MNL: 5.1 pre and post

After instruction about episiotomy​ care, which primiparous client statement indicates successful​ teaching?

"I'll wipe the area from front to back using a BLOTTING motion"

Four hours after a vaginal​ delivery, the nurse is assisting a primiparous​ client, who had an epidural​ anesthesia, to the bathroom to void. The client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that is most likely caused by which of the​ following?

Decreased blood volume in the vascular system

The nurse knows that which of the following physiologic responses is considered normal in the early postpartum​ period?

Rapid diuresis

A postpartum​ client, who is Rh​ negative, delivers a newborn who is Rh positive. The nurse anticipates a provider​'s order for which of the​ following?

RhoGam 300 mcg IM

Which safety device is most appropriate for the nurse making home​ visits?

cell phone

A nurse is assessing a postpartum client​'s response to morphine administered through an epidural. The nurse collects the following vital​ signs: 98.6​°F ​temperature, 80​ pulse, and 11 respirations. What actions should the nurse ​take?

-administer Narcan according to policy -Administer oxygen -notify the health care provider

A postpartal client recovering from a deep vein thrombosis is being discharged. What areas of teaching on​ self-care and anticipatory guidance should the nurse discuss with the ​client? Select all that apply.

-elevate the affected limb -increase activity gradually -apply moist heat to the affected area

A postpartum client reports having difficulty voiding. Which strategies would the nurse suggest to promote urine ​elimination?

-encouraging voiding in the shower or during sit bath -administer pain medication -ensuring privacy when voiding -running water in the sink

A postpartum client with an episiotomy reports perineal pain. Which of the following nursing interventions would be helpful for this ​client? select all that apply

-sitz bath -topical anesthetic spray -intermittent ice packs

A primiparous client has been discharged from the hospital after delivering a 5 lb baby girl. How many days postpartum should she expect the home care nurse to​ visit?

3-6 days after discharge

Which percentage of postpartum clients experiences​ "postpartum blues"?

70-80%

The nurse observes several interactions between a mother and her newborn daughter. Which maternal behaviors should the nurse identify as evidence of​ mother-infant ​attachment? (Select all that apply)

Cuddles her daughter close to her Talks and coos to her daughter

A new mother asks the nurse about starting postpartum exercises. What exercise would be most appropriate to include in the nurse​'s ​instructions?

Flex the knees while sup, then inhale deeply and exhale while contracting the abdominal muscles

A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the flow rate of the IV fluids containing​ oxytocin, with no noticeable decrease in the​ bleeding, the nurse should anticipate the health care provider requesting which​ medication?

Methergine

The nurse is assessing the client and asks how they are feeling. In response to the​ nurse's question, the postpartum client​ states, "I am​ fine." The client then begins talking to the​ baby, changing the​ diaper, and asking infant care questions. The nurse determines that the client is in which postpartum phase of psychological​ adaptation?

Taking hold

What intervention should the nurse teach the breastfeeding mother who reports engorged​ breasts?

Teach how to express her breasts in a warm shower

The nurse is receiving shift report on several postpartum clients. Which of the following would alert the nurse to a possible risk for postpartum ​hemorrhage? Select all that apply.

The client had polyhydramnios. The client had a​ forceps-assisted delivery. The client had a precipitous labor.

The nurse is preparing to administer RhoGam to a postpartum client. Which of the following nursing interventions are appropriate when giving this ​medication? Select all that apply.

checking the lot number and expiration date of the medication verifying the clients identity verifying Rh status of the mother and newborn monitoring for adverse effects of medication

The nurse is assisting a postpartum client in the bathroom. What teaching would the nurse use to help promote hygiene and​ comfort?

cleaning the vulva and the perineum with a spray bottle of warm water after voiding

The nurse reviews a postpartum client​'s chart and notes the client may have Percocet for pain. The nurse will monitor for which complication of the​ medicine?

constipation

The nurse is explaining the stages of lochia to a mother who just delivered a baby. Which statement best describes lochia rubra to the​ mother?

contains a mixture of mucus, tissue debris, and blood

A client who delivered by cesarean section is having difficulty holding her infant comfortably in order to breastfeed. She asks for assistance from the home care nurse. What position for the infant would the nurse suggest to provide maximum comfort for the​ mother?

football hold Rationale The football hold is the most comfortable position for a mother who is breastfeeding after a cesarean delivery. In this position the mother is in ​semi-Fowler​'s ​position, supporting the infant​'s head in her hand and resting the infant​'s body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the infant easy access to the mother​'s breast. The scissors​ hold, cross-cradle​ hold, and cradle hold would all put pressure on the incision and be uncomfortable for the mother.

The nurse is performing a thorough fundal check during a postpartum assessment on a newly delivered mother. What components are included in a fundal​ assessment?

fundal consistency, location, and height

A mother of three children confides in the nurse that she is concerned about how her two children ages 1 and 3 will react to their new sister when she goes home. What would be the best suggestion the nurse can make for the mother to do when she goes home from the​ hospital?

have the father carry the newborn into the home so that the mother's arms are free to hug the other children

While making a home visit to a primiparous client and her​ 4-day-old daughter, the nurse observes the mother changing the infant​'s diaper. Before putting the new diaper​ on, the mother begins to apply baby powder to the infant​'s buttocks. Which statement about baby powder would the nurse make to the​ mother?

it may cause pneumonia to develop

A primiparous client who is​ bottle-feeding her infant asks the​ nurse, "When will my menstrual cycle​ return?" What response by the nurse would be most​ appropriate?

it will probably be 6-10 weeks before it starts again

The nurse is assessing the lochia on the​ client's perineal pad. Which finding should the nurse report to the health care​ provider?

large clots

A postpartum client states that she​ can't understand why she​ doesn't enjoy being with her baby.What should the nurse be most concerned​ about?

postpartum depression

A breastfeeding mother is visited by the home care nurse 2 weeks after delivery. The woman is febrile with flulike symptoms. Which statement regarding mastitis is​ correct?

symptoms include fever, chills, malaise, and localized breast tenderness

On the first postpartum night a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which phase of psychological​ adaptation?

taking in phase

The nurse is caring for a postpartum client who had a cesarean section 1 day ago. Which nursing interventions will help prevent stasis of lung fluids and respiratory ​infection? Select all that apply.

teaching the client to cough correctly encouraging the client to breath deeply providing education about the use of an incentive spirometer

A postpartum client tells the nurse that she would like to know about a birth control method she can start prior to discharge. What is an appropriate response from the​ nurse?

you should discuss different types of birth control with your health care provider

A multipara mother mentions to the nurse that she does not understand why her​ 3-year-old daughter is so aggressive toward her new baby brother.​ "All she talked about was having a baby brother before I​ delivered." The nurse reassures the mother by stating which of the​ following?

You need to hold and reassure your 3 yo that she is loved and has not been replaced

The nurse is caring for a woman 8 hours after a vaginal delivery. On​ assessment, the nurse finds the woman​'s fundus to be firm but she continues to have heavy vaginal bleeding. Which of the following would the nurse​ suspect?

a laceration

Postpartum depression occurs in approximately​ 19% of postpartum clients. Assessment for factors predisposing a client to postpartum depression should begin prenatally. Of the following​ clients, which one would the nurse consider most at risk for postpartum​ depression?

a primipara with a history of depression and lack of a supportive relationship

A mother who gave birth to a baby boy vaginally after Pitocin augmentation 2 weeks ago returns to the office concerned because her flow has increased and is red but not foul smelling. The nurse suspects subinvolution. Which of the following can the nurse identify as a risk factor for this ​complication? Select all that apply.

abnormally adherent placenta history of leiomyomas manual removal of the placenta

The nurse is caring for a client who had a cesarean section delivery. Which assessment finding will indicate to the nurse that the client may be ready to tolerate clear​ liquids?

active bowel sounds

In preparation for​ discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. What would the nurse include as the most appropriate time for resuming sexual​ intercourse?

after the PP follow-up visit with the health care provider

The nurse is assessing a client for postpartum blues. Which of the following feelings or behaviors might the nurse document in a client experiencing postpartum ​blues? Select all that apply.

anxious tearfulness fatigue overwhelmed

The nurse is providing discharge teaching for a formula feeding mother. Which of the following will promote comfort for breast​ engorgement?

applying ice bags

A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the​ breast, but the mother​'s nipples are extremely sore during and after each feeding. Which statement by the mother indicates the need for further instruction from the home care​ nurse?

as long as some of my nipple is in the baby's mouth, the baby will receive enough milk

The nurse is doing a postpartum assessment on a client who delivered 8 hours ago. On completing the fundal​ assessment, the nurse notes the fundus is situated in the left side of the abdomen. Which nursing action is most​ appropriate?

ask the client to empty her bladder

The home care nurse is assessing a new mother who delivered 5 days ago. The mother has a temperature of 100.9​°F. What condition in a postpartum mother may cause a fever not caused by​ infection?

breast engorgement

A postpartum client who delivered 2 days ago has developed endometritis. Which charting entry would the nurse expect to find in this​ client's chart?

cesarean birth performed secondary to arrest of dilation

The nurse is preparing to discharge a postpartum client and will include information about thrombophlebitis in the discharge teaching. Which signs of thrombophlebitis must the nurse educate the client to assess after discharge from the​ hospital?

local tenderness, heat, and swelling

At a home​ visit, the nurse assesses a neonate delivered vaginally at 42 weeks gestation 6 days​ ago, noting the following​ findings: frequent​ hiccups; loose, watery stool in​ diaper; red rash on​ face; and​ dry, peeling skin. Which of these findings warrants further​ assessment?

loose, watery stool in diaper

The nurse is assessing a postpartum client and finds the client​'s uterus to be boggy. Which of the following would be the most appropriate nursing​ action?

massage the fundus until firm

A patient reports painful​ contractions, or​ afterpains, on her second postpartum day. The nurse knows that which condition could increase the severity of​ afterpains?

multiparity

A postpartum client is recovering from a cesarean section and has taken Tylenol​ #3 for pain for 2 days. Which of the following client statements is concerning to the​ nurse?

my stomach feels funny; I may be constipated

The nurse is making​ follow-up calls to several postpartum clients. Which client should the nurse schedule to be seen​ immediately?

the client reports hearing voices talking about the baby

During a home visit a client reports of a​ reddened, swollen, and tender breast 10 days after delivery. Once this is confirmed on​ assessment, which of the following would the nurse​ advise?

these symptoms are suggestive of an inflammatory or infectious process and need immediate attention; the nurse should notify the health care provider

What should the nurse include in the plan of care for a client with postpartum​ depression? Select all that apply.

use a depression scale to assess the client's status provide resources and referrals as needed help facilitate bonding with the infant educate the client and family about signs of postpartum depression

The nurse is caring for four postpartum clients. The nurse would question a provider​'s order for administering the rubella vaccine to which​ client?

vaginal delivery, HIV pos

The night shift nurse gets report on four clients who delivered between​ 7:00 a.m. and​ 8:00 a.m. that morning. Which of the following clients would the nurse assess​ first?

vaginal delivery, episiotomy, has not voided since delivery

A client who had a cesarean section asks the nurse why she needs to ambulate. Which of the following is an appropriate response by the​ nurse?

walking will help prevent blood clots in your legs

The home care nurse is visiting a mother who is breastfeeding. The nurse is teaching the mother how to care for her breasts to prevent complications. What should the mother be taught to prevent cracked nipples while she is​ breastfeeding?

wash the nipples with water daily Rationale Nipples should be washed with water only​ (no soap) to prevent drying. Soothing cream should be applied after feeding. Emptying the breast during feeding sessions can prevent engorgement. Plastic bra liners could lead to skin breakdown of the breast tissue since they would not absorb any milk leakage and moisture would accumulate on the skin

A mother who is bottle feeding her newborn asks to be discharged 24 hours postdelivery because she has no insurance and has a​ 3-year-old at home. The hospital provides a complementary visit from the home care nurse for the newborn. When should the nurse schedule this visit to​ occur?

within 36-48 hours of discharge

The nurse is teaching a postpartum client about her nutritional needs. What statement is appropriate to​ include?

you should continue to take your prenatal vitamins

A new father shares his concern regarding how the baby will bond with him. He​ states, "I read in the baby book that feeding time is the best time to bond with your baby. My wife is breastfeeding our​ baby, so how can I bond with our​ son?" What other ways of connecting and strengthening the father​'s relationship with his son can the nurse teach the ​father? select all that apply

-Bathing the baby -Changing the baby's diaper holding and talking to his son

The nurse is evaluating the nursing care provided to a client with postpartum hemorrhage​ (PPH). Which of the following would be included in the nurse​'s ​evaluation? Select all that apply.

-The client verbalizes a decrease in anxiety. -The client verbalizes understanding of her condition. -Maternal-newborn interaction has been maintained. -Signs of PPH are detected and managed effectively.

The nurse is observing a new mother with her newborn. Which nursing interventions allow a new mother acquaint herself with her​ newborn? (Select all that apply)

-Unwraps the newborn and explores the babies extremities with her fingertips -Holds the newborn in her arms and states, "He has his daddy's nose" -Hodls the newborn so that she is direct face to face and eye to eye contact

The student nurse is shadowing a home health care nurse for the day. The nurse talks to the student about ways to establish a therapeutic relationship with the families she visits. What should the nurse include in her discussion with the ​student?

-review the mother and infants history including any problems during pregnancy, type of birth, problems during labor or PP and infant feeding choices -verbal and nonverbal communication should be congruent -convery regard and respect for the family by asking to be introduced to other family members who may be present at the time of the visit

A student nurse is shadowing a home health care nurse who is making postpartum visits. The student asks the nurse what is the average length of stay in the hospital for a​ cesarean-section client. What is the correct​ response?

3-4 days

A client has just been diagnosed with mastitis. Which of the following should the nurse place in highest priority for teaching the​ client?

Breastfeed from both breast