NURSE 420 MATERNITY PREPU

On assessment of a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which actions are immediately initiated? Select all that apply.

Assess the client's vital signs Palpate the client's fundus

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 primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort?

"Apply ice packs to your breasts to reduce the amount of milk being produced."

A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?

"He looks like a frog to me."

The nurse is instructing a postpartum patient on observations to report to the health care provider that could signify retained placental fragments. Which patient statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?

redness in lower legs

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 client diagnosed with pelvic organ prolapse is being taught how to perform pelvic floor muscle exercises. During the teaching session, the client asks the nurse, "How do these exercises help?" Which response by the nurse would be most appropriate?

"They help to increase the volume of your muscles which leads to stronger muscle contraction."

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."

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.

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 postpartum patient is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the patient about this medication? Select all that apply.

Be sure to engage in activity to aid in intestinal motility. This medication works the best when a high-fiber diet is consumed. Take each dose of the medication with a full glass of water or juice.

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?

Bladder distention

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

Document the finding, as it is a normal finding at this time.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm.

The nurse is caring for a 28-year-old client after the delivery of a healthy neonate. What would the nurse expect to find when assessing this client's fundus?

Fundus 1 cm above the umbilicus 1 hour postpartum

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

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.

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?

Health-seeking behaviors related to care of newborn

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?

Maintain correct posture and positioning.

Which condition should the nurse look for in the client's history that may explain an increase in the severity of afterpains?

Multiple gestation

A nursing student is preparing a class for new mothers about adaptations they can expect in their newborns. Which information about newborn vision should the student include in the presentation?

Newborns have the ability to focus only on objects in close proximity.

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

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

Showing increased confidence when caring for the newborn

A woman who is two days postpartum has painful hemorrhoids. Which of the following positions would you suggest she use for resting?

Sims' position

When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action?

The fundus is firm and deviated sharply to the right side of the abdomen.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?

atony

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

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 new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra

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

applying ice

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?

decreased intra-abdominal pressure

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from:

developing Rh sensitivity.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed?

docusate

A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:

engorgement.

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply.

identify common features between themselves and the newborn make direct eye contact with the newborn

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts

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

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication?

increased lochia drainage

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.

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor.

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?

oxytocin

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

oxytocin

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go.

During an assessment, the nurse notes that the client has been unable to urinate properly since giving birth and is bleeding more than expected. The nurse suspects which condition?

uterine atony

If a delivering mother weighed 140 pounds at the time of delivery, how much weight should she have lost when she goes home 2 days later, based upon the average pattern?

17-29 pounds

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

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