Postpartum Adaptations
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which of the following would the nurse identify as the most likely factor for this development? a) Cracking of the nipple b) Inability of infant to empty breasts c) Inadequate secretion of prolactin d) Improper positioning of infant
Inability of infant to empty breasts Explanation: For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
A postpartum client complains of stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence? a) Reduce fluid intake b) Frequently empty the bladder c) Perform Kegel's exercises d) Perform aerobic exercises
Perform Kegel's exercises Explanation: The nurse should ask the client to perform the Kegel's exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client complains of engorgement. What suggestion should the nurse provide to alleviate breast discomfort? a) Apply warm compress b) Express milk frequently c) Apply hydrogel dressing d) Wear a well-fitting bra
Wear a well-fitting bra Correct Explanation: The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compress and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
You are the home health nurse making an initial call on a new mother who delivered her third baby five days ago. The woman says to you "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? a) "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 delivery. They will most likely go away in a day or two." b) "Tell me, are you seeing things that aren't there, or hearing voices?" c) "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." d) "It sounds like you need to make an appointment with a counselor. You may have postpartum depression."
"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 delivery. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
The nurse is assigned to a patient on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus? a) At level of umbilicus b) 1cm below the umbilicus c) At the symphysis pubis d) 1cm above the umbilicus
1cm below the umbilicus Explanation: The fundus of the uterus should be at the umbilicus after delivery. Every day after delivery it should decrease 1cm until it is descended below the pubic bone. Therefore options A, B, and D are incorrect.
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 due to perineal edema? a) Use a warm sitz bath or tub bath b) Use ointments locally c) Apply ice d) Apply moist heat
Apply ice Explanation: Ice is applied to perineal edema within 24 hours after delivery. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after delivery.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying ice b) Administering bromocriptine (Parlodel) c) Restricting fluids d) Applying warm compresses
Applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
A woman has just delivered a baby. Her prelabor vital signs were T - 98.8 B/P-P-R 120/70, 80, 20. Which combination of findings during the early postpartum period should be reported immediately to the RN? a) Shaking chills with a fever of 100.3 b) B/P-P-R 90/50, 120, 24 c) Bradycardia and excessive, soaking diaphoresis d) Blood loss of 250 mL and WBC 25,000 cells/mL
B/P-P-R 90/50, 120, 24 Explanation: The decrease in BP with an increase in HR and RR indicate a potential significant complication, and are out of the range of normals, from delivery and need to be reported to the RN and healthcare provider ASAP. Shaking chills with a temperature of 100.3ºF can occur due to stress on the body and is considered a normal finding. A fever of 100.4ºF should be reported to the RN. Options C and D are considered to be within normal limits after delivering a baby.
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 of the following is responsible for this change? a) Decreased intra-abdominal pressure b) Decreased bladder pressure c) Use of anesthesia during delivery d) Increased progesterone levels
Decreased intra-abdominal pressure Correct Explanation: The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during delivery causes the respiratory system to take a longer time to return to normal.
A client in the postpartum period complains of constipation. The nurse should inform the client of which of the following that contributes to postpartum constipation? a) Discomfort due to hemorrhoids b) Distention of abdominal muscles c) Relaxation of abdominal muscles d) Separation of rectus muscles
Discomfort due to hemorrhoids Explanation: The nurse should inform the client that hemorrhoids contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal.
The patient under your care is complaining she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement? a) Add dairy products to the patient's diet b) Encourage the patient to eat more fiber rich foods c) Have her hold her feces until she really feels the need to defecate d) Offer the patient a stimulant laxative
Encourage the patient to eat more fiber rich foods Explanation: Encouraging fiber rich foods will help with prevention of constipation. The patient needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.
The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain? a) Mastitis b) Interductal yeast infection c) Engorgement d) Blocked milk duct
Engorgement Explanation: The patient is only 72 hours post delivery and is complaining of bilateral breast tenderness. Milk typically comes in at 72 hours after delivery, and with the production of the milk comes engorgement. The other problems do not typically develop until there is fully established breastfeeding. Therefore options A, B, and D are incorrect.
A nurse is caring for a breastfeeding client who complains of engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which of the following should the nurse suggest to help her prevent engorgement? a) Dry the nipples following feedings b) Apply cold compresses to the breasts c) Provide the infant oral nystatin d) Feed the baby at least every two or three hours
Feed the baby at least every two or three hours Explanation: The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
A client in her sixth week postpartum complains of general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which of the following? a) Hyperglycemia b) Hypertension c) Hypovolemia d) Hypothyroidism
Hypovolemia Explanation: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
You assess a postpartum woman's perineum and notice that her lochial discharge is moderate in amount and red. You would record this as what type of lochia? a) Lochia serosa b) Lochia alba c) Lochia normalia d) Lochia rubra
Lochia rubra Explanation: Lochia rubra is red; it lasts for the first few days of the postpartal period.
During a postpartum exam on the day of delivery, the woman complains that she is still so sore that she can't sit comfortably. You examine her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point? a) Notify the RN b) Place an ice pack c) Put on a witch hazel pad. d) Apply a warm washcloth
Place an ice pack Explanation: The labia and perineum may be edematous after delivery and bruised, the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the physician. Notifying the RN is not necessary at this time as this is considered a normal finding.
A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which of the following conditions? a) Anxiety disorders b) Postpartum depression c) Postpartum psychosis d) Postpartum blues
Postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
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 of the following should the nurse identify as a potential cause for urinary frequency? a) Urinary tract infection b) Trauma to pelvic muscles c) Postpartum diuresis d) Urinary overflow
Postpartum diuresis Explanation: The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient? a) Acute pain related to afterpains or episiotomy discomfort b) Risk for infection related to multiple portals of entry for pathogens, including the former site of the placenta, episiotomy, bladder and breasts c) Risk for injury: postpartum hemorrhage related to uterine atony d) Risk for injury: falls related to postural hypotension and fainting
Risk for injury: postpartum hemorrhage related to uterine atony Explanation: The highest priority is the risk for injury related to postpartum hemorrhage. The patient needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum patient. However, options A, B, and D do not take precedence over the risk for postpartum hemorrhage.
What is the primary function of uterine contractions after delivery of the infant and placenta? a) Return the uterus to normal size b) Seal off the blood vessels at the site of the placenta c) Stop the flow of blood d) Close the cervix
Seal off the blood vessels at the site of the placenta Explanation: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood, but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, options A, C, and D are secondary to the constriction of blood vessels at the placental site.
While educating a class of postpartum patients before discharge home after delivery, one woman asks when "will I stop bleeding?" How should the nurse respond? a) You should stop bleeding and have no discharge in the next 1 to 2 weeks b) The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks c) Bleeding may occur on and off for the next 2 to 3 weeks d) The bleeding may continue for 6 weeks
The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks Explanation: The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week but a white discharge may continue for up to 6 weeks after delivery. Option A is incorrect because it is an incomplete answer. Option B is incorrect because bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. Option C is incorrect because the discharge may continue for up to six weeks.
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which of the following? a) Increased urine output b) Stress incontinence c) Loss of pelvic muscle tone d) Urinary tract infection
Urinary tract infection Explanation: The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a) Diaphoresis b) Lochia serosa c) Edematous vagina d) Uterus 1 cm below umbilicus
Uterus 1 cm below umbilicus Explanation: By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care? a) Wear a tight, supportive bra b) Massage the breast when they are painful c) Express small amounts of milk when they are too full d) Run warm water over the breast in the shower
Wear a tight, supportive bra Explanation: The patient trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? a) "It takes a while to get your body back to its normal function after having a baby." b) "Try doing Kegel exercises to get your pelvic muscles back in shape." c) "This is entirely normal, and many women go through it. It just takes time." d) "You might try using a water-soluble lubricant to ease the discomfort."
"You might try using a water-soluble lubricant to ease the discomfort." Correct Explanation: Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
Bonding between a mother and her infant can be defined how? a) Family growing closer together after the birth of a new baby b) A process of developing an attachment and becoming acquainted with each other c) The skin to skin contact that occurs in the delivery room d) An ongoing process in the year after delivery
A process of developing an attachment and becoming acquainted with each other Explanation: Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Because bonding is a process and not a single event, option B is incorrect. The process of bonding is not a year-long process, so option C is incorrect. The family growing closer together after the birth of a new baby is not bonding, so option D is incorrect.
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? a) Assist the woman in placing ice packs on her breasts b) Explain to the woman that she should breastfeed because she is producing so much milk c) Assist the woman into the shower and have her run cold water over her breasts d) Ask if she wants a breast pump to empty her breasts
Assist the woman in placing ice packs on her breasts Explanation: If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production
On assessment of a 2-day postpartum patient the nurses finds the fundus is boggy, at U and slightly to the right. What is the most likely cause of this assessment finding? a) Poor bladder tone b) Bladder distention c) Uteruine atony d) Full bowel
Bladder distention Explanation: The most often cause of a displaced uterus is a distended bladder. Ask the patient to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A nurse is caring for a client postpartum who complains of sore nipples. The nurse observes that the client's newborn is unable to suck properly although latched well. What intervention should the nurse perform to assist the baby to suck properly? a) Prolong the gap between feedings b) Position baby to face the nipple c) Suggest bottle feeding d) Check the baby's frenulum
Check the baby's frenulum Explanation: The nurse should check the baby's frenulum to determine if it is shortened and notify the health care provider who may clip the frenulum to allow the movement necessary to feed. The nurse should suggest lifting the infant's head up to face the nipple when the infant pinches the nipple with his or her gums. Prolonging the gap between breastfeeding and bottle feeding are not applicable suggestion for improper sucking motions of a baby.
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which of the following observations would indicate the presence of tissue? a) Yellowish white lochia b) Foul-smelling lochia c) Difficult to separate clots d) Easy to separate clots
Difficult to separate clots Explanation: If tissue is identified in the lochia, it is difficult to separate clots. Yellowish white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.
The process by which the reproductive organs return to the nonpregnant size and function is termed what? a) Evolution b) Involution c) Decrement d) Progression
Involution Explanation: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing . Progression is defined as movement through stages such as the progression of labor. Options A, C, and D are distracters for this question.
A nurse is caring for a client who is nursing her baby boy. The client complains of afterpains. Secretion of which of the following should the nurse identify as the cause of afterpains? a) Oxytocin b) Estrogen c) Prolactin d) Progesterone
Oxytocin Explanation: Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation
