Post Partum

A nurse is reinforcing teaching about reducing perineal infection with a client following a vaginal delivery. Which of the following should the nurse include in the teaching? (Select all that apply.) Hint 😊 There are 4! A. Blot the perineal area dry after cleansing. B. Clean the perineal area from front to back. C. Perform hand hygiene before and after voiding. D. Apply ice packs to the perineal area several times daily. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.

A. Blot the perineal area dry after cleansing. B. Clean the perineal area from front to back. C. Perform hand hygiene before and after voiding. E. Wash the perineal area using a squeeze bottle of warm water after each voiding.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean delivery, the client requests assistance in breast-feeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest? A. Football hold. B. Scissors hold. C. Cross-cradle hold. D. Cradle hold.

A. Football hold.

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a postpartum client when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A. Retained placental fragments. B. Urinary tract infection C. Cervical laceration D. Uterine atony

C. Cervical laceration

A nurse is caring for a client who delivered a healthy term newborn via cesarean birth. The client asks the nurse, "Is there a chance that I could deliver my next baby without having a cesarean section?". Which of the following responses should the nurse provide? A. "The primary consideration is what type of incision was performed this time" B. "There are so many variables that you'll have to ask your obstetrician C. "It's too soon for you to be worrying about this now" D. "A repeat cesarean for both you and your baby"

A. "The primary consideration is what type of incision was performed this time" (most common type is transverse incision and if low and thin it meets the criteria for vaginal birth after cesarean VBAC as other types of incision increases risk of uterine rupture)

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make? A. "You should place your nipple and some of the areola into her mouth." B. "Babies know instinctively how much of the nipple to take into their mouth." C. "Your baby's mouth is rather small so she will only take part of the nipple." D. "Try to place the nipple, the areola, and some breast tissue beyond the areola into her mouth."

A. "You should place your nipple and some of the areola into her mouth."

If a woman had a pregancy daily requirement of 1800 calories and she decides to breastfeed for newborn, how many calories should the nurse recommened the woman take in each day? A. 2300 calories B. 2500 calories C. 2000 calories D. 1800 calories

A. 2300 calories

The nurse is providing postpartum care to a client from a different culture. Which actions are appropriate to include in the client's plan of care? Select all that A. Assess for any assistance required during breastfeeding B. Ask if there are any specific customs the client wants to follow C. Limit client visitor to the immediate family D. Restrict interactions with the client

A. Assess for any assistance required during breastfeeding B. Ask if there are any specific customs the client wants to follow C. Limit client visitor to the immediate family

The nurse is planning care for a client who has a cesarean birth 4 hours ago. Which actions should be included in the client's plan of care? Select all that apply A. Encourage the use of breathing, relaxation, and distractions B. Encourage deep breathing and coughing every 2 to 4 hours C. Discourage leg exercises D. Withhold all analgescis

A. Encourage the use of breathing, relaxation, and distractions B. Encourage deep breathing and coughing every 2 to 4 hours

(This question is from Pearson NOT Linda) The nurse is caring for a patient who had uncomplicated vaginal delivery 24 hours prior assesses the patient's fundus and notes that it is above the umbilicus. Which is the priority nursing intervention? A. Encouraging the patient to void B. Encouraging ambulation C. Performing fundal massage D. No intervention is necessary

A. Encouraging the patient to void (24 hr after giving birth, the fundal height should be at the umbilicus. Deviation, most comonly to teh right or elevation above the umbilicus, is an indication of bladder distention which leaves pt at risk for hemmorrage)

Which symptoms would be the nurse recognize as bring consistent with postpartum endometriosis at 4 weeks postpartum? A. Foul-smelling lochia B. Bright red lochia C. Upper abdominal pain D. Bradycardia

A. Foul-smelling lochia

A client who gave birth to her first child 12 hours ago has the following assessment findings. Nasusea for 2 hours, boggy fundus that firmed with massage, moderately heavy lochia rubra, Ecchymotic and edematous perineum, and pain rating of 6 on a scale of 0-10. The client's partner is present and supportive. Breast feeding has been successful three times. Based on this data, which problem is the priority? A. Pain B. Insufficient fluid intake C. Anxiety related to role change D. Readiness

A. Pain

A nurse is caring for a client 2 hr. after a spontaneous vaginal birth and the client has saturated two perineal pads with blood in a 30-min period. Which of the following is the priority nursing intervention at this time? A. Palpate the client's uterine fundus. B. Assist the client on a bedpan to urinate. C. Prepare to administer oxytocic medication. D. Increase the client's fluid intake.

A. Palpate the client's uterine fundus.

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following statments should indicate to the nurse the teaching is effective? Select all that apply. A. "I am likely to have a fever during the first week I am home" B. "I will resume taking my prenatal vitamins" C. "I will call my provider if I have discharge from my incision" D. "I should not have unrelieved pain from my abdomen" E. "I will rest in a recliner until my incision is healed"

B. "I will resume taking my prenatal vitamins" C. "I will call my provider if I have discharge from my incision" D. "I should not have unrelieved pain from my abdomen"

A 26-year-old primiparous client is seen in the urgent clinic 2 weeks after delivering a viable female neonate. The client, who is breatfeeding, is diagnosed with infection mastitis of the right breast. The client asks the nurse, "Can I continue breast-feeding?" A. "You can continue once your symtpoms began to decrease" B. "You can continue to breat-feed, feeding your baby more frequently" C. "You must stop breast-feeding because the breast is contaminated" D. "You must discountinue breast-feeding until antibiotic therapy is completed"

B. "You can continue to breat-feed, feeding your baby more frequently

A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended into a third-degree laceration. B. A client who does not wash their hands between perineal care and breastfeeding. C. A client who is not breastfeeding and is using measures to suppress lactation. D. A client who has a cesarean incision that is well-approximated with no drainage.

B. A client who does not wash their hands between perineal care & breastfeeding

The nurse is providing discharge instructions for healthy 37-year-old first-time mother and her newborn. Which information should the nurse include in her instructions for this mother and her spouse? A. Information related to contraception and sexually transmitted infections (STIs). B. A reminder that addition of a newborn will alter established routines C. A referral to a group class that provides information on newborn care D. A referral for follow-up care with healthcare providers other than obstetrician

B. A reminder that addition of a newborn will alter established routines

A nurse is a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse? A. Assist the family to identify prior use of positive coping skills in family crises B. Ask the client has she has considered harming her newborn C. Anticipate a prescription by the provider for an antidepressant D. Reinforce postpartum and newborn care discharge teaching

B. Ask the client has she has considered harming her newborn

A nurse is assessing a client who is 4 hr. postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority? A. Saturated perineal pad in 30 min B. Deep tendon reflexes 4+ C. Fundus at level of umbilicus D. Approximated edges of episiotomy

B. Deep tendon reflexes 4+ (deep tendon reflexes 4+ are hyperactive & indicate the pt is at greatest risk for preeclampsia & seizures)

Before a first-mother is discharged from the hospital with her newborn, the nurse notices that the mother is taking directions on a newborn care from her parents and in-laws. Which stage of maternal role attaintment is the new mother in? A. Anticipatory B. Formal stage C. Informal stage D. Personal stage

B. Formal stage (women is influenced by guidance of others and tries to act as she believes others expect her to act)

A client in the early postpartum period is very excited and talkative. They repeatedly tell the nurse every detail of the labor and the birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? A. Come back later when the client is more cooperative. B. Give the client time to express feelings. C. Tell the client they need to be quiet so the assessment can be completed. D. Redirect the client's focus so that they will become quiet.

B. Give the client time to express feelings.

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? A. Moderate lochia rubra B. Steady trickle of blood C. Fundus at the umblical level D. Form fundus

B. Steady trickle of blood (Indicates a laceration in the birth canal and should be report to provider)

A postpartum client is experiencing pain from an episiotomy. Which actions will the nurse suggest to the client to decrease discomfort? Select all that apply. A. Washing the area with soap and water every day B. Tighteningthe buttocks before sitting C. Change the peri-pads daily D. Performing leg scissor kicks several times a day E. Increasing the intake of meat, cheese, fish, eggs, and nuts

B. Tightening the buttocks before sitting (technique reduces pain) E. Increasing the intake of meat, cheese, fish, eggs, and nuts (Lysine an amino acid decreases pain)

When palpating the fundus of a women on her first day postpartum, the nurse finds that the woman's uterus is higher than expected and is deviated to the right. She is not having exccessive uterine bleeding. Which action should the nurse take? A. Notify the client's midwife of this condition B. Ask another nurse to assess the client to verify the findings C. Ask the client to void and then reassess fundal height D. Perform a straight catherazation on the client and then assess fundal height

C. Ask the client to void and then reassess fundal height (distended bladder causing temporary upward displacement of the uterus)

(This question is from Pearson NOT Linda) The nurse is caring for a 3-day postpartum breastfeeding patient that states, "I wonder when my milk will come in?" Which best describes the nurse's understanding of transitional milk production in breastfeeding patients? A. By day 10 the mother is producing approximately 800mL/day B. The initial milk is immediately available to the baby after birth C. By day 5, mothers produce approximately 500 mL/day D. Transitional milk production begins after 24 hours of breastfeeding

C. By day 5, mothers produce approximately 500 mL/day

A nurse is performing a physical examination of a client who is 1 day postpartum. Which of the following findings requires immediate intervention? A. Decreased urge to void. B. Increased urine output C. Displaced fundus from the midline D. Fundal height below the umbilicus

C. Displaced fundus from the midline (may indicate uterine atony, which is the most common cause of postpartum hemorrhage)

Upon delivery of the newborn, which nursing intervention promotes parental attachment? A. Placing the newborn under the radiant warmer B. Placing the newborn on the bed next to the mother C. Placing the newborn on the maternal chest D. Taking the newborn to the nursery for the initial assessment

C. Placing the newborn on the maternal chest

A nurse is assessing a client who is 12 hr postpartum and received spinal anesthesia for a cesarean birth. Which of the following findings requires immediate intervention by the nurse? A. Blood pressure 100/70 mm Hg B. Headache pain rated a 6 on a scale of 0 to 10. C. Respiratory rate 10/min D. Urinary output 30 mL/hr.

C. Respiratory rate 10/min

A 16-year-old has just given birth, and she plans to keep and care for the baby. However, hte nurse determines that young mother has low self-esteem, and she does not appear to have adequate social support. The nurse should encourage adequate follow-up care for this young mother for which reason? A. She is at risk for postpartum hemorrhage B. She is at risk for postpartum endometritis C. She is at risk for postpartum depression D. She is at risk for postpartum weight gain

C. She is at risk for postpartum depression

A nurse is caring for a client who is postpartum and has a prescription for Rho (D) immunoglobulin. The nurse should verify which of the following prior to administration? A. Client is Rh positive, and the newborn is Rh positive. B. Client is Rh negative, and the newborn is Rh negative. C. Client is Rh negative, and the newborn is Rh positive. D. Client is Rh positive, and the newborn is Rh negative.

C. The client is Rh negative, and the newborn is Rh positive. (only applicable for a second pregnancy and beyond)

(This question is from Pearson NOT Linda) The nurse is teaching a patient who delivered vaginally about the importance of emptying the bladder. Which information should the nurse include in the teaching? A. "A full bladder increases uterine cramping" B. "A full bladder will worsen constipation" C. "A full bladder delays the healing of your perineum" D. "A full bladder places you at risk for increased bleeding"

D. "A full bladder places you at risk for increased bleeding" (A full bladder will cause the uterus to relax by displacing the uterus and interfering with its contractility, leading to hemorrhage)

The nurse is assessing a cesarean section client who is delivered 24 hours ago. Findings include a distended abdomen with faint bowel sounds x1 quadrant, lung sounds clear in all fields, fundus firm at -1U, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley cathetar have been discountinued and the client recieved medication 3 hours ago for pain. The client can have pain medicatrion every 3 to 4 hours. The nurse should first: A. Encourage the client to begin caring for her baby B. Give the client pain medication C. Have the client use the incentive spirometer D. Ambulate the client form bed to the hallway and back

D. Ambulate the client form bed to the hallway and back

(This question is from Pearson NOT Linda) A postpartum patient demonstrates decision making regarding mothering. Which stage of maternal role attainment should the nurse note the mother has achieved? A. Formal stage B. Personal stage C. Anticipatory stage D. Informal Stage

D. Informal Stage (The informal stage begins when mother starts making choices about mothering)

On the first postpartum day, the primiparous client reports perineal pain of 8 on a scale of 1 to 10 that was unrelieved by ibuprofen 800mg given 2 hours ago. The nurse should further assess the client for: A. Puerperal infection B. Vaginal lacerations C. History of drug abuse D. Perineal hematoma

D. Perineal hematoma

A nurse is caring for a client who is 5 hr. postpartum following a vaginal birth of a newborn weighing 9 lb. 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications? A. Puerperal infection B. Retained placental fragments. C. Thrombophlebitis D. Uterine atony

D. Uterine atony (risk factors for uterine atony: large or multiple babies, prolonged or rapid labor, overdisteneded uterus, use of xytocin or magnesium sulfate during labor, previous history of uterine atony)

A nurse is caring for a client who is 12 hr postpartum. Which of the following findings should alert the nurse to the possibilty of a postpartum complication? A. Orthostatic hypotension B. Fundus palpable at the umbilicus C. Urine output of 3,000 mL in 12hr D. heart rate 110/min

D. heart rate 110/min (Increasing or rapid heart rate can be manifestation of fluid volume depletion related to hemorrhage)