postpartum day at risk for hemorrhage? a) Moderate amount of lochia rubra b) Hemoglobin level of 12 g/dl c) Thrombophlebitis d) Uterine atony
d) Uterine atony Rationale: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. 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) infection c) fluid volume overload d) hemorrhage
d) hemorrhage Rationale: Some risk factors for developing hemorrhage after delivery 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.
A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following? a) diabetes b) feelings of increased self-esteem c) increased sex drive d) long-term obesity
d) long-term obesity Rationale: 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? a) too much milk being retained b) normal findings in breastfeeding mothers c) an improperly positioned baby during feedings d) mastitis
d) mastitis Rationale: 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 woman who had a cesarean delivery of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect? a) fluid volume overload b) infection c) hemorrhage d) pulmonay emboli
d) pulmonay emboli Rationale: One of the postpartum danger signs is calf pain with dorsiflexion of the foot. This would indicate a deep vein thrombosis. With the shortness of breath the patient might have a pulmonary emboli. This scenario would require immediate interventions to prevent the patient's death.