Postpartum

11. A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? A. Assess vital signs every 4 hours B. Inform health care provider of assessment findings C. Measure fundal height every 4 hours D. Prepare an ice pack for application to the area.

11. Answer: D. Prepare an ice pack for application to the area. Application of ice will reduce swelling caused by hematoma formation in the vulvar area.

18. A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: A. Assess for hypovolemia and notify the health care provider B. Begin hourly pad counts and reassure the client C. Begin fundal massage and start oxygen by mask D. Elevate the head of the bed and assess vital signs

18. Answer: A. Assess for hypovolemia and notify the health care provider. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

19. A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? A. Massage the fundus B. Place the mother in the Trendelenburg's position C. Notify the physician D. Record the findings

19. Answer: C. Notify the physician. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided because it may interfere with cardiac function.

24. Which of the following factors might result in a decreased supply of breastmilk in a PP mother? A. Supplemental feedings with formula B. Maternal diet high in vitamin C C. An alcoholic drink D. Frequent feedings

24. Answer: A. Supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother's nipples affects hormonal levels and milk production.

31. Which of the following behaviors characterizes the PP mother in the taking in phase? A. Passive and dependant B. Striving for independence and autonomy C. Curious and interested in care of the baby D. Exhibiting maximum readiness for new learning

31. Answer: A. Passive and dependant. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs.

46. Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? A. Postural hypotension B. Temperature of 100.4°F C. Bradycardia — pulse rate of 55 BPM D. Pain in left calf with dorsiflexion of left foot

46. Answer: D. Pain in left calf with dorsiflexion of left foot. Pain in left calf with dorsiflexion of left foot indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.

5. The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A. Normal B. Indicates the presence of infection C. Indicates the need for increasing oral fluids D. Indicates the need for increasing ambulation

5. Answer: B. Indicates the presence of infection. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal.

50. Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B. Encourage the woman to void every 2 hours C. Massage the fundus every hour for the first 24 hours following birth D. Teach the woman the importance of rest and nutrition to enhance healing

50. Answer: C. Massage the fundus every hour for the first 24 hours following birth. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.

52. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby B. Recognize this as a behavior of the taking-hold stage C. Record the behavior as ineffective maternal-newborn attachment D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

52. Answer: D. Recognize this as a behavior of the taking-hold stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

8. A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: A. One the day of the delivery B. 3 days PP C. 7 days PP D. within 2 weeks PP

8. Answer: B. 3 days PP. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

9. Select all of the physiological maternal changes that occur during the PP period. A. Cervical involution occurs B. Vaginal distention decreases slowly C. Fundus begins to descend into the pelvis after 24 hours D. Cardiac output decreases with resultant tachycardia in the first 24 hours E. Digestive processes slow immediately.

9. Answer: A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution.

32. Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A. Retained placental fragments B. Urinary tract infection C. Cervical laceration D. Uterine atony

32. Answer: C. Cervical laceration. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting.

33. What type of milk is present in the breasts 7 to 10 days PP? A. Colostrum B. Hind milk C. Mature milk D. Transitional milk

33. Answer: D. Transitional milk. Transitional milk comes after colostrum and usually lasts until 2 weeks PP.

39. Which of the following physiological responses is considered normal in the early postpartum period? A. Urinary urgency and dysuria B. Rapid diuresis C. Decrease in blood pressure D. Increase motility of the GI system

39. Answer: B. Rapid diuresis. In the early PP period, there's an increase in the glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis.

7. A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: A. One peripad per day B. Two peripads per day C. Three peripads per day D. Eight peripads per day

7. Answer: D. Eight peripads per day. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.

2. A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A. Retake the temperature in 15 minutes B. Notify the physician C. Document the findings D. Increase hydration by encouraging oral fluids

2. Answer: D. Increase hydration by encouraging oral fluids. The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.

20. A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? A. Prothrombin time B. International normalized ratio C. Activated partial thromboplastin time D. Platelet count

20. C. Activated partial thromboplastin time. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control.

26. On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? A. Ask the client to empty her bladder B. Straight catheterize the client immediately C. Call the client's health provider for direction D. Straight catheterize the client for half of her uterine volume

26. Answer: A. Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.

27. The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? A. Lower than during her pregnancy B. Higher than during her pregnancy C. Lower than before she became pregnant D. Higher than before she became pregnant

27. Answer: C. Lower than before she became pregnant. PP insulin requirements are usually significantly lower than pre pregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.

28. Which of the following findings would be expected when assessing the postpartum client? A. Fundus 1 cm above the umbilicus 1 hour postpartum B. Fundus 1 cm above the umbilicus on a postpartum day 3 C. Fundus palpable in the abdomen at 2 weeks postpartum D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

28. Answer: A. Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in the abdomen after day 10.

30. On which of the postpartum days can the client expect lochia serosa? A. Days 3 and 4 PP B. Days 3 to 10 PP C. Days 10-14 PP D. Days 14 to 42 PP

30. Answer: B. Days 3 to 10 PP. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

34. Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? A. Cervical laceration B. Clotting deficiency C. Perineal laceration D. Uterine subinvolution

34. Answer: D. Uterine subinvolution. Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution.

35. Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? A. The vaccine is safe in clients with egg allergies B. Breastfeeding isn't compatible with the vaccine C. Transient arthralgia and rash are common adverse effects D. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

35. Answer: D. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects

4. A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? A. Ask the client to turn on her side B. Ask the client to lie flat on her back with the knees and legs flat and straight. C. Ask the mother to urinate and empty her bladder D. Massage the fundus gently before determining the level of the fundus.

4. Answer: C. Ask the mother to urinate and empty her bladder. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.

40. During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make? A. The client appears interested in learning about neonatal care B. The client talks a lot about her birth experience C. The client sleeps whenever the neonate isn't present D. The client requests help in choosing a name for the neonate.

40. Answer: A. The client appears interested in learning about neonatal care. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.

41. Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? A. Hypertension B. Cervical and vaginal tears C. Urine retention D. Endometritis

41. Answer: C. Urine retention. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.

42. Which type of lochia should the nurse expect to find in a client 2 days PP? A. Foul-smelling B. Lochia serosa C. Lochia alba D. Lochia rubra

42. Answer: D. Lochia rubra

43. After the expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of Pitocin is ordered. The nurse understands that this is indicated for this client because: A. She had a precipitate birth B. This was an extramural birth C. Retained placental fragments must be expelled D. Multigravidas are at increased risk for uterine atony.

43. Answer: D. Multigravidas are at increased risk for uterine atony. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.

1. A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: A. Every 30 minutes during the first hour and then every hour for the next two hours. B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. C. Every hour for the first 2 hours and then every 4 hours D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

1. Answer: 2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

10. A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? A. Complaints of a tearing sensation B. Complaints of intense pain C. Changes in vital signs D. Signs of heavy bruising

10. Answer: C. Changes in vital signs. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma.

12. A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: A. Monitor fundal height B. Apply perineal pressure C. Prepare the client for surgery. D. Reassure the client

12. Answer: C. Prepare the client for surgery. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.

13. A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A. A temperature of 100.4*F B. An increase in the pulse from 88 to 102 BPM C. An increase in the respiratory rate from 18 to 22 breaths per minute D. A blood pressure change from 130/88 to 124/80 mm Hg

13. Answer: B. An increase in the pulse from 88 to 102 BPM. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume.

29. A client is complaining of painful contractions, or after pains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains? A. Bottle-feeding B. Diabetes C. Multiple gestation D. Primiparity

29. Answer: C. Multiple gestation. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains.

3. The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? A. Obtain hemoglobin and hematocrit levels B. Instruct the mother to request help when getting out of bed C. Elevate the mother's legs D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided.

3. Answer: B. Instruct the mother to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed.

36. Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications? A. Increase B. Decrease C. Remain the same as before pregnancy D. Remain the same as during pregnancy

36. Answer: B. Decrease. The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin during the first few PP days.

37. Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health? A. Mothers with diabetes who breastfeed have a hard time controlling their insulin needs B. Mothers with diabetes shouldn't breastfeed because of potential complications C. Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled. D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

37. Answer: D. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to breastfeed.

38. On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? A. Depression phase B. Letting-go phase C. Taking-hold phase D. Taking-in phase

38. Answer: D. Taking-in phase. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives.

6. When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? A. Document the findings B. Notify the physician C. Reassess the client in 2 hours D. Encourage increased intake of fluids.

6. Answer: B. Notify the physician. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

14. A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? A. Massage the fundus until it is firm B. Elevate the mother's legs C. Push on the uterus to assist in expressing clots D. Encourage the mother to void

14. Answer: A. Massage the fundus until it is firm. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus.

15. A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? A. Paleness of the calf area B. Enlarged, hardened veins C. Coolness of the calf area D. Palpable dorsalis pedis pulses

15. Answer: B. Enlarged, hardened veins. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

16. A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? 1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." 2. "I can use analgesics to assist in alleviating some of the discomfort." 3. "I need to wear a supportive bra to relieve the discomfort." 4. "I need to stop breastfeeding until this condition resolves."

16. Answer: D. "I need to stop breastfeeding until this condition resolves." In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation.

17. A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: A. Dysuria, ecchymosis, and vertigo B. Epistaxis, hematuria, and dysuria C. Hematuria, ecchymosis, and epistaxis D. Hematuria, ecchymosis, and vertigo

17. Answer: C. Hematuria, ecchymosis, and epistaxis. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

21. A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. A. Take the prescribed antibiotics until the soreness subsides. B. Wear supportive bra C. Avoid decompression of the breasts by breastfeeding or breast pump D. Rest during the acute phase 5. Continue to breastfeed if the breasts are not too sore.

21. Answers: B, D, and E. Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking analgesics to relieve discomfort. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra.

22. Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: A. Amount of lochia B. Blood pressure C. Deep tendon reflexes D. Uterine tone

22. Answer: B. Blood pressure. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

23. Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? A. Peripheral vascular disease B. Hypothyroidism C. Hypotension D. Type 1 diabetes

23. Answer: A. Peripheral vascular disease. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

25. Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? A. Applying ice B. Applying a breast binder C. Teaching how to express her breasts in a warm shower D. Administering bromocriptine (Parlodel)

25. Answer: C. Teaching how to express her breasts in a warm shower. Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.

44. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be: A. Soft, non-tender; colostrum is present B. Leakage of milk at let down C. Swollen, warm, and tender upon palpation D. A few blisters and a bruise on each areola

44. Answer: A. Soft, non-tender; colostrum is present. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.

45. Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: A. Return to pre-pregnant weight is usually achieved by the end of the postpartum period B. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-pound weight loss C. The expected weight loss immediately after birth averages about 11 to 13 pounds D. Lactation will inhibit weight loss since caloric intake must increase to support milk production

45. Answer: C. The expected weight loss immediately after birth averages about 11 to 13 pounds. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.

47. The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A. Place her on a bedpan to empty her bladder B. Massage her fundus C. Call the physician D. Administer Methergine 0.2 mg IM which has been ordered prn

47. Answer: B. Massage her fundus. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by options C and D, especially if the fundus does not become or remain firm with massage.

48. When performing a postpartum check, the nurse should: A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum B. Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen C. Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation D. Wash hands and put on sterile gloves before beginning the check

48. Answer: A. Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum. While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus.

49. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum B. Washes from symphysis pubis back to episiotomy C. Changes her perineal pad every 2 - 3 hours D. Uses the peri bottle to rinse upward into her vagina

49. Answer: D. Uses the peribottle to rinse upward into her vagina. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

51. When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth B. Exhibit a reduced attention span, limiting readiness to learn C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn D. Have reestablished her role as a spouse/partner

51. Answer: C. Express a strong need to review events and her behavior during the process of labor and birth. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response C. This stage lasts for as long as 4 to 5 weeks after birth.

53. Parents can facilitate the adjustment of their other children to a new baby by: A. Having the children choose or make a gift to give to the new baby upon its arrival home B. Emphasizing activities that keep the new baby and other children together C. Having the mother carry the new baby into the home so she can show the other children the new baby D. Reducing stress on other children by limiting their involvement in the care of the new baby

53. Answer: A. Having the children choose or make a gift to give to the new baby upon its arrival home.

54. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: A. Foster an active role in the baby's care B. Provide time for the mother to reflect on the events of and her behavior during childbirth C. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

54. Answer: B. Provide time for the mother to reflect on the events of and her behavior during childbirth. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.

55. All of the following are important in the immediate care of the premature neonate. Which nursing activity should have the greatest priority? A. Instillation of antibiotic in the eyes B. Identification by bracelet and footprints C. Placement in a warm environment D. Neurological assessment to determine gestational age

55. Answer: C. Placement in a warm environment