Test 4: postpartal care
A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? □ 1. By discharge, the family will bond with the neonate. □ 2. The nurse will demonstrate self-care and infant care by the end of the shift. □ 3. The nurse will state instructions for discharge during the first postpartum day. □ 4. By the end of the shift, the nurse will describe a safe home environment.
2. Educating the client about caring for herself and her infant are the two highest priority goals. Following birth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but it is only one aspect of the needs of this client, and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.
The nurse is providing follow-up care to a client 10 days after the birth. The nurse would anticipate what outcomes from the new mother? Select all that apply. □ 1. The client feels tired but is able to care for herself and her new infant. □ 2. The family has adequate support from one another and others. □ 3. Lochia is changing from red to pink and is smaller in amount. □ 4. The client feeds the baby every 6 to 8 hours without difficulty. □ 5. The client has positive comments about her new infant.
1, 2, 3, 5. Outcome evaluation for a family about 7 days after birth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 7-day-old infant feeds every 3 to 4 hours if bottle-feeding and every 1½ to 3 hours if breastfeeding. Follow-up questions the nurse would ask to further evaluate this situation include "How many wet diapers does the infant have daily? How alert is the infant? Did the infant gain any weight at the first checkup?" It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment
A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is having pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? □ 1. Begin sitz baths. □ 2. Administer pain medication per prescription. □ 3. Replace ice packs to the perineum. □ 4. Initiate prescription anesthetic sprays to the perineum.
2. Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.
A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, is bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which action? □ 1. Increase the IV rate. □ 2. Recheck the admission hematocrit and hemoglobin levels. □ 3. Report the findings to the health care provider (HCP). □ 4. Document the findings as normal.
3. At any point in the postpartum period, the lochia should be dark in color, rather than bright red. The volume should not be great enough to trickle or run from the vagina. The information provided states the fundus is firm, midline, and at the umbilicus, which are the expected outcomes at this point postpartum. These findings would indicate to the nurse that the bleeding is not coming from the uterus or from uterine atony. The bladder is not palpable, which indicates that the bleeding is not related to a full bladder, which is further validated by the fundus being at the umbilicus. The most likely etiology is cervical or vaginal lacerations or tears. The nurse is unable to do anything to stop this type of bleeding and must notify the HCP . Increasing the IV rate will not decrease the amount or type of vaginal bleeding. Rechecking the hematocrit and hemoglobin will only provide background information for the nurse and identify the beginning levels for this mother, rather than where she is now. It will do nothing to stop the bleeding. The bleeding level and color is not normal, and documenting such findings as normal is incorrect.
The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action next to ensure the safest transition of the infant to the mother? □ 1. Assess whether the mother is able to ambulate to care for the infant. □ 2. Ask the mother if there is anything else she needs for the care of her baby. □ 3. Check the crib to determine if there are enough diapers and formula. □ 4. Complete the hospital identification procedure with mother and infant.
4. The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.
The nurse is caring for a multigravida woman who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment? □ 1. hemoglobin 12.1 g/dL (121 g/L) □ 2. WBC count of 15,000 mcL (15 × 109/L) □ 3. pulse of 60 beats/min □ 4. temperature of 100.8°F (38.2°C)
4. Within the first 24 hours postpartum, maternal temperature may increase to 100.4°F (38°C), a normal postpartum finding attributed to dehydration. A temperature above 100.4°F (38°C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal range. WBC count is normally elevated as a response to the inflammation, pain, and stress of the birthing process. A pulse rate of 60 beats/min is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure from the uterus on vessels, blood flow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.
