HD-1

A client is 2 days postpartum and is experiencing bleeding. She asks the nurse, "Will it always be like this?" Which statement by the nurse would be the most accurate?

"This is lochia rubra and will last 3 to 4 days."

When reviewing self-care instructions with a postpartum client, the nurse emphasizes the need for the client to report heavy or excessive bleeding. The nurse would describe "heavy bleeding saturating one sanitary pad" within which time span?

1 hour

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.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority?

Ask the client when she last changed her perineal pad.

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?

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?

Demonstrating how to do cord care on the newborn

The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response?

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

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby?

Encourage the client to see, touch, and hold the dead neonate.

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?

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.

The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus?

Fundus two fingerbreadths below umbilicus and firm

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago?

Gently massage the fundus until it tones up

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple?

Stroke the neonate's lips gently with the nipple.

The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize?

Symptoms include fever, chills, malaise, and localized breast tenderness.

A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis. The nurse would also expect to assess an elevation in which of the following?

Temperature

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention?

The baby's lips smack.

A postpartum client has given birth to a healthy newborn by cesarean. Which information would the nurse most likely reinforce?

coughing and deep-breathing exercises

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?

identifies imperfections in the newborn's appearance

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which term best identifies the discharge?

lochia rubra

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

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition?

orthostatic hypotension

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

oxytocin

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?

postpartum diuresis

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?

postpartum hemorrhage

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony

The nurse is reviewing the medical record of a client who is 6 weeks postpartum and came for a follow up appointment with her health care provider. The client's uterus is enlarged and soft, and she is experiencing vaginal bleeding. Based on the findings, which condition would the nurse most likely suspect?

uterine subinvolution

A client has just given birth to her first child. The client is Rho(D)-negative and her baby is Rh-positive. At which time would the nurse most likely expect Rho(D) immune globulin IM to be given to the mother to reduce the risk of Rh incompatibility?

within 72 hours

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?

"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."

The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her?

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

A new mother who's breast-feeding asks how she can quickly lose the 40 lb she gained during pregnancy. Which response by the nurse is best?

"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."

During the assessment, the nurse observes a separation of the rectus muscle that is more than two fingerbreadths wide. Which instruction should the nurse offer the client?

Avoid lifting heavy objects

The nurse assesses a postpartum patient's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia?

Lochia rubra

A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period?

She did her perineal care independently.

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?

Sudden onset of shortness of breath

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

less than after a vaginal birth.

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."

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

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

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

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

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

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

The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?

"It's inappropriate to refuse this assignment; all clients should be treated equally."

One week after giving birth, a client comes to the clinic for a check up. The client tearfully tells the nurse, "I should feel happy, but I don't. What's wrong with me?" Which response by the nurse would be best?

"It's not unusual to have these feelings after giving birth."

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?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

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

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?

"Your body is undergoing many changes that cause your bladder to fill quickly."

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?

100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum

A nurse is making a home visit to a new mother who gave birth vaginally five days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks what the average weight loss at 5 days into the postpartal period is. Which information would the nurse incorporate into the response?

19 lb

Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)?

A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as mother by going through a series of four developmental stages. What is one of them?

Achieving a maternal identity

The nurse is doing discharge teaching with the parents of a baby. It is their second child. The nurse explains about sibling regression and offers ways to deal with regressive behavior. What is this called?

Anticipatory guidance

A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which of the following nursing action should the nurse take?

Ask the father if he would want to talk about his feelings regarding the newborn and being in the intensive care.

A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery?

Assess for calf redness and edema.

The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important?

Assessing fundal tone and lochia flow

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take?

Encourage the client to breast feed the baby more frequently and regularly.

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution?

Encourage the mother to breast feed.

A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?

Ensure the baby empties the breasts at each feeding

The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?

Harm to self

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?

Have the client void, and then massage the fundus until it is firm.

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client?

Height of fundus

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize?

Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client?

Her bladder for distension

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?

Homans sign

Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process?

Kissing, embracing, and caring for the infant

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which terms best identifies the discharge?

Lochia rubra.

What two elements play the biggest role in becoming a mother after delivery of her newborn?

Love and attachment to the child and engagement with the child

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding?

Massage the fundus.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate?

Massage the uterine fundus gently.

A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take?

Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.

On her third postpartum day, a client says she has chills and aches. Her chart shows that she has had a temperature of 38.1° C (100.6° F) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do first?

Obtain a vaginal swab for culture

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

Perineum

A 17-year-old woman is living with a 21-year-old man. The man often comes home drunk and then becomes jealous. He refers to the woman as lazy, stupid, and useless and makes accusations about her talking with people while he is working to support her. He rarely hits her. Given this history, the nurse recognizes this client is at risk for which condition associated with pregnancy?

Postpartum depression

While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best?

Review the client's understanding of the procedure in private.

The nurse is reviewing the history of a postpartum client. Which history factor strongly suggests that this client will experience afterpains?

The client is a gravida 6, para 5.

A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause?

The client is experiencing a common effect due to a morphine-based anesthetic.

A multiparous postpartum client is being discharged 48 hours after a successful 16-hour vaginal birth of an 8-lb, 14-oz (4,036-g) neonate. The nurse notes that the mother is rubella-immune with Rh-positive blood type. When assisting with the discharge plan, which outcome would be the priority?

The client will verbalize the importance of reporting any change in character of lochia.

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 is reluctant to touch the newborn for fear of hurting her.

The nurse is checking for rooting reflex in a newborn. Which response should the nurse expect to see?

The neonate will turn the head to the side of the stroked cheek.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding?

Two fingerbreadths below the umbilicus

A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?

Use the football hold to avoid incisional discomfort.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

Using a peri bottle to clean the perineum after each voiding or bowel movement

When developing a plan of care for a postpartum client, the nurse would identify which of the following as an expected outcome?

Vital signs within acceptable limits

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?

Wear a well-fitting bra.

The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues?

a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?

attachment

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

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation?

blood pressure 90/50 mm Hg

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

cannot be palpated

The nurse is caring for a client is who 24-hours post delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?

hemoglobin and hematocrit

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?

improves pelvic floor tone

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?

increased coagulation factors

A new mother is discharged 16 hours after a vaginal birth. After reviewing the client's discharge instructions, the nurse determines that the teaching was successful when the client states that she will contact her health care provider if she develops which symptom?

increased flow of bright red lochia

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 heart rate

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

instructing her to apply ice packs to both breasts every other hour

The nurse is caring for a postpartum client with diabetes who has developed an infection. The nurse would monitor this client for which complication?

ketoacidosis

A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day?

red with moderate flow

A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

slit-like.

A nurse is providing care to a postpartum client. As part of the client's plan of care, the nurse reinforces the need to perform Kegel exercises based on which reason?

to promote blood flow, enabling healing and muscle strengthening

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 below the umbilicus

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition?

urinary tract infection