saunders postpartum
The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?
"I will change the perineum pads three times a day."
The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?
"I will massage the breasts before feeding to stimulate let-down."
The nurse reinforces home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?
"If I develop a fever, I will call my doctor."
A postpartum client diagnosed with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?
"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."
The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn."
The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?
Check the uterine fundus and lochia.
A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?
Massage the breasts before feeding to stimulate let-down.
A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?
Request to hold the infant following delivery
The nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse should document which expected changes? Select all that apply
slowed pulse rate Elevated blood pressure
The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply.
tremors irritability hypertension exaggerated startle reflex
The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?
Keep the client and her family members informed of her progress.
In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn?
Lack of knowledge regarding ability to care for the newborn
The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?
500 calories per day
It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.
A
The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?
A positive nurse-client relationship
A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement?
A sitz bath will promote healing of the perineum."
The nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?
An adolescent experiencing an emergency cesarean delivery for fetal distress
The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?
An increase in the pulse rate from 88 to 102 beats per minute
A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?
Collect data regarding how the client perceived the event.
A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?
Covering her with a warm blanket
The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?
Dyspnea, tachypnea, and tachycardia
The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding?
Encourage her to hold the infant even when the infant is crying.
The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.
Epistaxis Hematuria Ecchymosis
When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider?
Her temperature is 99° F.
The nurse is reinforcing instructions to a client who had an episiotomy during the birthing process. Which statement by the client indicates a need for further teaching?
I should take sitz baths 3 or 4 times a day and test the water temperature to be sure that it is at 115° F."
The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action?
Prepare an ice pack for application to the area.
The nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action is appropriate?
Instruct the mother to request help when getting out of bed
The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?
My left breast is sore, so I will offer only my right breast frequently for breastfeeding."
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?
Prepare the client for surgery.
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
Red
A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply.
Retained placental fragments 5. Maternal reproductive tract infections
After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make?
The bright red bleeding is abnormal and should be reported.
The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?
The finding is normal.
A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. Which nursing response is appropriate?
The infection can occur at any time during breastfeeding."
Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?
The mother constantly complains of tiredness and fatigue.
The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?
The presence of infection
Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effective response from the medication?
Uterine contractions
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
he nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore.
The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.
Rh negative mother Negative Coombs test
As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?
She should alternately contract and relax the muscles of the perineal area.
A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breastfeed her infant. Which should the nurse tell the client?
"Breastfeed from the left breast and gently pump the right breast."
The nurse is assigned to care for a client who received methylergonovine maleate in the immediate postpartum period. The nurse determines the medication is effective when the client makes which statement?
"My afterpains are really strong."
The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement?
"Tell me about the delivery of your baby."
After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?
"The only medications that I will take are prenatal vitamins and stool softeners."
A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?
"Would you like to hold your baby?"
The nurse is assessing a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse should check which as a priority?
Vulva for a hematoma
A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?
"Breastfeeding is allowed once the baby has been vaccinated."
The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?
"I can start doing abdominal exercises as soon as I get home."
A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?
"I don't need birth control because I will be breastfeeding."
A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?
Begin feeding on the less sore nipple
The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition?
Bladder distention
The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis?
Abdominal tenderness and chills
The nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which signs/symptoms should the nurse expect to note when collecting data on the client? Select all that apply.
Absence of fetal movement Fetal heart tones not audible Prenatal record indicating no change in fundal height for several weeks
The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
Ask the client to urinate and empty her bladder
The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?
Assist the client to the bathroom to void and then reassess the fundus.
A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client?
Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?
Postpartum hemorrhage
The nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?
Postpartum hemorrhage
A new mother is attempting to breastfeed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breastfeeding the newborn?
Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.
The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?
The spouse lacks hope because of the loss of the baby and illness of his wife.
The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur?
adhesions
On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching?
"Foods and fluids that will increase urine alkalinity should be consumed."
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?
Ambulate frequently.
A postpartum client who delivered at 32 weeks of gestation would like to breastfeed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?
"You can begin pumping as soon as possible after delivery with an electric breast pump."
The postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. Which statement does the nurse anticipate that the client will make regarding her lochial flow?
"I am having a dark red discharge."
The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching?
"I can resume sexual activity at any time."
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?
"I do not feel any urges yet to empty my bladder.
The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement?
"I should alternately contract and relax the muscles of the perineal area."
The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?
"I should avoid wearing a bra at this time."
The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?
"It will help prevent bleeding and control bleeding if it occurs."
A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago. The mother's temperature is 100° F (38° C). What is the initial nursing action?
Encourage oral fluid intake.
The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate?
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider?
Pain, redness, or swelling in the breasts
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?
This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching?
"I need to isolate my infant for 48 hours after starting the antibiotics."
The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?
Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours
The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action?
Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).
When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which nursing action is appropriate?
Notify the registered nurse (RN).
A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which data support that the goal has been met?
Absence of fever
The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?
Administer anticoagulants as prescribed.
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider?
Administration of a subcutaneous rubella virus vaccine
Oxytocin is utilized in multiple ways in the labor and delivery unit. The nurse correctly identifies which purposes for administering this medication? Select all that apply.
Aids milk let down Controls uterine atony Augments labor contractions 5. Stimulates uterine contractions
After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?
At the level of the umbilicus
The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?
Encouraging the client to take pain medication as prescribed
In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.
Change breast pads frequently. Avoid the use of soap on your nipples. Intermittently expose your nipples to the air.
The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?
Changes in vital signs
The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?
Checks the calf areas for redness or swelling
The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?
Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.
The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate?
Gather data from the client and spouse about the perception of the event.
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.
Lengthening of the umbilical cord Sudden gush of dark blood from the vagina Appearance of fetal membranes at the introitus
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.
Less pain less blood loss More likely to extend with birth of LGA infant
The nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which interventions are included in the plan of care? Select all that apply.
Maintaining bed rest Elevating the affected extremity Applying warm compresses to the affected area as prescribed
A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first?
Obtain culture and sensitivity of lochia and urine.
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?
Provide support to the mother.
A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time?
Risk of ineffective bonding between the mother and newborn
A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?
Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.
The nurse is monitoring a new mother for signs of postpartum depression. Which observations in the mother indicate the need for further data collection related to this form of depression? Select all that apply.
Shows a lack of interest in eating 3. Lacks the ability to concentrate on tasks 4. Complains of feeling tired all of the time
The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?
The bright red bleeding is abnormal and should be reported.
The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?
This may be a sign of hemorrhage or shock.
The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?
To complete the entire antibiotic regimen
The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?
Washes and dries her hands before feeding
A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity should the nurse implement as part of the method to accurately determine the amount of flow for documentation purposes?
Weigh the perineal pad before and after use.
A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?
he client is required to stay on bed rest.
Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply.
performing sitz baths applying ice packs to the perineum for the first 12 to 24 hours