Chapter 17 After Delivery
oral temperature 100.8° F (38.2° C)
A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? oral temperature 100.8° F (38.2° C) pulse rate 75 beats per minute respiratory rate 16 breaths/minute uterine fundus 1 cm below umbilicus
"I can't wait for these stretch marks to disappear after I give birth."
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? "I can't wait for these stretch marks to disappear after I give birth." "I might lose some hair, but it will grow back." "This line on my belly will go away over time." "My nipples won't be so dark after I give birth."
temperature
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? redness temperature edema drainage
delayed hemorrhage
During a routine assessment the nurse notes the client is tachycardic. Which possible cause should be ruled out? delayed hemorrhage bladder distention extreme diaphoresis uterine atony
Ask the client when she last changed her perineal pad
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? Vigorously massage the fundus Immediately call the primary care provider Have the charge nurse review the assessment Ask the client when she last changed her perineal pad
taking-in, taking-hold, letting-go
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking, holding-on, letting-go. taking-in, holding-on, letting-go. taking-in, taking-hold, letting-go. taking-in, taking-on, letting-go.
policies that discourage unwrapping and exploring the infant
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 policies that allow rooming the infant and mother together policies that allow visitors policies that allow flexibility for cultural differences
vaginal dryness after the lochial flow has ended
The nurse is providing discharge instructions to a postpartum client after a vaginal birth. The nurse should inform the client that she may experience which normal finding? Redness or swelling in the calves A palpable uterine fundus beyond 6 weeks Vaginal dryness after the lochial flow has ended Dark red lochia for approximately 6 weeks after the birth
2 weeks
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? 1 week 2 weeks 3 weeks 4 weeks.
determine the newborns blood type and rhesus
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. Determine if this is the client's first baby. Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy.
an ice pack applied to the perineum
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 narcotic pain medication a heating pad applied to the perineum a sitz bath
postpartum diuresis
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles
assess the fundus
A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? Assess vital signs. Assess the fundus. Notify the health care provider. Begin an IV infusion of Ringer's lactate solution.
True
The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth.
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
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? "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Let me show you how to calm him down. I've been doing this for many years." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?"
Have the client void, and then massage the fundus until it is firm.
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? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.
"It might take up to a week for your bowels to return to their normal pattern."
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 to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your healthcare provider about this problem."
taking hold phase
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the taking-in phase the taking-hold phase the binding-in phase the letting-go phase
the urinary output is normal
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 100 to 200 mL with each void. How would the nurse interpret this finding? The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is inadequate suggestive of urinary retention. The urinary output is normal. The urinary output is above expected levels.
"How much blood was on the two pads?"
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? "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "When did you last void?"
dehydration
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? infection dehydration change in the temperature from the birth room fluid volume overload
Assess the client's vital signs Palpate the client's fundus
On assessment of a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which actions are immediately initiated? Select all that apply. Begin an IV infusion of lactated Ringer's solution Assess the client's vital signs Palpate the client's fundus Place the client in high Fowler's position Administer a pain medication
Ask the client to empty her bladder
On completing fundal palpation, the nurse notes that the fundus is situated in the client's left abdomen. Which action is appropriate? Ask the client to empty her bladder Straight-catheterize the client immediately Call the client's primary health care provider for direction Straight-catheterize the client for half of her urine volume
increased heart hate
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 blood pressure increased cardiac output increased hematocrit level increased heart rate
hemoglobin and hematocrit
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? blood type folic acid level hemoglobin and hematocrit iron level
The color and amount of the lochia is normal and there are no concerns.
The nurse is checking the lochia of a new mother at her 2-week checkup. The mother reports that the lochia is a small amount, pale yellow with occasional tinges of brown. She also reports that it has fleshy odor to it. How would the nurse evaluate these findings? The lochia's odor indicates that an infection may be present and the doctor needs to be notified. The color and amount of the lochia is normal and there are no concerns. The brownish tinges indicate that the mother is regressing on the expected pattern of lochia and this is problematic. Lochia should have stopped by now, so this is definitely concerning for the nurse and should be reported.
place an ice pack
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 appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Notify a primary care provider. Apply a warm washcloth. Place an ice pack. Put on a witch hazel pad.
1 cm below the umbilicus
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? At level of umbilicus 1 cm above the umbilicus 1 cm below the umbilicus At the symphysis pubis
1 cm below umbilicus
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? At level of umbilicus 1 cm above the umbilicus 1 cm below the umbilicus At the symphysis pubis
Vaginal dryness after the lochial flow has ended
The nurse is providing discharge instructions to a postpartum client after a vaginal birth. The nurse should inform the client that she may experience which normal finding? Redness or swelling in the calves A palpable uterine fundus beyond 6 weeks Vaginal dryness after the lochial flow has ended Dark red lochia for approximately 6 weeks after the birth
Involution
The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery 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? Evolution Involution Decrement Progression
placing one hand at the base of the uterus, one on the fundus
When palpating for fundal height on a postpartal woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus placing one hand on the fundus, one on the perineum resting both hands on the fundus palpating the fundus with only fingertip pressure
hemorrhage
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? hemorrhoids hemorrhage thromboembolism cervical laceration
pelvic floor
When teaching a woman how to perform Kegel exercises, the client asks what muscles are being helped with these exercises. The nurse would include reference to which muscles in the response? gluteus lower abdominal pelvic floor diaphragmatic
bonding
When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? reciprocity engrossment bonding attachment
apply ice packs to the site
A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure? Offer warm blankets. Encourage the woman to void. Apply an ice pack to the site. Offer a warm sitz bath.
taking in phase
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 puerperium is this client in? taking-in phase taking-hold phase letting-go phase rooming-in phase
massage the fundus
A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation? Massage the fundus Take a blood pressure Call the provider Encourage the client to void
sims position
A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting? Supine Sims position Knee-chest position Trendelenburg position
encouraging the client to wear a supportive bra.
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. having the client stand facing in a warm shower. informing the primary care provider that the client is showing early signs of breast infection. using a breast pump to facilitate removal of stagnant breast milk.
Body secreting the excess fluids from pregnancy
A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client? Change in pregnancy hormone Body secreting the excess fluids from pregnancy The patient may be drinking too much fluid. The body is trying to get rid of the extra blood made during pregnancy.
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain. Encourage the mother to breast-feed to help relax the uterus.
Her stroke volume has increased after delivery of the placenta, and a physiologic response in blood pressure is evident.
A mother delivered 90 minutes ago and has just arrived on the postpartum unit. Her initial set of vital signs reveals blood pressure of 138/86 mm Hg. Her blood pressure during labor never rose above 128/74. mm Hg. What is a possible explanation for this increase in blood pressure? She is having an allergic reaction to Pitocin. Her stroke volume has increased after delivery of the placenta, and a physiologic response in blood pressure is evident. Her stroke volume should decrease after delivery; this reflects a pathologic adjustment of her blood pressure. The patient is excited to have a chance to sleep after the labor and delivery experience.
You should not lift anything heavier than your infant in its carrier.
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 be able to resume normal activities after 2 weeks. You should not lift anything heavier than your infant in its carrier. Only clean half of the house per day to allow yourself more rest. You need to hire a maid for the first month after delivery to help out around the house.
bringing the newborn into the room
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? talking about how the nurse held her own newborn while on the birthing table. showing a video of parents feeding their babies. allowing the mother to pick the best time to hold her newborn. bringing the newborn into the room.
"If you are breast-feeding, that will help make your uterus contract and get smaller."
A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breast-feeding, that will help make your uterus contract and get smaller." "I would recommend that you rest for a few days to allow your body to heal and get back to normal." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "There is really nothing you can do to speed along the progress, so just be patient."
The color of the flow is red
A nurse helps a postpartum woman out of bed for the first time postpartally 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 flow contains large clots. The flow is over 500 mL. Her uterus is soft to your touch. The color of the flow is red.
Monitor the client's vital signs. Get a pad count. Assess the client's uterine tone.
A nurse is assessing a client with postpartal 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. Assess the client's uterine tone. Monitor the client's vital signs. Assess the client's skin turgor. Get a pad count. assess deep tendon reflexes
Feed the baby at least every two or three hours
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. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.
possible experience of fluctuations in sexual interest use of a water-based lubricant to ease vaginal discomfort possibility of increased breast sensitivity during sexual activity
A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. resumption of sexual intercourse about two weeks after birth possible experience of fluctuations in sexual interest use of a water-based lubricant to ease vaginal discomfort use of combined hormonal contraceptives for the first three weeks possibility of increased breast sensitivity during sexual activity
bleeding
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? bleeding postpartal gestational hypertension infection diabetes
identifies imperfections in the newborn's appearance
A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? demonstrates pleasure when touching or holding the newborn identifies imperfections in the newborn's appearance is able to distinguish his newborn from others in the nursery shows feelings of pride with the birth of the newborn
The client states, "He has my eyes and nose."
A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding? The client states, "He has my eyes and nose." The client shows interest in caring for the newborn. The client performs self-care independently. The client confidently cares for the newborn.
improves 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? reduces lochia promotes uterine involution improves pelvic floor tone alleviates perineal pain
commmitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role
A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. 1commmitment, attachment, and preparation for an infant 2acquaintance with and increasing attachment to the infant 3moving toward a new normal routine 4achievement of the parental role
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.
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? shaking chills with a fever of 100.4° F (38° C) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. heart rate 70 bpm and excessive, soaking diaphoresis blood loss of 250 mL and WBC 25,000 cells/mL
pulmonary embolism
A nursing student learns that a certain condition in 1 in every 2,000 pregnancies is a major cause of death. What is this condition? infection hemorrhage pulmonary embolism hypertension
Wash her perineum with her daily shower.
A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? Avoid using soap for any perineal care. Wash her perineum with her daily shower. Use an alcohol wipe to wash her episiotomy line. Refrain from washing lochia from the suture line.
moderate lochia serosa
A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? nonpalpable fundus moderate lochia serosa bruising on arms and legs fever
docusate
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? ferrous sulfate methylergonovine docusate bromocriptine
Educate the client on how to perform Kegel exercises.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Determine if the client is emptying her bladder. Ask the client when she last urinated. Perform an in and out catheter on the client. Educate the client on how to perform Kegel exercises.
Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed."
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best? "It doesn't hurt when the midwife takes out the stitches. You will only feel a little tugging and pulling sensation." "It is very important for you to go to your checkup visit. Besides, the stitches do not have to be removed." "Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed." "Oh, you must not miss your follow-up appointment. Don't worry. Your midwife will be very gentle."
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5
Her uterus is at the level of the umbilicus.
Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution? Her uterus is 2 cm above the symphysis pubis. Her uterus is three finger widths under the umbilicus. Her uterus is at the level of the umbilicus. She experiences "pulling" pain while breastfeeding.
diuresis
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? diuresis lactation blood loss nausea
Homan's sign
You are the senior LVN/LPN on the unit and you are orienting a new graduate LVN/LPN. One of the subjects you want to cover today is a postpartum assessment for a vaginal delivery. What would you know to cover during this assessment? Nagal sign Hagar sign Chadwick sign Homans sign
uterine infection prolonged labor hydramnios
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. uterine infection prolonged labor hydramnios breastfeeding early ambulation empty bladder
assess the woman's fundus
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? Initiate Ringer's lactate infusion. Assess the woman's vital signs. Call the woman's health care provider. Assess the woman's fundus.
30-35 lbs
A primigravida client has presented for her first prenatal visit and is concerned about the potential weight gain and the struggle to lose the weight after the baby's birth. How much weight should the nurse recommend this client with a normal BMI gain during her pregnancy to ensure a healthy fetus? 15 to 20 lbs 20 to 25 lbs 30 to 35 lbs 10 to 15 lbs
two finger breadths below the umbilicus
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? two fingerbreadths above the umbilicus at the level of the umbilicus two fingerbreadths below the umbilicus four fingerbreadths below the umbilicus
by frequently assessing uterine involution
A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? by assessing skin turgor by assessing blood pressure by frequently assessing uterine involution by monitoring hCG titers
wear a well fitting bra
A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Apply warm compresses. Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing.
uterus is boggy
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? Percussion reveals tympani. Uterus is boggy. Lochia is less than usual. Bladder is nonpalpable.
"After birth it is easier to develop an infection in the urinary system; we need to see you today."
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? "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." "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues."
Inability of infant to empty breasts
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? cracking of the nipple improper positioning of infant inadequate secretion of prolactin inability of infant to empty breasts
Notify the RN; she will notify the provider.
The nurse is monitoring a client who is 3 hours postpatrum. On assessment the nurse notes a temperature of 102.4 oF. Which action should the LPN prioritize? Notify the RN; she will notify the provider. Administer an antipyretic. Assist the client in ambulation. Continue to monitor for another hour.
Administer naloxone per the preprinted orders.
The night shift LPN is checking on a woman who had a cesarean delivery with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first? Administer naloxone per the preprinted orders. Awaken the woman and instruct her to breathe more rapidly. Call the anesthesiologist from the room for orders. Perform bag-to-mouth rescue breathing at a rate of 12 per minute.
developing Rh sensitivity
The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from: becoming Rh positive. developing Rh sensitivity. developing AB antigens in her blood. becoming pregnant with an Rh-positive fetus.
beginning attachment and preparation for family
The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation? Maternal identify Physical restoration and learning to care for infant Shift in normal life to new normal Beginning attachment and preparation for family
Fundus 1 cm above the umbilicus 1 hour postpartum
The nurse is caring for a 28-year-old client after the delivery of a healthy neonate. What would the nurse expect to find when assessing this client's fundus? Fundus 1 cm above the umbilicus 1 hour postpartum Fundus 1 cm above the umbilicus on postpartum day 3 Fundus palpable in the abdomen at 2 weeks postpartum Fundus slightly to right; 2 cm above umbilicus on postpartum day 2
The mother is reluctant to touch the newborn for fear of hurting her.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The mother states that she has her father's eyes. The father holds the newborn en face and talks to her. The mother is reluctant to touch the newborn for fear of hurting her. The parents explore the newborn's extremities, counting fingers and toes. The parents explore the newborn's extremities, counting fingers and toes.
wear a tight supportive bra
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Run warm water over the breast in the shower. Massage the breasts when they are painful. Wear a tight, supportive bra. Express small amounts of milk when they are too full.
difficult to separate clots
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? yellowish-white lochia foul-smelling lochia easy to separate clots difficult to separate clots
rubra colored lochia
When assessing a client who is 5 days pospartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage? Oliguria Fundal tenderness Rubra colored lochia Increased rectal pressure
Uterine Atony (when the uterus fails to contract after birth)
Which factor puts a client on her first postpartum day at risk for hemorrhage? hemoglobin level of 12 g/dl uterine atony thrombophlebitis moderate amount of lochia rubra
apply ice
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine
a 35-year-old who had estimated blood loss of 700 mL and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated
Which postpartum client will the nurse assess first? an 18-year-old who wants to sleep until 10:00 before the nurse brings the infant for a visit a 35-year-old who had estimated blood loss of 700 mL and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated a 22-year-old who has been up, showered, and packing for discharge later today a 30-year-old postpartum client who had a cesarean birth and is sleeping following pain medication administration
