Saunders ch29 Postpartum Period
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? a. Elevate the client's legs. b. Massage the fundus until it is firm. c. Ask the client to turn on her left side. d. Push on the uterus to assist in expressing clots.
B Massage the fundus until it is firm.
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? a. Encourage the mother to breast-feed soon after birth. b. Support the mother in her reaction to the newborn infant. c. Tell the mother that it is important to hold the newborn infant. d. Document a complete account of the mother's reaction on the birth record.
B Support the mother in her reaction to the newborn infant.
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? a. Document the findings. b. Reassess the client in 2 hours. c. Notify the health care provider (HCP). d. Encourage increased oral intake of fluids.
C Notify the health care provider (HCP).
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is MOST APPROPRIATE? a. raise the head of the client's bed b. obtain hemoglobin and hematocrit levels c. instruct the client to request help when getting out of bed d. inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided
C instruct the client to request help when getting out of bed
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? a. Document the finding. b. Encourage the client to ambulate. c. Encourage the client to increase fluid intake. d. Contact the health care provider (HCP) and inform the HCP of this finding.
D Contact the health care provider (HCP) and inform the HCP of this finding.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? a. The client with mild afterpains b. The client with a pulse rate of 60 beats/minute c. The client with colostrum discharge from both breasts d. The client with lochia that is red and has a foulsmelling odor
D The client with lochia that is red and has a foulsmelling odor
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the PRIORITY nursing action? a. document the findings b. retake the temperature in 15 minutes c. notify the health care provider d. increase hydration by encouraging oral fluids
D increase hydration by encouraging oral fluids
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the PRIORITY nursing consideration for this client? a. client pain level b. inadequate urinary output c. client perception of body changes d. potential for imbalanced body fluid volume
A client pain level
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? select all that apply a. "I should wear a bra that provides support" b. "Drinking alcohol can affect my milk supply" c. "The use of caffeine can decrease my milk supply" d. "I will start my estrogen birth control ills again as soon as I get home" e. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby" f. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily"
A, B, C, F "I should wear a bra that provides support" "Drinking alcohol can affect my milk supply" "The use of caffeine can decrease my milk supply" "I plan on having bottled water available in the refrigerator so I can get additional fluids easily"
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? a. "I will begin abdominal exercises immediately." b. "I will notify the health care provider if I develop a fever." c. "I will turn on my side and push up with my arms to get out of bed." d. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
A "I will begin abdominal exercises immediately."
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? a. 3 days postpartum b. 7 days postpartum c. on the day of birth d. within 2 weeks postpartum
A 3 days postpartum
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? a. the diet should include additional fluids. b. prenatal vitamins should be discontinued c. soap should be used to cleanse the breasts d. birth control measures are unnecessary while breast-feeding
A the diet should include additional fluids