Exam 2

The nurse assesses a 2-day postpartum, breastfeeding client. The nurse notes blood on the mother's breast pad and a crack on the mother's nipple. Which of the following actions should the nurse perform at this time? 1. Advise the woman to wash the area with soap to prevent mastitis. 2. Provide the woman with a tube of topical lanolin. 3. Remind the woman that the baby can become sick if he drinks the blood. 4. Get the woman an order for a topical anesthetic.

2. A small amount of lanolin should be applied to the nipple after each feeding Using lanolin on the breasts is a type of moist wound healing. The lanolin is soothing and allows the nipple to heal without a scab developing on the surface of the nipple.

The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2ºF. 2. White blood cell count of 14,500 cells/mm3 3. Diaphoresis during the night. 4. Malodorous lochial discharge.

4. Malodorous lochial discharge Although a client may have a slight temperature elevation, an elevated white cell count, and/or be diaphoretic, all three symptoms are normally seen in the postpartum client. The only finding that would make a nurse suspect infection is the malodorous lochial flow.

Your patient, who gave birth to a 7-lbs baby boy 24 hours ago, is complaining of uterine cramping (after-pains). This is her 2nd baby and she is breastfeeding. Your assessment reveals a firm fundus at midline 1 cm below umbilicus. Select all nursing actions. a. Instruct patient to bottle-feed for 36h until cramping stops b. Place warm blanket on her abdomen c. Explain that these are normal for second-time mothers d. Offer patient acetaminophen with codeine so she can continue to breastfeed

B, C

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. What should the nurse advise the woman to do if she should palpate tender, hard nodules in her breasts? 1. Gently massage the areas toward the nipple especially during feedings. 2. Apply ice to the areas between feedings. 3. Bottlefeed for the next twenty-four hours. 4. Apply lanolin ointment to the areas after each and every breastfeeding

1. Gently massage the areas toward the nipple especially during feedings.

Intermittent positive pressure boots have been ordered for a client who had an emergency cesarean section. Which of the following is the rationale for that order? 1. Postpartum clients are high risk for thrombus formation. 2. Post-cesarean clients are high risk for fluid volume deficit. 3. Postpartum clients are high risk for varicose vein development. 4. Post-cesarean clients are high risk for poor milk ejection reflex.

1. This rationale is correct. Because of an elevation in clotting factors, all postpartum clients are at high risk for thrombus formation.

A breastfeeding woman calls the pediatric nurse with the following complaint: "I woke up this morning with a terrible cold. I don't want my baby to get sick. Which kind of formula should I give the baby until I get better?" Which of the following replies by the nurse is appropriate at this time? 1. "Any formula brand is satisfactory, but it is essential that it be mixed with water that has been boiled for at least 5 minutes." 2. "Don't forget to pump your breasts every 3 hours while you are feeding the baby the prescribed formula." 3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." 4. "In addition to feeding the baby

3. "The best way to keep your baby from getting sick is for you to keep breastfeeding him rather than switching him to formula." First, the baby has already been exposed to the mother and will continue being exposed to her even if she switches to formula. More important, however, is the fact that the mother will produce antibodies that will be consumed by the baby in the breast milk. The baby will, therefore, be more protected by breastfeeding.

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

3. Auscultate lung fields. It is important to auscultate for rales after a C/S. Because this client had general anesthesia during her surgery, she is high risk for pulmonary complications, including atelectasis and pneumonia.

A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis.

A client has just received Hemabate (carboprost) because of uterine atony not controlled by IV oxytocin. For which of the following side effects of the medication will the nurse monitor this patient? 1. Hyperthermia, vomiting, and diarrhea. 2. Hypotension and respiratory collapse. 3. Anasarca and fluid volume overload. 4. Palpitations, anxiety, and insomnia.

1. Hyperthermia, vomiting, and diarrhea Hemabate is an oxytocic agent that acts on the myometrial tissue of the uterus. During the postpartum, it acts directly at the site of placental separation to stop uncontrolled bleeding. Hemabate is a type of prostaglandin.

Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma? 1. Pain. 2. Bleeding. 3. Warmth. 4. Redness.

1. Pain. Because the blood is trapped under the skin, the most common symptom is pain from the blood pressing on the pain sensors.

The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss. A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH).

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery.

A client is receiving IV heparin for deep vein thrombosis. Which of the following medications should the nurse obtain from the pharmacy to have on hand in case of heparin overdose? 1. Vitamin K. 2. Protamine. 3. Vitamin E. 4. Mannitol.

2. Protamine.

A postpartum client has been diagnosed with deep vein thrombosis. For which of the following additional complications is this client high risk? 1. Hemorrhage. 2. Stroke. 3. Endometritis. 4. Hematoma.

2. The client is at high risk for stroke if a clot should travel to the brain through the vascular tree.

A mother, G4P4004, is 15 minutes postpartum. Her baby weighed 4595 grams at birth. For which of the following complications should the nurse monitor this client? 1. Seizures. 2. Hemorrhage. 3. Infection. 4. Thrombosis.

2. The client should be monitored carefully for signs of postpartum hemorrhage. The mother's uterus has been stretched beyond its expected capacity. The client is, therefore, at high risk for uterine atony, which could result in a postpartum hemorrhage.

A client is 10 minutes postpartum from a forceps delivery of a 4500-gram Down syndrome neonate over a right mediolateral episiotomy. The client is at risk for each of the following nursing diagnoses. Which of the diagnoses is highest priority at this time? 1. Ineffective breastfeeding. 2. Fluid volume deficit. 3. Infection. 4. Pain.

2. This is the priority nursing diagnosis. Because the baby is macrosomic, the client is high risk for uterine atony that could lead to heavy vaginal bleeding possibly resulting in fluid volume deficit.

In which of the following situations should a nurse report a possible deep vein thrombosis (DVT) even when the woman has a negative Homan's sign? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. One of the woman's calves is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.

3. Even with a negative Homan's sign, these findings—swelling, redness, and warmth—indicate presence of a DVT

The nurse is developing a standard care plan for the post-cesarean client. Which of the following should the nurse plan to implement? 1. Maintain client in left lateral recumbent position. 2. Teach sitz bath use on second postoperative day. 3. Perform active range of motion exercises until ambulating. 4. Assess central venous pressure during first postoperative day.

3. Perform active range of motion exercises until ambulating This will help prevent thromboembolism risk.

A nurse has administered Methergine (methylergonovine) 0.2 mg po to a grand multipara who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time.

3. The fundal response indicates that the medication was effective in contracting the uterus

The nurse notes the following vital signs of a postoperative cesarean client during the immediate postpartum period: 100.0ºF, P 68, R 12, BP 130/80. Which of the following is a correct interpretation of the findings? 1. Temperature is elevated, a sign of infection. 2. Pulse is too low, a sign of vagal pathology. 3. Respirations are too low, a sign of medication toxicity. 4. Blood pressure is elevated, a sign of preeclampsia.

3. The respiratory rate of 12 is well below normal. Peripartum clients' respiratory rates average 20 rpm

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. PO3 from cesarean delivery complains of firm and painful breasts.

3. This client should be assessed first. The hemoglobin level is well below normal.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every 1 ⁄2 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

4. "The physician should see you. Please come in whenever you are ready." The quantity of lochia discharge is usually described as scant, moderate, or heavy. A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Since this client's lochia has already changed to alba (whitish), it is especially concerning thatshe is now experiencing a heavy lochia rubra (reddish) flow.

Match each term with the correct definition of maternal adaptation stages. a. Passive, dependent b. Begins to see self as a mother c. Autonomous, seeking information

A - Taking in B - Letting go C - Taking hold

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold

ANS: A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant.

A postpartum client who had a vaginal birth asks the nurse, Will my cervix return to its previous shape before I had my baby? Which is the best response by the nurse? a. The cervix will now have a slitlike shape. b. The cervix will be round and smooth after healing occurs. c. The cervix will remain 50% effaced now that you have had a baby. d. The cervix will be slightly dilated to 2 cm for about 6 months.

ANS: A After vaginal birth, the external os has an irregular slitlike shape and may have tags of scar tissue. The external os of a childless woman is round and smooth, but after a vaginal birth it will not be round and smooth. During labor, the cervix effaces (thins) and dilates (opens) to allow passage of the fetus. Once the baby is born, the cervix will close and return to close to 100% effacement.

If the clients white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.

ANS: A An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding.

An expectant client, diagnosed with oligohydramnios, asks the nurse about what this condition means for the baby. Which statement should the nurse give to the client? a. Oligohydramnios can cause poor fetal lung development. b. Oligohydramnios means that the fetus is excreting excessive urine. c. Oligohydramnios could mean that the fetus has a gastrointestinal blockage. d. Oligohydramnios is associated with fetal central nervous system abnormalities.

ANS: A Because an abnormally small amount of amniotic fluid restricts normal lung development, the fetus may have poor fetal lung development. Oligohydramnios may be caused by a decrease in urine secretion

A husband calls the nurses station stating that his wife, who delivered last week, is happy one minute and crying the next. He says, She was never like this before the baby was born. Which should be the nurses initial response? a. Reassure him that this behavior is normal. b. Advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: A Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Postpartum blues are a normal process that is short-lived; no medical intervention is needed. Telling him to ignore the moods blocks communication and may belittle the husbands concerns. Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

Which best describes what occurs during the fetal period of development? a. Maturation of organ systems b. Development of basic organ systems c. Resistance of organs to damage from external agents d. Development of placental oxygen carbon dioxide exchange

ANS: A During the fetal period, the body systems grow in size and mature in function to allow independent existence after birth. Basic organ systems are developed during the embryonic period. The organs are always at risk for damage from external sources; however, the older the fetus, the more resistant will be the organs. The greatest risk is when the organs are developing. The placental system is complete by week 12, but that is not the best description of the fetal period.

The nurse observes a client on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which appropriate action should the nurse take? a. Hand the baby to the woman. b. Explain taking-in to the woman. c Offer to hand the baby to the woman. d. No action, because this situation is perfectly acceptable.

ANS: A During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision.

Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth

ANS: A Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding.

A pregnant client asks the nurse how her baby gets oxygen to breathe. What is the nurses best response? a. Oxygen-rich blood is delivered through the umbilical vein to the baby. b. Take lots of deep breaths because the baby gets all of its oxygen from you. c. You dont need to be concerned about your baby getting enough oxygen. d. The babys lungs are not mature enough to actually breathe, so dont worry.

ANS: A Oxygen-rich blood travels from the mothers circulatory system to the placenta and from the placenta to the umbilical vein (veins carry blood to the heart). From the vein, most of the oxygenated blood travels to the fetal liver or the inferior vena cava.

The postpartum client who continually repeats the story of her labor, birth, and recovery experiences is doing which? a. Making the birth experience real b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. Taking hold of the events leading to her labor and birth

ANS: A Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. She is in the taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not the needs of others.

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold c. Patient reports she took two sitz baths in 12 hours d. Edges of the perineal laceration are well approximated

ANS: A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum.

Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Client who is bottle feeding her first child d. Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone

The nurse is assessing a newborn immediately after birth. After assigning the first Apgar score of 9, the nurse notes two vessels in its umbilical cord. What is the nurses next action? a. Assess for other abnormalities of the infant. b. Note the assessment finding in the infants chart. c. Notify the health care provider of the assessment finding. d. Call for the neonatal resuscitation team to attend the infant immediately.

ANS: A The normal finding in the umbilical cord is two arteries and one vein. Two vessels may indicate other fetal anomalies. Notation of the finding is the appropriate next step when the finding is expected. The health care provider will need to be notified; however, the infant is the nurses primary concern and must be assessed for abnormalities first. The initial Apgar score is 9, indicating no signs of distress or need of resuscitation.

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

ANS: A The presence of a full bladder will displace the uterus.

Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM

ANS: A, B, C If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered.

Which are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a. Provide comfort and ample time for rest. b. Keep the baby wrapped to avoid cold stress. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way. e. Limit the amount of modeling so the mother doesnt feel insecure.

ANS: A, C, D Provide comfort and ample time for rest, because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. Position the infant in an en face position and discuss the infants ability to see the parents face. Face to face and eye to eye contact is a first step in establishing mutual interaction between the infant and parent. Point out the characteristics of the infant in a positive way: She has such pretty little hands and beautiful eyes. The baby should be kept warm, but parents should be assisted to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the toes, fingers, and body. The nurse should model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones.

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas

ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks.

The nurse is teaching prenatal clients about avoiding substances or conditions that can harm the fetus. Which should the nurse include in the teaching session? (Select all that apply.) a. Elimination of use of alcohol b. Avoidance of supplemental folic acid replacement c. Stabilization of blood glucose levels in a diabetic client with insulin d. Avoidance of nonurgent radiologic procedures during the pregnancy e. Avoidance of maternal hyperthermia to temperatures of 37.8 C (100 F) or higher

ANS: A, C, D, E The best action is for the pregnant woman to eliminate use of nontherapeutic drugs and substances such as alcohol. A woman who has diabetes should try to keep her blood glucose levels normal and stable before and during pregnancy for the best possible fetal outcomes. Nonurgent radiologic procedures may be done during the first 2 weeks after the menstrual period begins, before ovulation occurs. Exposure to temperatures of 37.8 C (100 F) or higher is not advised for the pregnant client. Folic acid supplements should be taken. All women of childbearing age should take at least 0.4 mg (400 mcg) of folic acid daily before and after conception because this has been found to reduce the incidence of neural tube defects by 50% to 70%.

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a. I will gently pat the perineum dry rather than wipe. b. I will only use the perineal bottle after bowel movements. c. I will use cold water in the perineal bottle as I cleanse. d. I will use the perineal bottle without touching the perineum.

ANS: A, D The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.

A nurse is conducting prenatal education classes for a group of parents. Which purposes should the nurse explain that are performed by the amniotic fluid? (Select all that apply.) a. Cushions the fetus b. Protects the skin of the fetus c. Provides nourishment for the fetus d. Allows for buoyancy for fetal movement e. Maintains a stable temperature for the fetus

ANS: A, D, E The amniotic fluid provides cushioning for the fetus against impacts to the maternal abdomen. It provides a stable temperature and allows room and buoyancy for fetal movement. Vernix caseosa, the cheeselike coating on the fetus, provides skin protection. The placenta provides nourishment for the fetus.

The nurse is teaching a nonbreastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended . d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production.

In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth? a. Quantity of lochia rubra b. Pain management techniques c. Frequency of vital signs and fundal checks d. Assessment of infection risk from loss of skin integrity

ANS: B A cesarean section is major surgery. Pain relief is provided in various ways, including patient-controlled analgesia and oral and intramuscular analgesics.

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad

ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: Scant less than a 1-inch stain on the peripad Light 1- to 4-inch stain Moderate 4- to 6-inch stain Heavy saturated peripad Excessive saturated peripad in 15 minutes

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. I may not have a bowel movement until the 2nd postpartum day. b. If I breastfeed and supplement with formula, I wont need any birth control. c. I know my normal pattern of bowel elimination wont return until about 8 to 10 days. d. If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband.

ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formul

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention.

The nurse is planning a prenatal class on fetal development. Which characteristics of prenatal development should the nurse include for a fetus of 24 weeks, based on fertilization age? (Select all that apply.) a. Ear cartilage firm b. Skin wrinkled and red c. Testes descending toward the inguinal rings d. Surfactant production nears mature levels e. Fetal movement becoming progressively more noticeable

ANS: B, C, E A fetus of 24 weeks, based on fertilization age, will have wrinkled and red skin, testes descending toward inguinal rings, and the fetal movement becoming progressively more noticeable. Surfactant production nearing the mature levels does not occur until 32 weeks and ear cartilage is not firm until 38 weeks.

The nurse is explaining genetics to a group of nursing students. Which are autosomal recessive disorders that the nurse should include in the teaching session? (Select all that apply.) a. Hemophilia b. Cystic fibrosis c. Sickle cell disease d. Turners syndrome e. Phenylketonuria (PKU) disease

ANS: B, C, E Cystic fibrosis, sickle cell disease, and PKU disease are autosomal recessive disorders. Hemophilia and Turners syndrome are X-linked genetic disorders.

The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

ANS: B, D, E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa).

Which is the best measure to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles

ANS: C Activity can aid the movement of accumulated gas in the gastrointestinal tract

A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurses best response? a. You have pitting edema in your ankles. b. You have deep tendon reflexes rated 2+. c. You have calf pain when the nurse flexes your foot. d. You have a fleshy odor to your vaginal drainage.

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits.

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38 C (100.4 F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38 C (100.4 F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis.

When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage.

The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate. b. Document the finding. c. Encourage the use of an incentive spirometer. d. Ambulate the client around the nurses station.

ANS: C Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth.

Which action should the nurse do to provide support and encouragement to the new postpartum client? a. Recount how she solved her own problems. b. Correct the new mother at every opportunity. c. Praise the mothers early attempts at infant care. d. Explain to the new mother that everything will be fine.

ANS: C Positive reinforcement of the mothers attempt to provide care to the newborn will promote a healthy self-concept. The mother needs to learn how to solve problems on her own.

The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact? a. Any body fluids b. Any client at any time c. Blood and blood products d. Any client suspected of being HIV-positive

ANS: C Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids. Only certain body fluids can cause contamination.

A postpartum client asks, Will these stretch marks go away? Which is the nurses best response? a. No, never. b. Yes, eventually. c. They will fade to silvery lines but wont disappear completely. d. They will continue to fade and should be gone by your 6-week checkup.

ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines.

The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patients chart.

ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately.

A postpartum nurse is observing a client holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. Which action should the nurse should take? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

ANS: C The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate as parents. This is normal for an adjusting family.

A postpartum client who is a gravida 4, para 4, comes to the office for her 6-week postpartum checkup. Her presentation is untidy and unkempt. The client states that she is not sleeping well and relates that she feels overwhelmed at times. According to the client, family members responses have been nonsupportive. What recommendations would you advise to help the client at this time? a. Tell the client that this is a normal reaction to an increase in family size and that listening to music can help relieve anxiety. b. Tell the client to increase her exercise pattern because that will promote a sense of well-being. c. Make appropriate referrals for psychological intervention counseling because the client is exhibiting high-risk symptoms. d. Record the clients vital signs as part of the ongoing assessment and offer relaxation strategies as a method of support.

ANS: C This client is exhibiting symptoms that are consistent with postpartum depression, so she should be given priority intervention to maintain client safety.

The nurse is explaining the function of the placenta to a pregnant client. Which statement indicates to the nurse the need for further client teaching? a. My baby gets oxygen from the placenta. b. The placenta functions to help excrete waste products. c. The nourishment that I take in passes through the placenta. d. The placenta helps maintain a stable temperature for my baby.

ANS: D Amniotic fluid and not the placenta helps with thermoregulation. The remaining statements are correct regarding placental function.

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client.

The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a. Check for edema. b. Check for range of motion. c. Check for adequate reflexes. d. Check for deep vein thrombosis.

ANS: D Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion. b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence.

ANS: D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles.

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white.

6. Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle.

A client who is 16 weeks pregnant with her first baby asks how long it will be before she feels the baby move. Which is the nurses best answer? a. You should have felt the baby move by now. b. The baby is moving, but you cant feel it yet. c. Some babies are quiet and you dont feel them move. d. Within the next month you should start to feel fluttering sensations.

ANS: D Maternal perception of fetal movement (quickening) usually begins between 17 and 20 weeks after conception. Because this is her first pregnancy, movement is felt toward the later part of the 17 to 20 weeks

A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of: a. increased estrogen. b. increased progesterone. c. decreased human placental lactogen. d. decreased melanocyte-stimulating hormone.

ANS: D Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurses best response? a. When did these symptoms begin? b. Sounds like normal postpartum depression. c. Are you having trouble getting enough sleep? d. Are you able to get out of bed and provide care for your baby?

ANS: D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response Sounds like postpartum depression does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression.

If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

ANS: D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months

Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow d. Fundus below the symphysis and not palpable

ANS: D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable

Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history? a. Client has not been pregnant. b. Client has had a C section as a method of birth. c. Client has been treated for an STD with resultant scarring of the cervix. d. Client has a history of pregnancy.

ANS: D With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth.

A nurse is providing discharge teaching to a postpartum patient who is bottle feeding. The patient asks the nurse when she should expect to have her period return. The nurse's best response is: a. You can expect to have your period in 3-4 weeks b. Most women who choose not to breastfeed will have a period in 7-9 weeks after childbirth c. Your period will return at about 6 months d. Bottle feeding suppresses ovulation, so as long as you bottle feed, you will not have a period

B

Your postpartum client is 10 hours post-birth. She experienced an uncomplicated labor and birth and her newborn is full-term with Apgar score of 9. During assessment, you note that she was hungry and very interested in telling you about her birth experience. You had to remind her to change her baby's diaper and to feed her baby. Based on this assessment, you determine that she is: a. Having difficulty bonding with her baby b. Not concerned about baby's needs c. In the "Taking-In" phase d. In the "Taking-Hold" Phase

C. In the Taking-In phase

The nurse assists a patient who delivered vaginally 6h ago to the bathroom to void for the first time since delivery. The patient voids 65 mL of urine. The nurse's initial action is to: a. Document this as a normal finding b. Encourage patient to void again within next 4-6h c. Insert indwelling Foley catheter d. Palpate for bladder distention

D

Your postpartum patient is a 25-year-old, white, single woman who gave birth to a healthy infant. She is 36h post-birth. You note that she holds her infant at a distance and refers to her infant as "it." Based on this assessment, your initial nursing aciton is: a. obtain referral for a social worker b. ask the woman to tell you about her pregnancy and childbirth experience c. teach her the importance of holding her baby close to her body d. take her baby to the nursery so she can have uninterrupted sleep

b. Ask the woman to tell you about her pregnancy and childbirth experience

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patients chart.

d. Document the finding in the patients chart.