318 #3 (3 wrong)

On the third day postpartum, which temperature is internationally defined as a postpartal infection? 104.2° F (40.1° C) 102.4° F (39.1° C) 99.6° F (37.5° C) 100.4° F (38° C)

100.4° F (38° C)

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 100 mL 500 mL 250 mL 300 mL

500 mL

When planning care for a postpartum client, the nurse is aware that which site is the mostcommon for postpartum infection? In the urinary bladder Up the reproductive tract Within the blood stream In the milk ducts

Up the reproductive tract

During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? Urinary elimination Being too tired to eat Elimination of solid wastes Breathing off fluid vapor

Urinary elimination

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis? redness in lower legs edema in perineal area diaphoresis increased lochia

redness in lower legs

A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize? "After birth it is easier to develop an infection in the urinary system; we need to see you today." "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues." "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." "This is normal; give it a few days and then call back."

"After birth it is easier to develop an infection in the urinary system; we need to see you today."

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? "You'll notice that your shoe size will increase." "Exercise will help to improve the muscles." "Expect the color to lighten somewhat." "You'll notice that this will fade to silvery lines."

"Exercise will help to improve the muscles."

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "I need to get your vital signs and check your fundus to be sure you are not going into shock." "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Bruising and swelling of the perineum often causes excessive urination." "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus."

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

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 alba. Call her caregiver if lochia moves from serosa to rubra. Call her caregiver if lochia moves from rubra to serosa. Call her caregiver if amount of lochia decreases.

Call her caregiver if lochia moves from serosa to rubra.

The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? Making eye contact with the baby Asking for assistance changing a diaper Breastfeeding the infant on demand Calling the baby "it" or "they"

Calling the baby "it" or "they"

The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? Tell him that it would be better not to hold the infant. Give him some photographs of the infant. Encourage him to discuss this with the mother first. Dress the infant in a T-shirt and diaper and let him hold the infant.

Dress the infant in a T-shirt and diaper and let him hold the infant.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. Redness Bleeding Discharge Edema Slight bruising

Edema Slight bruising

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

Frequently ask the client how her head feels. Elevate the head of the bed for several minutes before getting her up. Walk alongside the client to the bathroom.

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. Moderate saturation of peripad every 3 hours Fundus one fingerbreadth below the umbilicus Hypotonic bowel sounds Inverted nipples following breastfeeding Urination of 100 mL every 4 hours

Moderate saturation of peripad every 3 hours Fundus one fingerbreadth below the umbilicus

A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence? Frequently empty the bladder. Reduce fluid intake. Perform Kegel exercises. Perform aerobic exercises.

Perform Kegel exercises.

A woman gave birth yesterday to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. Which intervention would be the priority? Provide time for the mother to grieve for the loss of the perfect baby. Encourage the mother to care for herself. Have the mother wait for a day or two to visit the child in the nursery. Review the causes of a cleft palate with the mother.

Provide time for the mother to grieve for the loss of the perfect baby.

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. Remove perineal pad in the direction of front to back. Wash hands and put on a pair of sterile gloves. Place a protective pad under the client's buttocks. Separate labia and clean discharge using spray bottle. Place the client in high-Fowler's position.

Remove perineal pad in the direction of front to back. Place a protective pad under the client's buttocks. Separate labia and clean discharge using spray bottle

A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: involution. engrossment. mastitis. engorgement.

engorgement.

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? reduce lochia alleviate perineal pain promote uterine involution improve pelvic floor tone

improve pelvic floor tone

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? alleviates perineal pain reduces lochia improves pelvic floor tone promotes uterine involution

improves pelvic floor tone

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? stirrup injury during birth decreased red blood cell count increased white blood cell count increased coagulation factors

increased coagulation factors

After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factors? Select all that apply. labor augmentation null parity prolonged labor hydramnios placenta previa

labor augmentation hydramnios placenta previa

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? lochia normalia lochia serosa lochia rubra lochia alba

lochia rubra

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention? moist cloths baby wipes alcohol wipes peribottle and warm water

peribottle and warm water

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest? sleeping with the infant playing a recording of their voices at all times keeping the baby in the same room at all times promoting skin-to-skin contact on the chest

promoting skin-to-skin contact on the chest

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? "This line on my belly will go away over time." "I might lose some hair, but it will grow back." "My nipples won't be so dark after I give birth." "I can't wait for these stretch marks to disappear after I give birth."

"I can't wait for these stretch marks to disappear after I give birth."

The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her? "It is all right to suppress the urge to have a stool for a few days to allow my stitches to heal." "A good meal for me is cream of chicken soup, cheese toast and ice cream for dessert." "I will avoid medications for constipation such as psyllium (Metamucil) because it can upset the baby's stomach." "I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow."

"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow."

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? "We will be discussing birth control with our primary care provider to find the best method for us." "I'm going back on the pill as soon as the doctor okays it." "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." "We're going to use a barrier for the first few months and then decide what we want to do."

"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months."

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Tell me, are you seeing things that aren't there, or hearing voices?" "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." "You may have developed mastitis. I'll ask the primary care provider to examine you." "It takes about 3 days after birth for milk to begin forming." "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in."

"It takes about 3 days after birth for milk to begin forming."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? "You don't have to worry about that now. It'll be quite a while." "You won't have to worry about it returning for at least 3 months." "It's difficult to say, but it will probably return in about 2 to 3 weeks." "It varies, but you can estimate it returning in about 7 to 9 weeks."

"It varies, but you can estimate it returning in about 7 to 9 weeks."

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? "Stop breastfeeding until the pain and swelling subside." "Try applying warm compresses to your breasts to encourage the milk to be released." "Limit the amount of fluid you drink so your breasts don't get much fuller." "You'll need to take this medication to stop the milk from being produced."

"Try applying warm compresses to your breasts to encourage the milk to be released."

Which action would most make the nurse believe that a postpartum woman is accepting a child well? She comments that her baby has the most hair of any in the nursery. She asks the nurse to use her camera to take a photo of the child. She turns her face to meet the infant's eyes when she holds her. She states she has named the child after a well-loved friend.

She turns her face to meet the infant's eyes when she holds her.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To answer questions the new parents may have To check for postpartum hemorrhage To monitor the mother's blood pressure to note any elevations To determine if the mother's milk is coming in

To check for postpartum hemorrhage

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? Consistency, location, and place Consistency, shape, and location Content, lochia, place Location, shape, and content

Consistency, shape, and location

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply. Use a bottle to feed the infant until the pain and tenderness subside. Until antibiotics are completed, pump the left breast and dispose of the milk. Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply? Take cold baths. Empty the breasts frequently. Apply ice to the breasts. Perform Kegel exercises.

Empty the breasts frequently.

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? Endometritis Episiotomy infection Subinvolution Mastitis

Endometritis

A nurse is developing a plan of care for a woman who has had a spontaneouls vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Third stage of labor of 10 minutes Labor induction with oxytocin Hemoglobin 10.0 g/dL (100.0 g/L) Forceps birth Labor of 1 1/2 hours

Hemoglobin 10.0 g/dL (100.0 g/L) Forceps birth Labor of 1 1/2 hours

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication? She can walk without experiencing dizziness. Her hematocrit level is over 45%. Her urine output is over 50 mL/h. Her blood pressure is below 140/90 mm Hg.

Her blood pressure is below 140/90 mm Hg.

A young mother is at the office for her 6-week visit. She is still experiencing mild loch alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion? fleshy smell light brown discharge foul odor creamy discharge

foul odor

The nurse is caring for a client is who 24-hours post delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? hemoglobin and hematocrit iron level folic acid level blood type

hemoglobin and hematocrit

A nurse is reviewing the medical record of a postpartum client. The nurse identifies that the woman is at risk for a postpartum infection based on which information? Select all that apply. labor of 12 hours hemoglobin level 10 mg/dL history of diabetes rupture of membranes for 16 hours placenta requiring manual extraction

hemoglobin level 10 mg/dL history of diabetes placenta requiring manual extraction

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? uterine atony hematoma uterine inversion laceration

laceration

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

the level of the umbilicus.

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition? calcium depletion hyperglycemia varicose veins thromboembolism

thromboembolism

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect? subinvolution urinary tract infection uterine atony stress incontinence

urinary tract infection

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

uterine atony

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? iron deficiency diuresis uterine atony hemorrhoid

uterine atony