OB R&R ch 10 (the normal postpartal experience)
Which laboratory finding should the nurse assess further on a client 24 hours after delivery? 1. Hemoglobin 7.2 grams/dL 2. White blood cell count 20,000/mm3 3. Trace to 1+ proteinuria 4. Hematocrit 35%
Answer: 1 Rationale: A client with a hemoglobin of 7.2 grams/dL would most likely have significant signs and symptoms of anemia, and this could be life-threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. The hematocrit is within normal limits, and mild proteinuria or leukocytosis up to 30,000/mm3 are common in early postpartum. Cognitive Level: Analyzing Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal laboratory finding warranting further investigation. Eliminate the option that presents normal data. Eliminate two others because they contain data commonly found in the postpartum. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 805-806.
Which assessment should alert the nurse to withhold the scheduled dose of methylergonovine maleate (Methergine) for a postpartum client and notify the health care provider? 1. Blood pressure 142/86 2. Apical pulse 56 3. Blood type O positive 4. Mother is planning to breastfeed
Answer: 1 Rationale: A potential side effect of Methergine is hypertension. If a client's blood pressure is elevated, the nurse should withhold the scheduled dose and notify the physician. An apical heart rate of 56 is within normal limits postpartum. Blood type and Rh factor are not related to the use of Methergine. The chosen method of feeding method is not impacted by the use of Methergine. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is an adverse effect of Methergine, an oxytocic drug. The correct answer is the option that contains a true statement about a side effect. Eliminate incorrect options because they include normal findings or data not related to Methergine use. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 834.
A new mother complains of "afterpains." The nurse's first action should be to do which of the following? 1. Administer an analgesic. 2. Advise her to stop breastfeeding until the pain stops. 3. Encourage her to empty her bladder. 4. Assess her vital signs.
Answer: 1 Rationale: Afterpains are anticipated in the postpartum client and are effectively treated with analgesics. It is unnecessary to stop breastfeeding, empty the bladder, or assess vital signs. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is afterpains, a common occurrence that can increase pain. The correct answer would be the option that contains a nursing action to effectively manage pain. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 807.
A client delivered 90 minutes ago. She is alert and physically active in bed. She states that she needs to go to the bathroom. What is the nurse's most appropriate response? 1. "I'll walk you to the bathroom and stay with you." 2. "I'll get a bedpan for you." 3. "It's important that you wipe yourself from front to back after urinating." 4. "Wipe the stitches back and forth to increase circulation."
Answer: 1 Rationale: Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should stay with the client the first time she ambulates after delivery to promote safety. Early ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region. It is unnecessary to use a bedpan. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The most therapeutic response would be the option that promotes client safety in the immediate postpartal period. Eliminate options that contain false statements as points of client education. Eliminate another as early ambulation is encouraged, not bedrest, to prevent circulatory stasis. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 830-831.
This is the first postoperative day for a client who had a cesarean delivery. The client asks the nurse why she has to get up and walk when it hurts her incision so much. What would the nurse include in a response? 1. Walking decreases the risk of blood clots after surgery. 2. Walking encourages deep breaths to blow off the anesthetic from surgery. 3. Early ambulation is important to stimulate milk production. 4. Walking will decrease the occurrence of afterpains.
Answer: 1 Rationale: Clients who have had a cesarean delivery are at risk for complications of surgery, including thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and other postoperative complications. Cognitive Level: Applying Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The positive wording of the question indicates that the correct answer is also a true statement. Use knowledge of the factors associated with increased risk of thromboembolic disease such as cesarean section and immobility to answer the question. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 846-848.
A client has a temperature of 100.2°F four hours after delivery. What is the appropriate action for the nurse to take? 1. Encourage increased fluid intake. 2. Do nothing since this is an expected finding at this time. 3. Check the physician's orders for an antibiotic to treat the client's infection. 4. Medicate the client for pain.
Answer: 1 Rationale: Temperature elevation immediately after delivery is often caused by dehydration during labor. Increasing the client's fluid intake will usually decrease the temperature to within normal limits. There is no indication for analgesia or antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recognize that the focus of the question is dehydration fever after delivery. The correct answer would be the option that contains a nursing action to correct this minor and typically temporary finding. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 811-816.
The nurse would assess for which common causative factor in a client who shows signs of retarded uterine involution? Select all that apply. 1. The use of general anesthesia 2. Overdistended urinary bladder 3. Mother is a primigravida 4. Uterine infection 5. Prolonged labor
Answer: 1, 2, 4, 5 Rationale: Among the factors contributing to uterine subinvolution are prolonged labor (frequent contractions), general anesthesia (muscle relaxant), overdistended urinary bladder and uterine infection, among others. Being a primigravida is not necessarily associated with subinvolution. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct. Recall common factors that contribute to retarded uterine involution to choose correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 801.
Which interventions should be included when caring for a client with a midline episiotomy with a third-degree laceration? Select all that apply. 1. Increase fiber in diet. 2. Administer bisacodyl (Dulcolax) suppository. 3. Increase fluid intake. 4. Administer an oral stool softener. 5. Administer an enema.
Answer: 1, 3, 4 Rationale: A third-or fourth-degree perineal laceration involves the rectal sphincter, therefore suppositories, enemas, and rectal exams are contraindicated until the rectum heals. Increased fiber and fluids or use of stool softeners are appropriate to promote bowel elimination in all postpartum clients. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct Use knowledge of interventions and contraindications for a third-or fourth-degree laceration to make your selections. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 820-823.
The infant of a breastfeeding client was transferred to the neonatal intensive care unit because of respiratory distress. The nurse interprets that follow-up teaching has been effective when the client states which reason to pump the breasts? 1. Prevent breast engorgement 2. Stimulate the milk supply 3. Remove the infected milk 4. Keep the uterus contracted
Answer: 2 Rationale: Breast-milk production is based on supply and demand. The more the breasts are stimulated to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: The critical word in the stem of the question is effective, which tells you the correct option is also a true statement. Use knowledge of breastfeeding and how to stimulate milk production to aid your selection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 712-713.
A client who had a vaginal delivery had an episiotomy prior to birth. The maternal newborn nurse would evaluate the client's perineum following delivery is using which method? 1. REDA-redness, edema, discharge, approximation 2. REEDA-redness, edema, ecchymosis, discharge, approximation 3. REAA-redness, edema, approximation, assessment 4. RED-redness, edema, discoloration
Answer: 2 Rationale: Nursing assessment of the perineum includes the following observations, which are abbreviated as REEDA: redness, edema, ecchymosis, discharge, and approximation. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Critical words are episiotomy and evaluation of perineum. Recall the mnemonic for perineal assessment to choose correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 820.
A client's vital signs following delivery are: (Day 1) BP 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; (Day 3) BP 114/80, T 101.6, P 80. The nurse should suspect which of the following about the client's status? 1. Is dehydrated 2. May have an infection 3. Has normal vital signs 4. Is going into shock
Answer: 2 Rationale: The vital signs are not normal. An elevation in body temperature greater than 100.4°F after the first 24 hours postpartum could indicate maternal infection. An elevated temperature within the first 24 hours is usually related to dehydration, although the possibility of infection still exists. Rising pulse and falling blood pressure rather than rising temperature is an indicator of hypovolemic shock. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The assessment data includes an abnormal and increasing temperature, a sign of infection. Eliminate options that suggest other complications. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 830-832.
While assessing the incision of a client two days after cesarean delivery, the nurse notes the skin edges around the incision are red, edematous, and tender to the touch. A scant amount of purulent drainage is noted. What is the most appropriate initial action by the nurse? 1. Cleanse the wound with povidone iodine (Betadine). 2. Notify the physician. 3. Document this expected response. 4. Observe the incision closely for the next 24 to 48 hours.
Answer: 2 Rationale: This client has signs of an incisional infection. The physician needs to be notified first so that treatment can be started as soon as possible. Betadine has not yet been ordered. Documentation should follow reporting. Continued observation would be an ongoing intervention. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of this question is the collection of assessment data indicating a change in the client's condition: development of infection. The correct answer would be the option that best provides for the safety of the client, reporting the abnormal findings so treatment can be instituted. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 848.
The nurse is assessing a client's fundus and finds it firm, two centimeters above the umbilicus and displaced to the right. What is the most appropriate intervention at this time? 1. Massage the fundus until firm. 2. Have the client void and reassess the fundus. 3. Notify the physician. 4. Start a pad count.
Answer: 2 Rationale: This client's fundus is already firm, so it is not appropriate to massage the fundus. It is also higher in the abdomen than expected, and it is displaced to the right, which is probably caused by a distended bladder. Having the client void may return the uterus to the expected position; palpating the fundus after voiding will confirm this finding. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The critical words in the question are firm but displaced uterine fundus, common findings with a full bladder. Eliminate options that do not focus on this condition. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 817-818.
The nurse is reviewing infection control policies with a nursing student. The nurse knows that the teaching has been effective when the student states, "The best way to prevent postpartum infection starts 1. in the recovery room with strict use of sterile technique when palpating the fundus." 2. on the postpartum unit by teaching the client the principles of perineal care." 3. by limiting the number of sterile vaginal exams during labor." 4. when the client goes home by avoiding tub baths until the lochia stops."
Answer: 3 Rationale: Even when perfect sterile technique is used when doing a vaginal exam, organisms present on the perineum are transported into the vagina and close to the cervix. By limiting the number of vaginal exams, the risk is decreased. The option discussing technique is incorrect because clean technique, not sterile technique, is used when palpating the fundus. Teaching the client the principles of peri-neal care and avoiding tub baths until the lochia stops are correct answers, but not the earliest intervention a nurse could perform. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: Critical words are best way to prevent postpartum infection. Knowledge of medical and surgical asepsis and preventing postpartum complications will aid in choosing the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 431-435.
The nurse is assessing a client 24 hours after delivery and finds the fundus to be slightly boggy and two centimeters above the umbilicus. What should be the nurse's priority nursing intervention? 1. Document this expected finding and check lochia. 2. Assess the mother's vital signs. 3. After having the mother void, gently massage the fundus until firm. 4. Notify the physician and document.
Answer: 3 Rationale: The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage and decrease one centimeter below the umbilicus each day. All nursing interventions presented are appropriate, but massaging the fundus until firm is the most important to prevent hemorrhage. Full urinary bladders can interfere with uterine contraction. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is the priority action to promote maternal safety and prevent hemorrhage related to a boggy uterus. The correct answer would be the option that contains a nursing action to prevent hemorrhage. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 801.
The nurse is caring for a client who has decided not to breastfeed. What should the nurse include in client teaching to promote lactation suppression? Select all that apply. 1. Applying warm compresses 2. Pumping the breasts 3. Applying ice bags 4. Using medication to suppress lactation 5. Binding the breasts, either with a snug bra or binder
Answer: 3, 5 Rationale: Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the breasts. Medications to suppress lactation are not recommended. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Knowledge of the ways to suppress lactation in the non-breastfeeding mother will help to answer the question correctly. The correct answers are options that include a true statement about a point of client education. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 816, 839-840.
The nurse is preparing to instruct a new mother on resuming sexual intercourse postpartum. The nurse should include which of the following in the teaching plan? Select all that apply. 1. Pregnancy is not possible prior to the first menses postpartum. 2. An IUD is an appropriate method of birth control in the early postpartum period. 3. Wait until the episiotomy has healed and the lochia has stopped before resuming intercourse. 4. Refrain from intercourse until the first menstrual period after delivery is completed. 5. A water-soluble lubricant may be used if necessary.
Answer: 3, 5 Rationale: Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases the risk of infection. Water-soluble lubricants can be used, if necessary. An IUD is contraindicated during the early postpartum period. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Use the process of elimination and look for statements that are true. Knowledge of client teaching for resumption of sexual activity after delivery will help to answer the question correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 803-804.
A client's prenatal laboratory findings reveal that she is not immune to rubella. The health care provider prescribes rubella vaccine prior to discharge. The nurse concludes that teaching about this medication is effective when the client makes which statement? 1. "I'll need another shot in one month and again in six months." 2. "This shot may cause a fever and make me vomit." 3. "I'll need another shot after each baby I have with Rh-positive blood." 4. "I should not get pregnant for at least three months after the vaccine."
Answer: 4 Rationale: The rubella vaccine is a live virus. If a client becomes pregnant within the first three months after administration, her fetus is at risk for congenital anomalies related to the virus. Women who are not rubella immune should be vaccinated postpartum, prior to discharge. Teaching should include an effective method of birth control and the importance of avoiding pregnancy for the next three months. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: The wording of the question indicates that the correct answer is also a true statement. Use knowledge of rubella immunizations in the postpartum period to aid in answering the question. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 839.
The nurse is caring for a woman who gave birth to a daughter yesterday, but greatly desired a son. Today she seems withdrawn, staying in bed and staring at the wall. What is the most appropriate intervention? 1. Monitor this normal response after delivery. 2. Refer the client for a psychiatric consultation. 3. Tell the client she should be thankful her baby is healthy. 4. Encourage the mother to verbalize her disappointment.
Answer: 4 Rationale: This client should be encouraged to verbalize her disappointment as the first step in resolving her negative feelings. The other responses are incorrect. This is not a normal response nor is it one that requires a psychiatric referral. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recognize that the data given in the question may be related to disappointment with the sex of the infant. The best response would be the option that facilitates therapeutic communication to encourage the client to express her feelings. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 808.
