Chpt. 16"Nursing Management During the Postpartum Period"

"A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. a. Breasts are hard. b. Breasts are tender. c. Nipples are fissured. d. Nipples are cracked. e. Breasts are soft."

"Answer: a & b RATIONALE: Engorged breasts are hard and ten- der, and the nurse should assess for these signs. Improper positioning of the infant on the breast, not engorged breasts, results in cracked, blis- tered, fissured, bruised, or bleeding nipples in the breastfeeding woman."

"1. A nurse has been assigned to the care of a client who has just given birth. How fre- quently should the nurse perform the assess- ments during the first hour after delivery? a. Every 30 minutes b. Every 15 minutes c. After 60 minutes d. After 45 minutes"

"Answer: b RATIONALE: Postpartum assessment is typically performed every 15 minutes for the first hour. After the second hour, assessment is performed every 30 minutes. The client has to be monitored closely during the first hour after delivery; assess- ment frequencies of 45 or 60 minutes are too long." (MEd 309)

"3. During assessment of the mother during the postpartum period, what would alert the nurse that the client is likely experiencing uterine atony? a. Fundus feels firm b. Foul-smelling urine c. Purulent vaginal drainage d. Boggy or relaxed uterus" (MEd 77)

"Answer: d RATIONALE: A boggy or relaxed uterus is a sign of uterine atony. This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foul- smelling urine and purulent drainage are signs of infections but are not related to uterine atony. The firm fundus is normal and is not a sign of uterine atony." (MEd 309)

"7. Which of the following exercises should a nurse suggest to the client during the first day of postpartum? a. Abdominal exercises b. Buttock exercises c. Thigh-toning exercises d. Kegel exercises"

"Answer: d RATIONALE: Routine exercise should be resumed gradually, beginning with Kegel exercises on the first postpartum day. The client should be allowed to perform abdominal, buttock, and thigh-toning exercises only during the second week after deliv- ery and not earlier." (MEd 309)

"5. A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. Which of the following classifications will the nurse use to describe the laceration? a. First-degree laceration b. Second-degree laceration c. Third-degree laceration d. Fourth-degree laceration"

"Answer: d RATIONALE: The nurse should classify the lacera- tion as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall."

"4. The nurse observes a 2-in lochia stain on the perineal pad of a postpartum client. Which of the following terms should the nurse use to describe the amount of lochia present? a. Light b. Scant c. Moderate d. Large"

"Answer: b RATIONALE: "Scant" would describe a 1- to 2-in lochia stain on the perineal pad, or an approxi- mate 10-mL loss. "Light" or "small" would describe an approximate 4-in stain, or a 10- to Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Maternity and Pediatric Nursing, 2nd Edition. 25-mL loss. "Moderate" lochia would describe a 4- to 6-in stain, with an estimated loss of 25 to 50 mL. A large or heavy lochia loss would describe pad saturation within an hour after changing it." (MEd 309)

"A client who has given birth is being dis- charged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth? a. Avoid use of water-based gel lubricants. b. Resume intercourse if bright-red bleeding stops. c. Avoid performing pelvic floor exercises. d. Use oral contraceptives for contraception."

"Answer: b RATIONALE: The nurse should inform the client that intercourse can be resumed if bright-red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives." (MEd 310)

"2. A nurse, assigned to check the pulse, dis- cerns tachycardia in a postpartum client. Which of the following does it suggest? a. Pulmonary edema b. Atelectasis c. Excessive blood loss d. Pulmonary embolism"

"Answer: c RATIONALE: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss, infection, or underlying cardiac problems. Pulmonary edema, atelectasis, and pulmonary embolism are associated with out- of-normal-range changes in respiratory rate." (MEd 309)

"A nurse is assessing a client during the post- partum period. Which of the following indicate normal postpartum adjustment? Select all that apply. a. Abdominal pain b. Active bowel sounds c. Tender abdomen d. Passing gas e. Nondistended abdomen"

"Answer: b, d, & e RATIONALE: Finding active bowel sounds, verifi- cation of passing gas, and a nondistended abdo- men are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into."

"When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. a. Give newborns water and other foods to balance nutritional needs. b. Show mothers how to initiate breastfeed- ing within 30 minutes of birth. c. Encourage breastfeeding of the newborn infant on demand. d. Provide breastfeeding newborns with pacifiers. e. Place baby in uninterrupted skin-to-skin contact with the mother."

"Answer: b, c, & e RATIONALE: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns."

"A client has been discharged from the hos- pital after a cesarean birth. Which of the following is the most appropriate time for scheduling a follow-up appointment for the client? a. Within 3 weeks of hospital discharge b. Between 4 and 6 weeks after hospital dis- charge c. Within 2 weeks of hospital discharge d. Within 1 week of hospital discharge"

"Answer: c RATIONALE: The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge. One week after hospital discharge is too early for a follow-up visit, whereas 3 weeks after discharge is too long because the client can develop complications that would go undiagnosed. For clients with an uncomplicated vaginal birth, an office visit is usually scheduled for between 4 and 6 weeks after childbirth."

"6. A nurse is applying ice packs to the perineal area of a client who has had a vaginal deliv- ery. Which of the following interventions should the nurse perform to ensure that the client gets the optimum benefits of the procedure? a. Apply ice packs directly to the perineal area. b. Apply ice packs for 40 minutes continuously. c. Ensure ice pack is changed frequently. d. Use ice packs for a week after delivery.

"Answer: c RATIONALE: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after delivery." (MEd 309)

"A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobu- lin be injected in the mother? a. 72 b. 75 c. 78 d. 80"

"Answer: a RATIONALE: Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobu- lin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. It may be too late to administer Rh immunoglobulin after 72 hours."

"8. A first-time mother is nervous about breast- feeding. Which of the following interven- tions should the nurse perform to reduce maternal anxiety about breastfeeding? a. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. b. Explain that breastfeeding comes natu- rally to all mothers. c. Tell her that breastfeeding is a mechanical procedure that involves burping once in a while and that she should try finishing it quickly. d. Ensure that the mother breastfeeds the newborn using the cradle method."

"Answer: a RATIONALE: The nurse should reassure the moth- er that some newborns "latch on and catch on" right away, and some newborns take more time and patience; this information will help to reduce the feelings of frustration and uncertainty about their ability to breastfeed. The nurse should also explain that breastfeeding is a learned skill for both parties. It would not be correct to say that breastfeeding is a mechanical procedure. In fact, the nurse should encourage the mother to cuddle and caress the newborn while feeding. The nurse should allow sufficient time to the mother and child to enjoy each other in an unhurried atmo- sphere. The nurse should teach the mother to burp the newborn frequently. Different positions, such as cradle and football holds and side-lying posi- tions, should be shown to the mother." (MEd 309)

"9. A client who has a breastfeeding newborn complains of sore nipples. Which of the fol- lowing interventions can the nurse suggest to alleviate the client's condition? a. Recommend a moisturizing soap to clean the nipples. b. Encourage use of breast pads with plastic liners. c. Offer suggestions based on observation to correct positioning or latching. d. Fasten nursing bra flaps immediately after feeding."

"Answer: c RATIONALE: The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observa- tion to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry." (MEd 309)