CHAPTER 12: POSTPARTUM PHYSIOLOGICAL ASSESSMENT
A postpartum nurse is caring for a client who gave birth 1 hour ago following a 24-hour long induction. The client had an epidural for pain control during labor. What assessment finding should immediately be reported to the health-care provider? A. UTERINE ATONY B. BILATERAL LOWER EXTREMITY NUMBNESS C. UNCONTROLLABLE SHAKING D. MODERATE VAGINAL BLEEDING
ANSWER: A
Immediately after birth, the nurse notes the client's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? A. DOCUMENT THE FINDING AS WITHIN NORMAL LIMITS B. PERFORM FUNDAL MASSAGE C. INSTRUCT THE WOMAN TO EMPTY HER BLADDER D. REASSESS EVERY 5 MINUTES
ANSWER: A
A nurse is caring for a client in the first hour following a vaginal delivery. What is the priority nursing intervention? A. FACILITATE BONDING BETWEEN THE MOTHER AND INFANT B. ASSESS THE FUNDUS FOR LOCATION, POSITION AND TONE C. ADMINISTER PAIN MEDICATIONS D. INSPECT THE PERINEUM FOR TEARING
ANSWER: A
When performing a fundal assessment on a client, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this client? A. MASSAGE THE FUNDUS WITH THE PALM OF THE HAND B. PLACE AN INDWELLING CATHETER C. NOTIFY THE PHYSICIAN OR MIDWIFE D. GIVE OXYTOCIN AS PER THE PHYSICIAN'S ORDER
ANSWER: A
The postpartum nurse is preparing to administer Rho (D) immune globulin (RhoGAM) to a post-cesarean section client on the mother-baby unit. What statements made by the client indicate an understanding of RhoGAM? Select all that apply. A. I NEED THIS BECAUSE MY BLOOD TYPE IS NEGATIVE AND MY BABY IS POSITIVE B. I WILL AVOID PREGNANCY FOR 4 WEEKS C. THIS MEDICATION WILL HELP PROTECT MY FUTURE BABIES D. I ONLY NEED TO GET THIS ONCE IN MY LIFETIME E. I NEED TO RECEIVE RHOGAM WITHIN 48 HOURS OF GIVING BIRTH
ANSWER: A & C
When educating a non-breastfeeding primiparous client, what information is important for the nurse to include? Select all that apply. A. WEAR A SUPPORTIVE BRA B. IF YOUR BREAST BECOME ENGORGED, YOU SHOULD PUMP TO RELIEVE THE PRESSURE C. DO NOT APPLY ICE PACKS TO THE BREAST BECAUSE IT WILL STIMULATE MILK PRODUCTION D. YOU CAN TAKE AN ANALGESIC FOR PAIN
ANSWER: A & D
A nurse is caring for a G2P2002 client in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this client? Select all that apply. A. ASSESS THE UTERUS FOR LOCATION, POSITION, AND TONE OF FUNDUS Q15 B. TITRATE IV OXYTOCIN INFUSION RATE TO UTERINE TONE C. PROVIDE INFO REGARDING AFTERPAINS D. ASSESS LOCHIA FOR COLOR, AMOUNT AND ODOR E. INSPECT THE INSIDE OF THE VAGINA FOR TEARING
ANSWER: A, B, C ,D
A postpartum nurse caring for a client who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this client? Select all that apply. A. ASSESS THE POSITION, TONE AND LOCATION OF THE FUNDUS B. MASSAGE A BOGGY UTERUS C. DOCUMENT FINDING AND REASSESS IN 1 HOURS D. QUANTIFY BLOOD LOSS E. INSTRUCT THE CLIENT TO VOID AND REEVALUATE
ANSWER: A,B,D,E
A postpartum client expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? A. BLOOD CLOTS DO NOT RUN IN FAMILIES SO YOU HAVE NOTHING TO WORRY ABOUT B. I UNDERSTAND YOUR CONCERN. LET'S TAKE A LOOK AT THE BACK OF YOUR LEGS TOGETHER C. WOMEN ARE ONLY AT RISK FOR DEVELOPING BLOOD CLOTS DURING PREGNANCY D. I WILL ASSIST YOU TO AMBULATE AROUND THE HALLWAY SO THAT DOESN'T HAPPEN
ANSWER: B
The nurse is doing her morning assessment on a G1P1 client who delivered 6 hours ago. The client has ambulated to the restroom and voided, has latched the infant twice with no discomfort, and has eaten 90% of her breakfast. Her fundus is below her umbilicus and firm, lochia is small to moderate, rubra is present, and she has a second-degree laceration. Which of the following is a nonpharmacological intervention appropriate for this client? A. ADMINSTER 600 MG IF IBPROFURN B. PROVIDE HER WITH A SITZ BATH AND EDUCATE HER ON ITS ISSUE C. PROVIDE HER WITH A BREAST PUMP D. PERFORM FUNDAL MASSAGE
ANSWER: B
A nurse is caring for a client in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. A. NOTIFY THE PHYSICIAN OR MIDWIFE OF EXCESSIVE BLOOD LOSS B. PERFORM FUNDAL MASSAGE C. TITRATE THE STANDING ORDER OF OXYTOCIN AS APPROPRIATE D. INCREASE FREQUENCY OF VITAL SIGNS
ANSWER: B, C, A, D
A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. A. YOU HAD A FEVER DURING LABOR AND THE ANTIBIOTICS HAVE NOT STARTED WORKING YET B. THE HARD WORK OF LABOR CAN CAUSE YOUR TEMPERATURE TO INCREASE C. IT IS COMMON FOR WOMEN TO EXPERIENCE MILD TEMPERATURE ELEVATION AFTER GIVING BIRTH D. YOUR BODY IS GOING THROUGH A LOT OF HORMONAL CHANGES RIGHT NOW, WHICH CAN INCREASE YOUR TEMPERATURE E. DO YOU FEEL HOT? I WILL GET YOU SOME TYLENOL
ANSWER: B, C, D
Which response by a postpartum client indicates to the nurse the client understands uterine involution? Select all that apply. A. MY UTERUS WILL STAY THIS BIG UNTIL MY PERIOD AGAIN B. IT WILL TAKE BETWEEN 6 AND 8 WEEKS FOR MY UTERUS TO REUTN TO NORMAL SIZE C. CONTRACTIONS WILL CAUSE MY UTERUS TO SHRINK D. IN ABOUT 7 WEEKS, I WON'T BE ABLE TO FEEL MY UTERUS E. IF THERE ARE ANY COMPLICATIONS LIKE INFECTION, MY UTERUS WON'T SHRINK AS MUCH
ANSWER: B,C,E
