Prep U chapter 16 Maternal

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

atony

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement?

"I might feel like laughing one minute and crying the next."

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?

"Some women just can't breastfeed. Maybe I'm one of these women."

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

-Help the mother initiate breastfeeding within 30 minutes of birth. -Encourage breastfeeding of the newborn infant on demand. -Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.

-Low self-esteem -Feeling overwhelmed and out of control -Low socioeconomic status -Lack of social support

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?

25 to 50 ml

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day

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 is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

Resume intercourse if bright red bleeding stops.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

Touching

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:

moderate

When palpating for fundal height on a postpartum woman, which technique is preferable?

placing one hand at the base of the uterus, one on the fundus

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

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels to return to their normal pattern."

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider?

100.8°F (38.2°C)

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m.

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.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus.

The LVN/LPN will be assessing a postpartum client for danger signs of infection after a vaginal birth. What assessment finding would the nurse assess as a possible sign of infection for this client?

fever more than 100.4° F (38° C)

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintaining previous household routines to prevent infection.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.

-vital signs of mother -pain level -head-to-toe assessment

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops

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.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage

Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means? Select all that apply.

-stasis -altered coagulation -localized vascular damage

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Apply an ice pack to the perineal area.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention?

Uterus is boggy.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?

2 weeks

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.

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red.