Postpartum

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

"Postpartum depression develops gradually, appearing within the first 6 weeks." rationale: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy. ricci, ch. 22, p. 820

A new mother comes in for her first visit and reports pain and tenderness in her breast just before feeding. Based on her description, the nurse determines she is experiencing breast engorgement. Which instruction should the nurse provide to her?

"Take a warm shower just before feeding your infant." rationale: Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses, but not ice, to her breasts between feedings to reduce swelling. ricci, ch. 15, p. 509

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply.

- Fundus one finger-breadth below the umbilicus - Moderate saturation of peripad every 3 hours rationale: A fundus should be one finger-breadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of 100 ml every 4 hours is inadequate given the occurrence of diuresis. ricci, ch. 16, p. 525

Rho(D) immune globulin is administered to which clients? Select all that apply.

- An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday - An Rh-negative woman following an ectopic pregnancy - A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood rationale: Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate. ricci, ch. 16, p. 803

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?

2 weeks rationale: 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. ricci, ch. 16, p. 550

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?

25 to 50 mL rationale: Typically, the amount of lochia is described as follows: scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-mL loss; light or small: an approximately 4-in (10-cm) stain or a 10- to 25-mL loss; moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 mL; large or heavy: a pad saturated within 1 hour after changing it or over 50-mL loss. ricci, ch. 16, p. 527

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL rationale: Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL after a vaginal birth and greater than 1,000 mL after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process. ricci, ch. 22, p. 800

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?

Ambulate the client as soon as her vital signs are stable. rationale: The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision. ricci, ch. 22, p. 811

The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client?

Anticoagulants rationale: The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Narcotic analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation. ricci, ch. 22, p. 811

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema. rationale: Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return. ricci, ch. 22, p. 810

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching?

Avoid over-the-counter (OTC) salicylates. rationale: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism. ricci, ch. 22, p. 812

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra. rationale: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra). ricci, ch. 22, p. 801

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia. rationale: The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus. ricci, ch. 22, p. 802

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. 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. ricci, ch. 16, p. 526

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond?

Pierced nipple rationale: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads. ricci, ch. 22, p. 813

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

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. ricci, ch. 16, p. 536

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate. rationale: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery. ricci, ch. 22, p. 819

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

Uterine atony rationale: Early postpartum hemorrhage usually results from one of the following conditions: uterine atony, lacerations, or hematoma. Most cases of early postpartum hemorrhage result from uterine atony, which is due to the uterine muscles remaining relaxed and not contracting as they should. Disseminated intravascular coagulation is a complication which can occur with excessive postpartum hemorrhage. ricci, ch. 22, p. 803

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?

Weak and rapid pulse rationale: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted. ricci, ch. 22, p. 800

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug?

cardiovascular disease rationale: Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident (stroke) in women at risk with preexisting conditions. Low blood pressure, respiratory problems, or mild fever are not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage. ricci, ch. 22, p. 807

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color?

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). ricci, ch. 16, p. 525

The nurse reviews the history of a postpartum woman, G3, P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?

deep venous thrombosis rationale: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity. ricci, ch. 22, p. 810

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?

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. ricci, ch. 16, p. 532

Not all mothers express joy at seeing their newborn upon birth and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is:

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. ricci, ch. 16, p. 532

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

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. ricci, ch. 16, p. 527

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

uterine atony rationale: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also 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. ricci, ch. 22, p. 804

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." rationale: Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away. ricci, ch. 22, p. 813-814

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 ml rationale: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth. ricci, ch. 22, p. 800

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m. rationale: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame. ricci, ch. 16, p. 537

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus. rationale: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered. ricci, ch. 22, p. 809

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4°F (38.8°C) orally. rationale: As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature. ricci, ch. 22, p. 800

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?

Risk for injury: postpartum hemorrhage related to uterine atony rationale: The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage. ricci, ch. 15, p. 506

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?

Schedule home visits for high-risk families. rationale: 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. ricci, ch. 16, p. 547

An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor rationale: The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk. ricci, ch. 22, p. 815

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

"I know you are hurting, but you can have another baby in the future." rationale: Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful. ricci, ch. 22, p. 785-786

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant. rationale: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered. ricci, ch. 16, p. 527

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm. ricci, ch. 16, p. 528

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

Mastitis rationale: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis. ricci, ch. 22, p. 813

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin rationale: Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate. ricci, ch. 22, p. 806

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

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. ricci, ch. 16, p. 527

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?" rationale: The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having. ricci, ch. 22, p. 809

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

- Get a pad count. - Monitor the client's vital signs. - Assess the client's uterine tone. rationale: A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin. ricci, ch. 22, p. 808

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?

an ice pack applied to the perineum rationale: Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice. ricci, ch. 16, p. 536

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The bladder is distended. rationale: If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia. ricci, ch. 22, p. 801-802

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula rationale: Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production. ricci, ch. 15, p. 509

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?

Ensure ice pack is changed frequently. rationale: 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. ricci, ch. 16, p. 536

When caring for a client with postpartum blues, which intervention would be most appropriate?

Validate the client's emotions, allowing her to express them freely. rationale: When caring for a client with postpartum blues, the nurse should validate the client's emotions and allow the client to express them freely. The nurse should not administer antidepressants to the client since these drugs are administered only during depression, postpartum or otherwise. Recommending the client to a support group or a mental health professional is not an appropriate intervention when caring for a client with postpartum blues. The nurse need not avoid contact between the mother who is experiencing postpartum blues and her infant. ricci, ch. 22, p. 819

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

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. ricci, ch. 16, p. 540

The nurse notes uterine atony in the postpartum client. Which assessment is completed next?

Assessment of the perineal pad rationale: Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern. ricci, ch. 22, p. 810

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf. rationale: A positive Homans sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for redness and warmth/ In addition, assess to see if she has increased pain when she ambulates or bears weight. ricci, ch. 22, p. 810

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 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. ricci, ch. 16, p. 538

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in?

taking-in phase rationale: The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period. ricci, ch. 15, p. 514

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness rationale: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more. ricci, ch. 22, p. 808

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?

Pad count rationale: The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour. ricci, ch. 22, p. 808

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus. rationale: The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended. ricci, ch. 22, p. 805

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?

Postpartum psychosis rationale: Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women. ricci, ch. 22, p. 822

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice rationale: Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression. ricci, ch. 22, p. 813

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting:

centrality. rationale: Centrality, which is a component of commitment, is demonstrated when the parents place the infant at the center of their lives, acknowledging and accepting their responsibility to promote the infant's safety, growth and development. Contact, a dimension of proximity, refers to the sensory experiences of touching, holding, and gazing at the infant. Individualization, a dimension of proximity, reflects parental awareness of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately. Reciprocity is the process by which the infant's abilities and behaviors elicit a parental response. ricci, ch. 16, p. 531

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth rationale: Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology. ricci, ch. 22, p. 817

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:

postpartum depression. rationale: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation. ricci, ch. 22, p. 817

A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth?

postpartum hemorrhage rationale: Early postpartum hemorrhage can be assessed within the first few hours following birth. Postpartum infection may be noticed as a rise in temperature after the first 24 hours following birth. Postpartum blues and postpartum depression are emotional disorders noticed much later, in the days to weeks following birth. ricci, ch. 22, p. 800

The mental health clinical nurse specialist is teaching a postpartum nurse how to use the Postpartum Depression Predictor Scale (PDSS) to assess for postpartum depression. The nurse specialist determines the need for additional teaching when the nurse identifies which component as being screened with the scale?

family and social support system rationale: The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance; emotional lability; loss of self-esteem; guilt/shame; cognitive impairment; and suicidal thoughts. ricci ch. 22, p. 820

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack. rationale: The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding. ricci, ch. 15, p. 504

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client?

oxytocin agent rationale: The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion. ricci, ch. 22, p. 807

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor rationale: The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time. ricci, ch. 16, p. 528

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?

"I only eat a low-fiber diet." rationale: 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. ricci, ch. 16, p. 540

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement?

"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. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur. ficci, ch. 16, p. 550

A nursing instructor teaching students how to check the client's uterus postpartum realizes that further instruction is needed when one of the students says:

"One to two 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 6 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. ricci, ch. 16, p. 525

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 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. ricci, ch. 16, p. 525

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 rationale: Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding. ricci, ch. 15, p. 503

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid." rationale: The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy. ricci, ch. 22, p. 812

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

- "The newborn is not really mine emotionally, since I was never pregnant and do not have children." - "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." - "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." rationale: Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill. ricci, ch. 22, p. 822

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.

- breastfeeding - early ambulation rationale: Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution. ricci, ch. 15, p. 502

A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the healthcare provider. Which nursing assessments would be essential to begin each nursing shift? Select all that apply.

- pain - platelet count - clotting profiles - evidence of bleeding rationale: Thrombophlebitis interrupts blood flow causing pain. A pain assessment is needed every shift. The nurse should also monitor platelet counts and clotting profiles and assess bleeding in the client prescribed heparin therapy, an anticoagulant. Monitoring fluid status would be important for any client. This assessment is not related to heparin therapy. ricci, ch. 22

A woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed endometritis? Select all that apply.

- pain on both sides of the abdomen - leukocytosis rationale: Signs and symptoms of endometritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection. ricci, ch. 22, p. 814

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void. rationale: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations. ricci, ch. 22, p. 800

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection. rationale: A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract. ricci, ch. 22, p. 817

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?

Sims position ricci, ch. 15, p. 416

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed rationale: When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction. ricci, ch. 22, p. 802

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice rationale: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression. ricci, ch. 15, p. 511

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother?

indirect Coombs' test rationale: The indirect Coombs' test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to evaluate for immunization and autoimmune disorders. ricci, ch. 16, p. 551

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly rationale: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime. ricci, ch. 22, p. 803

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony rationale: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad. ricci, ch. 22, p. 805

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?

"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. ricci, ch. 16, p. 549

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." rationale: Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the health care provider needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul-smelling both indicate a possible infection and the physician needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks. ricci, ch. 15, p. 525

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?

"It might take up to a week for your bowels return to their normal pattern." rationale: 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 to gain additional information. 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 healthcare provider is not necessary, and this statement could add to the client's current concern. ricci, ch. 16, p. 526

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?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." rationale: 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. ricci, ch. 16, p. 526

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." rationale: Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities. ricci, ch. 15, p. 533, 545, 547-549

The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?

"Ovulation may return as soon as 3 weeks after birth." rationale: Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth. ricci, ch. 15, p. 511

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." rationale: Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis. ricci, ch. 16, p. 551

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?

"Some women just can't breastfeed. Maybe I'm one of these women." rationale: 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. ricci, ch. 16, p. 545

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?

"Walking is the best way to prevent complications such as blood clots." rationale: The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education. ricci, ch. 16, p. 793

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort." rationale: Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness. ricci, ch. 15, p. 504

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply.

- Breasts are hard. - Breasts are tender. rationale: Engorged breasts are hard and tender, and the nurse should assess for these signs. Improper positioning of the infant on the breast, not engorged breasts, results in cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman. ricci, ch. 16, p. 525

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. - Encourage breastfeeding of the newborn infant on demand. - Place baby in uninterrupted skin-to-skin contact with the mother. rationale: 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. ricci, ch. 16, p. 543

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.

- Low self-esteem - Feeling overwhelmed and out of control - Low socioeconomic status - Lack of social support rationale: Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression. ricci, ch. 16, p. 820

When teaching an unlicensed assistant personnel (UAP) how to provide perineal care on a postpartum woman, the nurse would include which steps? Select all that apply.

- Place a protective pad under the client's buttocks. - Remove perineal pad in the direction of front to back. rationale: Before beginning perineal care, the nurse should be certain to wash the hands well and don clean, not sterile, gloves. The nurse should then place a plastic-covered pad under the woman's buttocks to protect the bed from lochia or water. With the woman lying supine, the nurse should remove the perineal pad from front to back. A common method of cleaning is to spray the perineum with clear tap water from a spray bottle. When doing this, the nurse should direct the spray toward the front of the perineum and allow it to flow from front to back, from the vaginal to the rectal area, to reduce cross-bacterial transmission into the vagina. The labia have a tendency to close and cover the vaginal opening, and the nurse should not separate the labia. ricci, ch. 16,p. 540

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

- inability to concentrate - loss of confidence - decreased interest in life rationale: The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis. ricci, ch. 22, p. 820

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply.

- previous oral contraceptive use - severe varicose veins - preeclampsia rationale: Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia. ricci, ch. 16, p. 528

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

- prolonged labor - uterine infection - hydraminos rationale: Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution. ricci, ch. 15, p. 502

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.

- vital signs of the mother - pain level - head to toe assessment rationale: 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. ricci, ch. 16, p. 523

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 on antithyroid medications - women on antineoplastic medications - women using street drugs rationale: 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. ricci, ch. 16, p. 543

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?

1 cm below the umbilicus rationale: The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone. ricci, ch: 15, p. 502

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider?

100.8°F (38.2°C) rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. ricci, ch. 16, p. 524

If a delivering mother weighed 140 pounds at the time of delivery, how much weight should she have lost when she goes home 2 days later, based upon the average pattern?

17-29 pounds rationale: Normal expected weight loss is approximately 12-14 pounds with the delivery of the fetus, placenta and amniotic fluid then an additional 5-15 pounds in the early postpartum period from fluid loss. ricci, ch. 15, p. 508

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

500 additional calories per day rationale: The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day. ricci, ch. 16, p. 542

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises. rationale: Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream. ricci, ch. 16, p. 540

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:

assess and massage the fundus. rationale: 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. ricci, ch. 16, p. 527

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony rationale: 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. ricci, ch. 16, p. 525

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. rationale: The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby. ricci, ch. 15, p. 505

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

Determine the newborn's blood type and rhesus. rationale: 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. ricci, ch. 16, p. 551

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begins to feel better. rationale: Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time. ricci, ch. 22, p. 813

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours. rationale: The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain. ricci, ch. 15, p. 509

The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?

Harm to self rationale: When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed. ricci, ch. 15, p. 720-723

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. rationale: The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority. ricci, ch. 15, p. 502

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection rationale: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration. ricci, ch. 22, p. 812

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

Inspecting posture, color, and respiratory effort rationale: The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age. ricci, ch. 16, p. 587

The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

Involution rationale: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor. ricci, ch. 15, p. 502

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?

Offer suggestions based on observation to correct positioning or latching. rationale: The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry. ricci, ch. 16, p. 533

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding. rationale: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps. ricci, ch. 22, p. 817

A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding?

Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. rationale: The nurse should reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience; this information will help to reduce the feelings of frustration and uncertainty about their ability to breastfeed. The nurse should also explain that breastfeeding is a learned skill for both parties. It would not be correct to say that breastfeeding is a mechanical procedure. In fact, the nurse should encourage the mother to cuddle and caress the newborn while feeding. The nurse should allow sufficient time to the mother and child to enjoy each other in an unhurried atmosphere. The nurse should teach the mother to burp the newborn frequently. Different positions, such as cradle and football holds and side-lying positions, should be shown to the mother. ricci, ch. 16, p. 544

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops. rationale: The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives. ricci, ch. 16, p. 541

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate. rationale: The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed. ricci, ch. 22, p. 813

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?

Sitz baths decrease pain and aid healing by increasing blood flow to the perineum. 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. ricci, ch. 16, p. 535

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. 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. ricci, ch. 16, p. 527

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus. rationale: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal. ricci, ch. 16,p. 793

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. rationale: Expected urinary output for a postpartum woman is at least 150 mL with each void on an hourly basis. Therefore 150 to 200 mL is a normal volume for each void. ricci, ch. 16, p. 537-438

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?

Walk with the nurse the length of her room. rationale: Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged. ricci, ch. 16, p. 533

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier. rationale: New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with. ricci, ch. 15, p. 537-538

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth rationale: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection. ricci, ch. 22, p. 815

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra rationale: The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks. ricci, ch. 15, p. 504

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia rationale: Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever. ricci, ch. 16, p. 524

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 rationale: 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. ricci, ch. 16, p. 529

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

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 primary care provider's order and is not necessary as a prevention measure. ricci, ch. 16, p. 526

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintaining 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. ricci, ch. 16, p. 540

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

dehydration rationale: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours. ricci, ch. 16, p. 524

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage rationale: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow. ricci, ch. 16, p. 524

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots rationale: If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis. ricci, ch. 15,p. 503

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

during the first 24 hours after birth owing to dehydration from exertion rationale: Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth 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. ricci, ch. 16, p. 524

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:

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 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. ricci, ch. 16, p. 547

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone?

estrogen rationale: The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis. ricci, ch. 15, p. 508

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?

fourth degree rationale: 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. ricci, ch. 16, p. 527

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 within 3 to 6 weeks rationale: 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. ricci, ch. 16, p. 541

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

hemorrhage rationale: Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention. ricci, ch. 16, p. 524

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

hypovolemia rationale: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements. ricci, ch. 15, p. 505

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation?

lochia rubra rationale: Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels. ricci, ch. 15, p. 503

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate rationale: Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage. ricci, ch. 15, p. 505

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 rationale: 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. ricci, ch. 16, p. 524

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 3-in (7.5-cm) lochia stain. This amount should be documented as which type?

light rationale: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-in (2.5- to 5-cm) stain, and light or small an approximately 3- to 4-in (7.5- to 10-cm) stain. Heavy or large lochia would describe a pad that is saturated within 1 hour. ricci, ch. 16, p. 527

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:

moderate rationale: 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. ricci, ch. 16, p. 527

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

one fingerbreadth below the umbilicus 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. ricci, ch. 16, p. 525

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 rationale: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation. ricci, ch. 16, p. 526

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 discourage unwrapping and exploring the infant rationale: 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. ricci, ch. 16, p. 531

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression rationale: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness. ricci, ch. 15, p. 514

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression. rationale: Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother. ricci, ch. 16, p. 720-723

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis rationale: The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues. ricci, ch. 22, p. 822

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in rationale: The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth. ricci, ch. 15, p. 514

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go. rationale: The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child. ricci, ch. 15, p. 514

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. 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. ricci, ch. 16, p. 525

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?

thromboembolic disorder of the lower extremities rationale: 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. ricci, ch. 16, p. 528

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching rationale: Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process. ricci, ch. 16, p. 529

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?

uterus is boggy 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. ricci, ch. 16, p. 526

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

venous duplex ultrasound of the right leg 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 would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency. ricci, ch. 16, p. 528

The nurse is preparing discharge training for a G2P2 client who will breast-feed her infant. The client mentions she wants more children but wants to wait a couple years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals?

when she resumes sexual activity rationale: She should use mechanical means of birth control as soon as she resumes sexual activity. She can ovulate even though she is not having a normal menstrual cycle. She needs to take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or as soon as she stops breast-feeding is not affording her protection from getting pregnant. ricci, ch. 15, p. 511

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white rationale: The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink. ricci, ch. 15, p. 503