33.C Postpartum Care

A mother has just given birth to a healthy infant. As she is holding the infant, she begins to experience intense tremors resembling shivering. Is this a normal response in the postpartum client?

Yes As long as the shivering is not followed by a fever, it is of no clinical concern. The nurse can increase the woman's comfort through the use of a warmed blanket and warm beverage. Potential causes of postpartum shivering: - Result of the sudden release of pressure on the pelvic nerves after birth - Response to a fetus-to-mother transfusion that occurred during placental separation - Reaction to maternal adrenaline production during labor and birth - Reaction to epidural anesthesia

The nurse identifies that teaching has been effective when a postpartum client makes which statement about how her 2-year-old will act when the newborn goes home? a. "He may want to drink from a bottle again." b. "He may want to spend more time with his friends." c. "He will be a great help." d. "He will decide he is ready to potty-train."

a. "He may want to drink from a bottle again." Explanation: Being of help may occur over time but is not an expected characteristic of a 2-year-old when the newborn first goes home. Regression to previous behaviors is normal in young children when a new sibling is brought into the family. An example for a 2-year-old is drinking from a bottle again, which is characteristic of an earlier stage of growth and development. Potty training is expected to happen with future growth and development, but would not be characteristic at this time. Spending more time with friends is expected to happen with future growth and development, but would not be characteristic at this time.

A new mother calls the clinic 4 days after delivery. She is breast-feeding and is concerned that her baby is not getting enough milk. What is the most important question for the nurse to ask this mother? a. "How many wet diapers has your baby had in the last 24 hours?" b. "Do your breasts tingle when you begin nursing?" c. "Are your nipples sore or bleeding?" d. "Do you have any red or tender areas on the breasts?"

a. "How many wet diapers has your baby had in the last 24 hours?" Explanation: Once the mother's milk comes in, typically after the third postpartum day, breastfed babies should have 6-8 wet diapers each day. This would indicate the baby is getting enough milk. Red, tender areas or sore, bleeding nipples contribute to infection such as mastitis. Tingling is often used to describe the feeling mothers experience with the letdown reflex.

A client has a temperature of 37.9°C (100.2°F) 4 hours after delivery. What is the appropriate action for the nurse to take? a. Encourage increased fluid intake. b. Check the healthcare provider's prescribesfor an antibiotic to treat the client's infection. c. Medicate the client for pain. d. Do nothing since this is an expected finding at this time.

a. Encourage increased fluid intake. Explanation: Temperature elevation immediately after delivery is often caused by dehydration during labor. Increasing the client's fluid intake will usually decrease the temperature to within normal limits. The elevated temperature requires an intervention. There is no indication for antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted. There is no indication for analgesia at this time.

The nurse is caring for a woman who gave birth to a daughter yesterday, but greatly desired a son. Today she seems withdrawn, staying in bed and staring at the wall. What is the most appropriate intervention? a. Encourage the mother to verbalize her disappointment. b. Monitor this normal response after delivery. c. Tell the client she should be thankful her baby is healthy. d. Refer the client for a psychiatric consultation.

a. Encourage the mother to verbalize her disappointment. Explanation: This is not a normal response. This is not a response that requires a psychiatric referral. It is not therapeutic to fail to address the client's concerns. This client should be encouraged to verbalize her disappointment as the first step in resolving her negative feelings.

The nurse determines the father of a newborn is not displaying positive bonding behaviors. Which action made by the nurse may facilitate parental bonding? a. Encouraging the father to discuss his feelings about being a parent. b. Instructing the father to fill out the birth certificate. c. Showing a videotape on expected fathering behaviors. d. Introducing the father to other fathers on the unit.

a. Encouraging the father to discuss his feelings about being a parent. Explanation: Providing a videotape does not engage the new father in discussion about his feelings and any concerns about his new role as father. New fathers may feel overwhelmed with caring for a newborn, especially if they have not had many opportunities to interact with babies. By encouraging him to discuss his feelings, the nurse may help him explore his new role as a father and feel more comfortable asking questions related to infant care. The nurse may also be able to identify cultural expectations of the father's role and avoid misinterpreting the father's behavior. Introduction to other fathers on the unit does not directly address the father's issues with bonding with his own infant. Filling out the birth certificate is unrelated to the psychosocial concern about father-infant bonding.

The nurse notes that a client's postpartum hematocrit is 27% and hemoglobin is 9 grams/dL. Which manifestation related to these laboratory values is the most important aspect for the nurse to include in this client's teaching? a. Feeling lightheaded or dizzy b. Getting cold more easily c. Finding concentrating more difficult d. Feeling tired more easily

a. Feeling lightheaded or dizzy Explanation: Feeling tired could occur in an anemic client and should be included in the teaching plan, but this is not most important because it does not threaten client safety. Feeling cold more easily could occur in an anemic client and should be included in the teaching plan, but this is not most important because it does not threaten client safety. Difficulty concentrating could be experienced by an anemic client and should be included in the teaching plan, but this is not the most important because it does not threaten client safety. The manifestation most likely to risk the client's safety is that she may feel lightheaded or dizzy. Because this could cause the client potential injury, it is the most important information to include.

The nurse should notify the healthcare provider immediately of which assessment finding? a. Firm uterus with steady trickle of blood 2 hours after delivery b. Musty odor to lochia 48 hours postpartum c. Three pea-sized clots passed 4 hours after delivery d. Scant amount of rubra lochia after cesarean delivery

a. Firm uterus with steady trickle of blood 2 hours after delivery Explanation: Three pea-sized clots passed 4 hours after delivery is normal. A musty odor to the lochia 48 hours postpartum is normal. A scant amount of rubra lochia after cesarean delivery is normal. A steady trickle of blood in the presence of a firm uterus could indicate the presence of a vaginal or cervical laceration. The healthcare provider should be notified immediately so further evaluation can be initiated.

A new mother spends increasingly more time with her infant positioned to have direct face-to-face and eye-to-eye contact. How should the nurse interpret this finding? a. It is the en face position, which promotes positive parent-infant attachment. b. It is the enfolding position, characteristic of initial maternal-newborn touch. c. It is acquaintance position used by mothers to learn about their newborn's behavior. d. It is an avoidance position, an indicator of abnormal bonding.

a. It is the en face position, which promotes positive parent-infant attachment.Explanation: Face-to-face and eye-to-eye contact is not needed to learn about the infant's behavior. The en face position is not an avoidance position; rather it is the opposite. The en face position facilitates parent-infant attachment, and is assumed when the mother positions the newborn to have direct face-to-face and eye-to-eye contact in the same plane. There is intense interest in having the infant's eyes open and when they are, the mother typically talks to the newborn in a soft, high-pitched tone of voice. The emphasis in face-to-face and eye-to-eye contact is on vision rather than touch.

This classification of lochia has the following characteristics: Dark red; first 2-3 days; contains epithelial cells, erythrocytes, leukocytes, shreds of decidua; and occasionally fetal meconium, lanugo, and vernix. A few small clots may be present. a. Lochia rubia b. Lochia serosa c. Lochia alba

a. Lochia rubia

A client delivered an infant by cesarean 2 days ago. While assessing the client's incision, the nurse notes that the skin edges around the incision are red, edematous, and tender to the touch. A scant amount of purulent drainage is noted. What is the most appropriate initial action by the nurse? a. Notify the healthcare provider. b. Document this expected response. c. Cleanse the wound with povidone-iodine solution. d. Observe the incision closely for the next 24-48 hours.

a. Notify the healthcare provider. Explanation: Povidone-iodine solution has not been prescribed and may or may not be the current solution approved by agency policy, which is not stated. This client has signs of an incisional infection. The healthcare provider needs to be notified first so that treatment can be started as soon as possible. Documentation should follow reporting. Continued observation would be an ongoing intervention.

An inflammation of the endometrium portion of the uterine lining occurring anytime up to 6 weeks postpartum, may occur in 30-35% of those who give birth by cesarean after an extended period of labor and ruptured membranes. a. Postpartum endometritis b. Postpartum hemorrhage (PPH) c. Uterine atony d. Diastasis recti abdominis

a. Postpartum endometritis

What interventions should be included in the care plan when caring for a client who has a midline episiotomy with a third-degree laceration?Select all that apply. a. Administer an enema. b. Increase fluid intake. c. Administer an oral stool softener. d. Administer bisacodyl suppository prn. e. Increase fiber in diet.

b, c, e Explanation: Increased fiber and fluids or use of stool softeners is appropriate to promote bowel elimination in all postpartum clients. A third- or fourth-degree perineal laceration involves the rectal sphincter, therefore suppositories, enemas, and rectal exams are contraindicated until the rectum heals.

Which of the following clients would be more likely to have an increase in the amount of lochia they release postpartum? [SATA] a. Primaparas b. Multiparas c. Client undergoing cesarean birth d. Client undergoing vaginal birth

b, d Pearson pg. 2331 "Multiparous women usually have more lochia than first-time mothers. Women who undergo a cesarean birth typically have less lochia than women who give birth vaginally."

Although a client initially wanted to breast-feed, she has now decided to bottle-feed her newborn with formula. The nurse concludes that teaching regarding breast care for this client has been effective when the client makes which statement? a. "I'll soak my breasts in a warm tub twice daily for the first week." b. "I'll wear a snug bra continuously until my breasts are soft again." c. "I'll rub lotion on my breasts if they are sore." d. "I'll pump 2-3 times each day until my milk supply decreases."

b. "I'll wear a snug bra continuously until my breasts are soft again." Explanation: Pumping the breasts is a form of breast stimulation that should be avoided. Applying lotion to the breast is a form of breast stimulation that should be avoided. Applying heat via a warm bath will stimulate the breasts and should not be done. Mothers who are bottle-feeding should be encouraged to suppress milk production by wearing a snug bra or breast binder, applying cold compresses, and avoiding breast stimulation until primary engorgement subsides.

What should the nurse include when teaching a new mother how to care for herself after delivery? a. "Wait one week before resuming sexual intercourse." b. "Your diaphragm will need to be refitted." c. "Call your healthcare provider if you experience night sweats." d. "Change your perineal pad twice daily."

b. "Your diaphragm will need to be refitted." Explanation: Night sweats are common and need not be reported. Sexual intercourse can be safely resumed once the episiotomy is healed and the lochia stops in about 3 weeks. Perineal pads should be changed after each elimination. Diaphragms need to be refitted after each delivery and a change in body weight of greater than 4.5?6.8 kg (10?15 lb).

In addition to facilitating uterine contractions, oxytocin has an ______________ effect a. Antipyretic b. Antidiuretic c. Anti-inflammatory d. Analgesic

b. Antidiuretic Following cessation of oxytocin administration, the women will likely experience rapid bladder filling.

A nurse is assessing a postpartum client's peripad and notes a strong foul odor from the lochia present. What is the appropriate response? a. Lochia is known to have a strong foul odor. Change the pad to promote client comfort and dispose of the old pad. b. Any foul smell should be assessed because it suggests assessment. The nurse should assess for uterine tenderness, fever, and obtain a CBC with diff to screen for infection.

b. Any foul smell should be assessed because it suggests assessment. The nurse should assess for uterine tenderness, fever, and obtain a CBC with diff to screen for infection.

The nurse notes the following maternal attachment behaviors. Which behavior indicates the need for further observation? a. Refers to the baby as "my little angel." b. Does not pick up the baby when he cries, to avoid "spoiling." c. Holds the baby in the en face position. d. Talks to the baby during feedings.

b. Does not pick up the baby when he cries, to avoid "spoiling." Explanation: Establishing an emotional bond with the newborn includes meeting the infant's needs. Holding the newborn helps to establish trust. Consoling the baby when he cries meets the infant's need for comfort and helps to establish trust. Establishing an emotional bond with the newborn includes responding to behavioral cues.

The follow-up clinic nurse is assessing a single primigravida, who delivered 3 days ago. The client beings to cry and tells the nurse, "I just can't do all this." What should the nurse do at this time? a. Report the client's behavior to the healthcare provider. b. Evaluate the client's support system. c. Determine with which parenting skills the client is uncomfortable. d. Ask the client if she needs some pain medication.

b. Evaluate the client's support system. Explanation: There is no indication that the client is in pain. Reporting the behavior to the healthcare provider isn't necessary. Because this mother is single and this is her first baby, it is important to assess her support system. There is no indication that the client is uncomfortable with her parenting skills.

The milk that flows from the breast at the start of a feeding or pumping session. It is watery milk that is high in protein and low in fat. a. Colostrum b. Foremilk c. Hindmilk

b. Foremilk

The nurse is assessing a client 24 hours after delivery and finds the fundus to be slightly boggy and 2 centimeters above the umbilicus. What should be the nurse's priority intervention? a. Document this expected finding. b. Gently massage the fundus until firm. c. Assess the mother's vital signs. d. Notify the healthcare provider.

b. Gently massage the fundus until firm. Explanation: Documentation is routine and therefore appropriate, but a boggy fundus is not expected and requires intervention. Assessing vital signs is a routine measure but is not the priority based on the status of the uterus. The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage, and should drop 1 centimeter below the umbilicus each day. Massaging the fundus until firm is the most important to prevent hemorrhage. It is unnecessary to notify the healthcare provider at this time.

The nurse assessing a postpartum client's fundus finds it firm, 2 centimeters above the umbilicus and displaced to the right. What is the most appropriate nursing intervention at this time? a. Massage the fundus until firm. b. Have the client void and reassess the fundus. c. Notify the healthcare provider. d. Start a pad count.

b. Have the client void and reassess the fundus. Explanation: This client's fundus is already firm, so it is not appropriate to massage the fundus. The fundus is higher in the abdomen than expected, and is displaced to the right, which is probably caused by a distended bladder. Having the client void may return the uterus to the expected position. It is unnecessary to notify the healthcare provider at this time. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated.

A female client has just experienced a vaginal delivery of a male infant. What conclusion should the nurse make regarding the infant after the newborn is assessed? Male newborn. Weight 7 lb, 8 oz; length 20.5 in. Body pink with blue extremities; loud, continuous cry; some flexion of extremities noted; blood pressure 70/40 mmHg; heart rate 160 beats per minute; respirations 45 per minute; rectal temperature 37°C. Quiets when swaddled. Newborn brings hand to mouth; sucks thumb. Eyes open, alert, appears to be gazing about. When placed at the breast, roots and latches on with assistance; sucked vigorously for approximately less than 1 minute. a. Manifestations of hypoxia b. Indications of normal newborn c. Cyanosis related to heart defect d. Behavior indicative of hypoglycemia

b. Indications of normal newborn Explanation: The newborn appears to be normal in both physical and behavioral assessments. There is no indication that the newborn is experiencing hypoxia. The newborn?s temperature is normal; hypothermia is a major cause of hypoxia in the newborn. The cyanosis of the hands and feet is normal for some newborns and does not indicate a heart defect. Vital signs are within normal limits. The newborn does not exhibit signs of hypoglycemia.

A client had a cesarean delivery 12 hours ago. Pain management includes a patient-controlled pump for the administration of morphine sulfate (generic). Which nursing diagnosis, if formulated for the client, has highest priority? a. Ineffective family processes b. Ineffective breathing pattern c. Pain d. Constipation

b. Ineffective breathing pattern Explanation: Constipation could occur but is not as high a priority. There is no basis in the question as stated for ineffective family processes. This client is at risk for respiratory depression related to the administration of morphine. For this reason, ineffective breathing pattern is of greatest concern. Remember airway, breathing, and circulation as priorities for patient safety and promoting maintenance of health. Morphine should help to alleviate the pain and could have the next highest priority after making certain that respirations are not affected.

This classification of lochia has the following characteristics: Pinkish color; day 3 until day 10; contains serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and numerous microorganisms a. Lochia rubia b. Lochia serosa c. Lochia alba

b. Lochia serosa

A postpartum client who had an episiotomy reports perineal discomfort. She is also afraid to have a bowel movement. Which nursing diagnosis is the highest priority for this client at this time? a. Risk for Constipation b. Pain c. Deficient Knowledge d. Activity Intolerance

b. Pain Explanation: There is no indication that the client cannot tolerate activity. The client is not demonstrating insufficient knowledge at this time. If a postpartum client is experiencing pain, she will be less likely to ambulate, less receptive to teaching, and more likely to experience constipation because of the fear of pain with a bowel movement. By treating her pain first, interventions for the other nursing diagnoses will be more successful. By treating her pain first, interventions to prevent constipation (such as ambulation) will be more successful.

Clinically defined as a drop in maternal hematocrit levels of 10% or more from predelivery baseline or excessive bleeding that causes hemodynamic instability or the need for a blood transfusion. a. Postpartum endometritis b. Postpartum hemorrhage (PPH) c. Uterine atony d. Diastasis recti abdominis

b. Postpartum hemorrhage (PPH)

The nurse is teaching a new mother how to breast-feed her infant. Which intervention should be included in the teaching plan? a. Place pillows under the baby's buttocks to elevate the hips while nursing. b. Provide positive feedback to the mother for correctly positioning the infant at the breast. c. Reposition the baby with the hips rotated away from the mother's abdomen. d. Encourage the mother to use the football hold exclusively.

b. Provide positive feedback to the mother for correctly positioning the infant at the breast. Explanation: The baby should be positioned with the head midline and with the abdomen toward the mother's abdomen. The mother should be encouraged to find a hold that works for her and her baby. Positive reinforcement will facilitate the development of maternal competence and confidence in infant care.

A postpartum client's hemoglobin is 10.5 mg/dL. The nurse should encourage the client to include which food item in her diet? a. Yellow vegetables b. Red meat c. Whole wheat bread d. Skim milk

b. Red meat Explanation: Whole wheat bread is important to a well-balanced diet but is not high in iron. A hemoglobin level of 10.5 is low and indicates anemia. Because of this, the client should eat foods high in iron, such as red meat. Yellow vegetables are important to a well-balanced diet but are not high in iron. Skim milk is important to a well-balanced diet but is not high in iron.

The nurse is caring for an Rh negative client who delivered vaginally 2 hours ago. The client's fundus is firm at 1 centimeter below the umbilicus and vital signs are stable. She received morphine IV 4 hours ago for labor pain. The nurse should question which new prescription from the healthcare provider? a. Bathroom privileges b. Sitz bath 20 minutes TID c. Rh0(D) gamma globulin d. Regular diet

b. Sitz bath 20 minutes TID Explanation: Application of heat to the perineum 2 hours after delivery will cause vasodilation, and increase the client's risk of edema and hematoma formation. Ice should be applied for the first 24 hours. Bathroom privileges is an appropriate intervention. Regular diet is an appropriate intervention. Rh0(D) gamma globulin for an Rh-negative client is an appropriate intervention.

This stage of maternal adjustment is characterized by the following Third to tenth day postpartum; obsessed with body functions; rapid mood swings; anticipatory guidance most effective now a. Taking-in phase b. Taking-hold phase c. Letting-go phase

b. Taking-hold phase

The milk "coming in" that has qualities intermediate between those of colostrum and mature milk. It is still light yellow in color but is more copious than colostrum and contains more fat, lactose, water-soluble vitamins, and calories. a. Colostrum b. Transitional milk c. Mature milk

b. Transitional milk

The nurse is caring for a client who is postoperative day one from a cesarean delivery. The client asks the nurse why she has to get up and walk when it hurts her incision so much. What should the nurse include in a response? a. Early ambulation is important to stimulate milk production. b. Walking decreases the risk of blood clots after surgery. c. Walking will decrease the occurrence of afterpains. d. Walking encourages deep breaths to blow off the anesthetic from surgery.

b. Walking decreases the risk of blood clots after surgery. Explanation:Clients who have had a cesarean delivery are at risk for complications of surgery, including thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and possible pulmonary embolus.

The nurse is reviewing infection-control policies with a nursing student. The nurse concludes that the teaching has been effective when the student states, "The best way to prevent postpartum infection starts:" a. "In the recovery room with strict use of sterile technique when palpating the fundus." b. "On the postpartum unit by teaching the client the principles of perineal care." c. "In the labor room by limiting the number of sterile vaginal exams." d. "When the client goes home by avoiding tub baths until the lochia stops."

c. "In the labor room by limiting the number of sterile vaginal exams." Explanation: Clean technique, not sterile technique, is used when palpating the fundus. Teaching perineal care is a correct answer but is not the earliest intervention a nurse could perform. Even when perfect sterile technique is used when doing a vaginal exam, organisms present on the perineum are transported into the vagina and close to the cervix. By limiting the number of vaginal exams, the risk is decreased. Avoiding tub baths until lochia stops is a correct answer but not the earliest step for prevention of postpartum infection.

The nurse should notify the healthcare provider about which laboratory result of a client who is one day postpartum? a. White blood cell count of 20,000/mm3 b. An increase in fibrinogen levels c. +3 proteinuria d. A drop in hematocrit of 2 %

c. +3 proteinuria Explanation: A, B, and D are within normal limits for a client in the first postpartum day, and reflect expected physiologic changes related to labor and delivery. +3 proteinuria is significant and could indicate the presence of pre-eclampsia within the first 48-72 hours postpartum.

The registered nurse (RN) is assigned to the postpartum unit. Which task could the RN safely delegate to a certified nursing assistant (CNA)? a. Call the healthcare provider to report a low hemoglobin level. b. Complete the admission assessment on a newly delivered client. c. Ambulate a client who delivered by cesarean section two days ago. d. Verify a unit of blood prior to transfusion.

c. Ambulate a client who delivered by cesarean section two days ago. Explanation: The RN is responsible for delegating tasks appropriately, and for the actions of unlicensed employees. Ambulating a postoperative client is the only task that the RN could delegate from those listed because it is a routine care activity. Completing the admission assessment requires higher-level assessment and critical thinking skills and should be performed by the RN. It is outside the scope of practice for a CNA to assess a client. Communicating with the healthcare provider requires higher-level assessment and critical thinking skills and should be performed by the RN. It is outside the scope of practice for a CNA. Verifying a unit of blood requires higher-level assessment and critical thinking skills and should be performed by the RN. It is outside the scope of practice for a CNA.

Three hours after a vaginal delivery, the client reports increased perineal pain. What should the nurse do first? a. Apply ice to the perineum b. Perform perineal care c. Assess the perineum d. Administer analgesia as prescribed

c. Assess the perineum Explanation: The first step of the nursing process is assessment. Increased perineal pain in a client with a vaginal delivery could be a normal process as delivery anesthetics administered locally wear off. It could also indicate abnormal processes, such as the development of a hematoma. Assessment of this client is needed prior to intervention.

The nurse formulates the nursing diagnosis risk for impaired parenting related to knowledge deficit in newborn care for a 15-year-old primipara who delivered yesterday. Which is the most appropriate intervention when planning this client's discharge teaching? a. Have the client watch a video on newborn care. b. Give her information about a support group for adolescent mothers. c. Demonstrate how to care for the newborn and have the client return the demonstration. d. Give the client printed instructions on newborn care.

c. Demonstrate how to care for the newborn and have the client return the demonstration. Explanation: A video may be appropriate, but does not allow the nurse to evaluate the effectiveness of the teaching session. Giving information about support groups may be appropriate, but does not allow the nurse to evaluate the effectiveness of the teaching session. Demonstrating newborn care will allow the client to ask questions and gain confidence as she cares for her baby. Having her return the demonstration will allow the nurse to evaluate the teaching. Printed instructions may be appropriate, but does not allow the nurse to evaluate the effectiveness of the teaching session.

A postpartum client who delivered 3 hours ago states, "I feel all wet underneath." What should be the initial action of the nurse? a. Determine when she last voided. b. Ask the client to rate her discomfort on a 0-10 scale. c. Have the client roll over to assess her lochia flow. d. Perform perineal care.

c. Have the client roll over to assess her lochia flow. Explanation: It is possible that a significant amount of lochia could pool beneath the client after delivery. The highest priority at this time is risk for hemorrhage, and this should be the initial assessment. Assessing time of last voiding could then follow. Rating discomfort is irrelevant to the question as stated. It is possible that a significant amount of lochia could pool beneath the client after delivery. The highest priority at this time is risk for hemorrhage, and this should be the initial assessment. Perineal care could then follow. It is possible that a significant amount of lochia could pool beneath the client after delivery. The highest priority at this time is risk for hemorrhage, and this should be the initial assessment.

Which laboratory finding should the nurse assess further on a client who delivered an infant 24 hours ago? a. Hematocrit 35% b. Trace to 1+ proteinuria c. Hemoglobin 7.2 grams/dL d. White blood cell count 20,000/mm3

c. Hemoglobin 7.2 grams/dL Explanation: A client with a hemoglobin of 7.2 grams/dL would most likely have significant signs and symptoms of anemia, and this could be life-threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. Leukocytosis up to 30,000/mm3 is common in early postpartum. Mild proteinuria is common in early postpartum. The hematocrit is within normal limits for early postpartum.

The process by which a woman learns mothering behaviors and becomes comfortable with her identity as a mother a. Level of trust b. Identity attainment c. Maternal role attainment d. Postpartum maturation

c. Maternal role attainment

White or slightly blue-tinged in color. Present by 2 weeks postpartum and continues thereafter until lactation ceases. Contains 13% solids 87% water. Appearance is similar to skim cow's milk. By 6 months postpartum, mother produces approximately 800 mL/day. a. Colostrum b. Transitional milk c. Mature milk

c. Mature milk

After delivering a 4355-gram (9-lb, 10-oz) baby, a client who is a gravida 5, para 5 is admitted to the postpartum unit. What should be a priority in delivering nursing care to this client? a. Perform passive range of motion on extremities because she is at risk for thromboembolism. b. Assess client's diet because she is at risk for anemia. c. Palpate the fundus because she is at risk for uterine atony. d. Offer fluids, since multiparas generally dehydrate faster during labor.

c. Palpate the fundus because she is at risk for uterine atony. Explanation: Uterine atony is the most common cause of early postpartum hemorrhage. This client is at greater risk for hemorrhage because she had an overdistended uterus with a large baby, and she is a grand multipara. Parity does not influence dehydration. The client may be at risk for thromboembolism, but there is no indication passive range of motion should be implemented rather than early ambulation. Nutritional assessment is important, but there is no indication the client is anemic and this action is not the priority for the client.

A goal on the nursing care plan is "to facilitate parent-infant bonding." Which nursing intervention should the nurse give priority in order to attain this goal? a. Encourage the parents to join a new parent support group. b. Teach the parents infant-care skills to increase their confidence. c. Provide assistance and encouragement with rooming-in. d. Keep the newborn in the nursery at night to allow the parents to rest.

c. Provide assistance and encouragement with rooming-in. Explanation: Bonding occurs best when parents have direct and prolonged contact with their newborn in a supportive environment. Although joining a support group may be appropriate, it would not be the priority in facilitating bonding. Although infant-care skills may be appropriate, they would not be the priority in facilitating bonding.

The postpartum period. Begins immediately after birth and continues for approximately 6 weeks or until woman has readjusted physically and psychologically from pregnancy and birth. a. Subinvolution b. Involution c. Puerperium d. Uterine atony

c. Puerperium

After delivery, a client of Chinese descent states that she needs to restore the balance between hot and cold forces in her body, and refuses to bathe. What is the most appropriate nursing intervention? a. Show her a videotape on postpartum self-care. b. Discuss postpartum complications related to poor personal hygiene. c. Recognize her cultural beliefs and respect her wishes. d. Request a psychiatric consult for this client.

c. Recognize her cultural beliefs and respect her wishes. Explanation: Showing a videotape will not change the client's cultural beliefs and is not appropriate. Clients of Chinese descent may perceive an imbalance in hot and cold forces in the body after delivery. They will avoid sources of cold, such as wind, cold beverages, and water (even if warmed) to regain a sense of balance between these extremes. A client's culture plays a very important part in who they are, and nurses should respect their wishes as long as it will not result in harm to the client or others. Focusing on hygiene does not show evidence of acceptance of another's culture. Initiating a psychiatric consult does not show evidence of acceptance of another's culture.

A postpartum client's hemoglobin is 9.2 mg/dL after delivery. As a result, she has been instructed to take an iron supplement at home. The nurse should include which instruction when teaching the client about this medication? a. Don't drive a car while taking this medication. b. Call the healthcare provider if your stools become black. c. Take your iron with a glass of orange juice. d. Diarrhea is a common side effect of iron pills.

c. Take your iron with a glass of orange juice. Explanation: Darker-colored stools are common side effects of iron administration. Iron absorption is enhanced when taken with vitamin C, and orange juice is a good source of vitamin C. Iron should not cause impaired judgment or dizziness that would impair safety while driving. Constipation (not diarrhea) is a common side effect of iron administration.

A client is discharged 12 hours after a vaginal delivery. Which finding should the nurse teach the client to notify the healthcare provider immediately if it occurs? a. Temperature of 37.8ºC (100.0ºF) b. Tender lump in one breast that disappears after breastfeeding c. Urgency with urination d. Frequent tearful episodes

c. Urgency with urination Explanation: A tender lump that disappears after breastfeeding is normal and does not require immediate attention. A temperature of 37.8ºC (100.0ºF) is normal and does not require immediate attention. Postpartum clients are at risk for urinary tract infections related to urinary retention after delivery. The risk is increased if the client has been catheterized during labor, delivery, or postpartum. Signs of a urinary tract infection include urgency, burning, and frequency of urination. Frequent tearful episodes may be due to hormonal changes and does not require immediate attention at this time.

A client delivered a newborn 90 minutes ago. She is alert and physically active in bed. She states that she needs to go to the bathroom. What is the nurse's most appropriate response? a. "Let me wipe your stitches back and forth to increase circulation." b. "It's important that you wipe yourself from front to back after urinating." c. "I'll get a bedpan for you." d. "I'll walk you to the bathroom and stay with you."

d. "I'll walk you to the bathroom and stay with you." Explanation: Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should stay with the client the first time she ambulates after delivery to promote safety. Early ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region.

A three day postpartum client says to the nurse "I know this is uncomfortable, but when will I start to look normal again in my private area?" What is the most appropriate response by the nurse? a. "Your vagina has suffered trauma during the birth, but will return completely to the way it was in 3 weeks." b. "Your vagina is unlikely to change from this state now that you have had your first child." c. "Don't worry, I've seen many cases like yours." d. "What you are seeing is bruising and swelling that comes from birth. Your vagina should reduce in size in about six weeks, but it will not look the same as it did before you had your baby."

d. "What you are seeing is bruising and swelling that comes from birth. Your vagina should reduce in size in about six weeks, but it will not look the same as it did before you had your baby." Pearson pg. 2331

A new mother reports "afterpains" especially while breast-feeding. What should be the nurse's first action? a. Assess her vital signs. b. Advise her to stop breastfeeding until the pain stops. c. Encourage her to empty her bladder. d. Administer an analgesic.

d. Administer an analgesic. Explanation: Afterpains are anticipated in the postpartum client, especially during breastfeeding because of the let-down reflex and subsequent uterine contractions. They are effectively treated with analgesics. Breastfeeding should not be terminated. A full bladder is not the cause of afterpains. Afterpains are not associated with abnormal changes in vital signs.

In planning care for a postpartum client who delivered 2 days ago, the nurse should expect the client to exhibit which behavior? a. Request the baby be fed in the nursery at night. b. Need help with hygiene and ambulation. c. Hesitate in making decisions. d. Ask questions about infant care.

d. Ask questions about infant care. Explanation: By the second or third postpartum day, mothers are moving into the taking-hold phase of adjustment and are eager to care for the baby and self independently. Hesitation in making decisions is characteristic of the taking-in phase, which occurs earlier and reflects greater dependence on the part of the mother. Needing help with hygiene and ambulation are characteristic of the taking-in phase, which occurs earlier and reflects greater dependence on the part of the mother. Requesting the baby be fed in the nursery at night is characteristic of the taking-in phase, which occurs earlier and reflects greater dependence on the part of the mother.

How can a postpartum client reduce their risk of thromboembolism? a. Antidiuretics b. Taking NSAIDs like ibuprofen c. Bed rest d. Early ambulation

d. Early ambulation

What is the most common neurologic symptom in postpartum women? a. Dizziness b. Drowsiness c. Loss of consciousness d. Headache

d. Headache

The healthcare provider prescribes rubella vaccine prior to discharge for a postpartum client who is not immune to rubella. The nurse concludes that teaching about this medication is effective when the client makes which statement? a. "This shot may cause a fever and make me vomit." b. "I'll need another shot in 1 month and again in 6 months." c. "I'll need another shot after each baby I have with Rh-positive blood." d. I should not get pregnant for at least 3 months after the vaccine.

d. I should not get pregnant for at least 3 months after the vaccine. Explanation: Women who are not rubella-immune should be vaccinated postpartum, prior to discharge. Mild discomfort at the injection site may be expected. Rubella is a viral infection and is not related to Rh status of the blood. The rubella vaccine is a live virus. Becoming pregnant within 3 months of vaccine administration increases risk for congenital fetal anomalies related to the virus. Teaching should include an effective method of birth control and the importance of avoiding pregnancy for the next 3 months.

The nurse notes that the postpartum client is Rh-negative and her baby is Rh-positive. Which maternal laboratory result should the nurse review next in determining if the client is a candidate for Rh0(D) gamma globulin? a. Hemoglobin b. Bilirubin c. Direct Coombs' test d. Indirect Coombs' test

d. Indirect Coombs' test Explanation: Hemoglobin is not a determinant for the administration of Rh0(D) gamma globulin. Direct Coombs' test is conducted on the newborn. An indirect Coombs' test assesses for the presence of Rh antibodies in the maternal blood. Bilirubin tests are conducted on the newborn.

When teaching a new mother how to breast-feed, the nurse should include which instruction? a. Begin nursing with the right breast at each feeding. b. Wash the nipples with soap and water twice daily. c. Supplement the baby with formula every 12 hours until the milk supply is established. d. Slide a finger into the baby's mouth to break suction before removing from the breast.

d. Slide a finger into the baby's mouth to break suction before removing from the breast. Explanation: The nipples should be cleansed with water after each feeding, but soaps can be harsh or irritating. The client should alternate between the right and left breasts for first use at each feeding. It is important for a breastfeeding mother to break the infant's suction on the nipple before removing the baby from the breast. This will help prevent the nipples from becoming sore and the skin from cracking. Milk production and supply is enhanced when no supplementation is used.

The newborn of a postpartum client was sent to the neonatal intensive care unit with respiratory distress. The nurse concludes that teaching about breast-feeding has been effective when the client states that what would be the purpose of pumping the breasts? a. Keep the uterus contracted. b. Prevent engorgement. c. Remove the infected milk. d. Stimulate the milk supply.

d. Stimulate the milk supply. Explanation: Preventing engorgement is a benefit of pumping but not the primary purpose. Breast milk production is based on supply and demand. The more the breasts are stimulated to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced. The milk is not infected. Although stimulation of the breast may stimulate uterine contractions because of the let-down reflex, this is not the primary purpose for pumping the breasts.

A client is to be discharged 12 hours after delivery. The nurse should delay the discharge and notify the healthcare provider if which of the following is observed? a. Moderate lochia rubra b. Fundus firm at umbilicus c. Pulse 62 beats per minute d. Three voidings totaling 240 mL in 12 hours

d. Three voidings totaling 240 mL in 12 hours Explanation: Moderate lochia rubra is expected 12 hours after delivery. A firm fundus is expected 12 hours after delivery. A pulse rate of 62 is expected 12 hours after delivery. An adult client should have a minimum urinary output of 30 mL/hr and this client is below that minimum. In a postpartum client, this is most likely related to urinary retention secondary to perineal edema and trauma from delivery. It is important that postpartal clients are able to empty their bladders without assistance prior to discharge.

Which of the following should be increased in the postpartum breastfeeding woman's diet? [SATA] a. Overall calories to 2500-2700 kcal/day b. Protein to 65 g/day c. Calcium to 1000 mg/day d. Fluids - 8-10 8oz glasses/day

a, b, c, d Pearson pg. 2338

Which of the following are postpartum women at risk for? [SATA] a. Sluggish bowels b. Fear of defacating/urinating if episiotomy or laceration present c. Hastened bowels d. Buildup of residual urine

a, b, d

This stage of maternal adjustment is characterized by the following 10 days to 6 weeks postpartum; mothering functions established; sees infant as a unique person a. Taking-in phase b. Taking-hold phase c. Letting-go phase

c. Letting-go phase

Are women who gain excessive weight during pregnancy more likely to sustain that weight gain after childbirth?

Yes

Which of the following would be considered an abnormal WBC count to see in a 1 day postpartum client? a. 3,500 b. 8,000 c. 12,000 d. 20,000

a. 3,500 It is expected that WBC will increase, not decrease following labor.

The total average volume of lochia is typically: a. 100 mL b. 225 mL c. 360 mL d. 600 mL

b. 225 mL

Cramplike pains caused by intermittent contractions of the uterus that occur after childbirth. Often more severe in multiparas than in primiparas. a. Subinvolution b. Afterpains c. Puerperium d. Uterine atony

b. Afterpains

This term refers to the rapid reduction in size as the uterus returns to the nonpregnant state. a. Subinvolution b. Involution c. Puerperium d. Uterine atony

b. Involution

The milk that flows during "let down." It is rich in fat and therefore is high in calories. a. Colostrum b. Foremilk c. Hindmilk

c. Hindmilk

What is the leading cause of early postpartum hemorrhage? a. Postpartum endometritis b. Gallstones c. Uterine atony d. Diastasis recti abdominis

c. Uterine atony

This classification of lochia has the following characteristics: Creamy or yellowish color, persists for 1-2 more weeks following day 10, composed of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria. a. Lochia rubia b. Lochia serosa c. Lochia alba

c. Lochia alba

Blood loss during a vaginal birth averages _____ to _____ mL.

Blood loss during a vaginal birth averages 200 to 500 mL.

Which is more common, early postpartum hemorrhage or late postpartum hemorrhage?

Early postpartum hemorrhage

Will platelet levels rise or fall as a result of placental separation in the postpartum client?

Fall, then will increase by days 3-4 and return to normal by sixth week postpartum

[TRUE/FALSE] Evidence has shown that the father has a strong attraction to his newborn and that the feelings he experiences are similar to the mother's feelings of attachment.

True Additionally, the father's characteristic sense of absorption, preoccupation, and interests in the newborn demonstrated during early contact is termed engrossment.

If the fundus is higher than expected on palpation and is not in the midline (usually distended to the right), what should the nurse ask the client?

When was the last time you voided? The nurse should assist the client to empty her bladder.

Any slowing of uterine descent, can be caused by oversized uterus during pregnancy or infection. a. Subinvolution b. Involution c. Puerperium d. Uterine atony

a. Subinvolution

This stage of maternal adjustment is characterized by the following First 3 days postpartum; needs to discuss labor and delivery; preoccupied with own needs; passive and dependent; touches and explores infant a. Taking-in phase b. Taking-hold phase c. Letting-go phase

a. Taking-in phase

How far does the fundus descend every day? Give in terms of cm and fingerbreadths

1 cm or 1 fingerbreadth per day for 10 days until fully descended

How long does healing at the placental site take to complete postpartum?

6 weeks

Blood loss during a cesarian birth averages _____ mL.

Blood loss during a cesarian birth averages 1000 mL.

Which assessment should alert the nurse to withhold the scheduled dose of methylergonovine maleate for a postpartum client and call the healthcare provider? a. Blood pressure 162/86 b. Apical pulse 56 c. Blood type O positive d. Mother is planning to breastfeed

a. Blood pressure 162/86 Explanation: A potential side effect of methylergonovine maleate is hypertension. If a client's blood pressure is elevated, the nurse should hold the scheduled dose and notify the healthcare provider. An apical heart rate of 56 is within normal limits postpartum. Blood type is not related to the use of methylergonovine maleate. The chosen feeding method is not related to the use of methylergonovine maleate.

TRUE/FALSE: Seizures are less likely during labor or in the first 24 hours postpartum than during pregnancy.

False Seizures are more likely during labor or in the first 24 hours postpartum than during pregnancy

TRUE/FALSE: Breastfeeding slows involution of the uterus

False, breastfeeding hastens uterine involution by stimulating uterine contractions through the release of oxytocin

The initial milk that begins to be secreted during midpregnancy and that is immediately available to the baby at birth. a. Colostrum b. Foremilk c. Hindmilk

a. Colostrum

Initial healing of an episiotomy should occur within __ to __ weeks after birth, but complete healing may take up to __ to __ months.

Initial healing of an episiotomy should occur within 2 to 3 weeks after birth, but complete healing may take up to 4 to 6 months.

A 2 day postpartum client complains to the nurse about a headache. The nurse's first priority action is to: a. Obtain vital signs, especially BP b. Administer an analgesic c. Notify provider d. Tell client they have scheduled pain medicine due in 8 hours

a. Obtain vital signs, especially BP Headache during the postpartum period could be a sign of preeclampsia, so the nurse should check a blood pressure prior to analgesic administration to rule out hypertension as the cause. Pearson pg. 2234

The nurse is preparing to instruct a new mother on resuming sexual intercourse postpartum. What items should the nurse include in the teaching plan? a. A water-soluble lubricant may be used if necessary. b. Wait until episiotomy has healed and lochia has stopped before resuming intercourse. c. An intrauterine device (IUD) is appropriate for birth control in the early postpartum period. d. Use petroleum jelly for vaginal lubrication. e. Refrain from intercourse until first menstrual period after delivery is completed.

a, b Explanation: Water-soluble lubricants can be used, if necessary. An IUD is contraindicated during the early postpartum period. Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases the risk of infection. Sexual intercourse should be held off until the episiotomy is healed or the lochia has stopped to decrease the risk of infection.

Which of the following are considered to be normal vital sign changes in the first few days postpartum? [SATA] a. Rise in both systolic and diastolic BP b. Drop in both systolic and diastolic BP c. Puerperal bradycardia (50-70 bpm) d. Tachycardia above 100 bpm e. Temperature of 101.1 during first 24 hours when milk is coming in.

a, c, e Drop in systolic and diastolic BP may reflect hypovolemia secondary to hemorrhage. Tachycardia above 100 bpm could indicate hypovolemia, infection, fear, or pain and requires further assessment.

The nurse is caring for a client who has decided not to breastfeed. What elements should the nurse include in client teaching to promote suppression of lactation? a. Binding the breasts, either with a snug bra or binder b. Using medication to suppress lactation c. Applying warm compresses d. Pumping the breasts e. Applying ice bags

a, e Explanation: Milk supply is stimulated by applying heat to the breasts. Milk supply is stimulated by expressing milk. Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Medications to suppress lactation are not recommended. Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the breasts. Medications to suppress lactation are not recommended.

A postpartum client asks the nurse how to strengthen her perineal muscles. The nurse teaches the client which strengthening technique? a. Try to start and stop the flow of urine. b. Gently squeeze the uterus while pushing downward on the fundus. c. Straighten the leg and point the toes toward the head. d. Bear down as though having a bowel movement.

a. Try to start and stop the flow of urine. Explanation: Kegel exercises are designed to strengthen the muscles of the perineum. By alternately tensing and releasing the muscles of the perineum, as if to start and stop the flow of urine, muscle tone and strength are enhanced. Bearing down is the opposite type of exercise for this set of muscles. Squeezing the uterus is an incorrect statement of technique. Straightening the leg and pointing the toes toward the head is an incorrect statement of technique.

Which of the following are true statements regarding postpartum clients' experiences? [SATA] a. Often report ease in finding time for themselves b. Report feelings of incompetence because they have not mastered mothering role c. Fatigue related to sleep deprivation is common d. Finding time for older children is not described as a stressor e. Infant's behavior can be challenging, especially around 8 months of age

b, c, e

A client's vital signs following delivery are: (Day 1) BP 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; (Day 3) BP 114/80, T 101.6, P 80. The nurse should suspect that the client has which problem? a. Dehydration b. Impending shock c. No problem; normal status d. Possible infection

d. Possible infection Explanation: An elevated temperature within the first 24 hours is usually related to dehydration, but this client is 3 days postpartum. An elevation in body temperature greater than 38ºC (100.4ºF) after the first 24 hours postpartum could indicate maternal infection and warrants further follow-up. The vital signs are not normal. Rising pulse and falling blood pressure rather than rising temperature are an indicator of hypovolemic shock.