64Qw/exp NICEEE Ch 19: Nursing Care of the Family during the Postpartum Period NCLEX

Baby-friendly hospitals mandate their infants be put to breast within the first _______ after birth. a) 1 hour b) 30 minutes c) 2 hours d) 4 hours

A (1 hour)

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a. At the time of admission to the nurse's unit. b. When the infant is presented to the mother at birth. c. During the first visit with the physician in the unit. d. When the take-home information packet is given to the couple.

A (Discharge planning, the teaching of maternal and newborn care, begins on the woman's admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.)

In the recovery room, if a woman is asked either to raise her legs off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. Has recovered from epidural or spinal anesthesia. b. Has hidden bleeding underneath her. c. Has regained some flexibility. d. Is a candidate to go home after 6 hours.

A (If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.)

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: A. Place her on a bedpan to empty her bladder. B. Massage her fundus. C. Call the physician. D. Administer Methergine, 0.2 mg IM, which has been ordered prn.

B (A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.)

The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding? A. Risk of infection B. Evidence of severe pain C. Potential risk of hypovolemic shock D. Potential risk of impaired urinary elimination

C (If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination.)

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation? A. Administer prostaglandins. B. Administer oxytocin. C. Document the findings and continuing to monitor. D. Massage the fundus every 15 minutes.

C (Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.)

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. The father of the infant. b. Her mother (the infant's grandmother). c. Her eldest daughter (the infant's sister). d. The nurse.

D (In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.)

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. Pouring water from a squeeze bottle over the woman's perineum. b. Placing oil of peppermint in a bedpan under the woman. c. Asking the physician to prescribe analgesics. d. Inserting a sterile catheter.

D (Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.)

The primary health care provider (PHP) has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine? Select all that apply. A. "Stop breastfeeding after receiving the vaccine." B. "You need not return to the hospital because one dose is enough for you." C. "Stop taking all medications after returning home." D. "You must return for a second dose in 4 to 8 weeks." E. "Use contraception for 1 month to avoid pregnancy."

D, E (After receiving the first dose of Varivax, the patient must take the second dose 4 to 8 weeks later. The patient must use contraception for 1 month after being vaccinated to avoid pregnancy because the vaccine has teratogenic effects. Mothers who receive the varicella vaccine can continue to breastfeed because the vaccine is not transmitted to the fetus through breast milk. Postpartum women usually have low immunity, so one dose is not sufficient. Stopping of all medications is not necessary and can endanger the patient.)

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh?2-, baby Rh+ c. Mother Rh+, baby Rh+ b. Mother Rh?2-, baby Rh?2- d. Mother Rh+, baby Rh?2-

A (An Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.)

While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient? A. Apply an ice pack to limit edema during the first 12 to 24 hours. B Instruct the patient to use two or more perineal pads. C. Teach the patient to avoid taking sitz baths. D. Remind the patient to avoid doing perineal (Kegel) exercises.

A (Applying a covered ice pack to the perineum from front to back during first 24 hours decreases edema and increases comfort. Using two or more perineal pads would be helpful in absorbing the heavy menstrual flow but will not reduce the pain or promote perineal healing. Sitz baths and Kegel exercises are important measures to provide pain relief and comfort to the patient with a fourth-degree laceration. Therefore the nurse should not advise the patient to avoid taking sitz baths and performing perineal (Kegel) exercises.)

The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient? A. 300 mcg of intramuscular Rh immune globulin B. 400 mcg of intramuscular Rh immune globulin C. 100 mcg of intramuscular Rh immune globulin D. 200 mcg of intramuscular Rh immune globulin

A (If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. A dose of 400 mcg of intramuscular Rh immune globulin may result in an overdosage. A dose of 100 mcg or 200 mcg of intramuscular Rh immune globulin is not sufficient to prevent maternal sensitization.)

A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation? A. Apply ice packs in the perineum. B. Administer fluids to the patient. C. Administer blood to the patient. D. Refer the patient for hematologic tests.

A (If the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient.)

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. Is inconsistent with the Baby Friendly Hospital Initiative. b. Promotes longer periods of breastfeeding. c. Is perceived as supportive to both bottle-feeding and breastfeeding mothers. d. Is associated with earlier cessation of breastfeeding.

A (Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers.)

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? a. The woman leaves the infant on her bed while she takes a shower. b. The woman continues to hold and cuddle her infant after she has fed her. c. The woman reads a magazine while her infant sleeps. d. The woman changes her infant's diaper and then shows the nurse the contents of the diaper.

A (Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant's elimination patterns.)

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. Determine which pad is best. c. Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off.

A (Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is' possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.)

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

A (The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse.)

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient? A. Take stool softeners regularly. B. Continue prenatal vitamins. C. Include iron supplements. D. Take analgesics as prescribed.

A (The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean.)

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d. A Kleihauer-Betke test should be performed.

A (This client's rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.)

The nurse is caring for a lactating patient with a body temperature of 102° F (38.9° C). The nurse finds that the patient's breasts are engorged, swollen, hard, and red. Which interventions related to patient care would be helpful in managing breast engorgement? Select all that apply. A. Taking warm showers before breastfeeding B. Nursing the baby frequently C. Using a tight supportive bra or a breast binder D. Applying cold cabbage leaves to the breasts E. Avoiding use of lanolin or hydrogel pads

A, B, D (Engorgement in a breastfeeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Taking warm showers can increase milk flow. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. Cold cabbage leaves work well to reduce pain and swelling and should be applied every 4 hours. Binding the breasts is not appropriate because it decreases the milk supply. To ease the discomfort associated with sore nipples, the mother may apply topical preparations such as purified lanolin or hydrogel pads.)

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? Select All That Apply a. The mother should check the photo ID of any person who comes to her room. b. The baby should be carried in the parent's arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the patient's room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person.

A, D, E (Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in arms between the mother's room and the nursery, but rather is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photos of their new baby on the Internet and other public forums.)

The nurse finds that a postpartum patient's perineal pad is soaked after 15 minutes. What should the nurse infer from the finding? A. Normal finding after childbirth B. Sign of excessive hemorrhage C. Presence of lochial discharge D. Sign of postpartum hypotension

B (A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient.)

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a. Rectal suppositories. b. Early and frequent ambulation. c. Tightening and relaxing abdominal muscles. d. Carbonated beverages.

B (Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.)

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

B (Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.)

The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5 cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding? A. Light bleeding B. Scanty bleeding C. Heavy bleeding D. Moderate bleeding

B (If the area of saturated pad is less than 2.5 cm, it indicates that the patient had scanty bleeding. If it is less than 10 cm, then the patient had light bleeding. If the pad is saturated within 2 hours, the patient had heavy bleeding. If it is 10 cm or more, the patient had moderate bleeding.)

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching? A. "I need to wear a supportive bra to relieve the discomfort." B. "I need to stop breastfeeding until this condition resolves." C. "I can use analgesics to alleviate some of the discomfort." D. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

B (In most cases, the patient can continue to breastfeed. If the affected breast is too sore, the patient can pump the breast gently. Regular emptying of the breast is important to prevent the formation of abscess. Use of a supportive bra suppresses milk production and prevents breast engorgement. Additional supportive measures include ice packs, breast supports, and analgesics. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours.)

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: a) Place her on a bedpan to empty her bladder b) Massage her fundus c) Call the physician d) Administer methylergonovine (Methergine), 0.2mg IM, which has been ordered prn

B (Massage her fundus)

As relates to rubella and Rh issues, nurses should be aware that: a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

B (Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination.)

The nurse is monitoring a postpartum patient for signs of hemorrhage. Which observation would indicate excessive blood loss? A. A body temperature of 100.4º F B. An increase in pulse from 88 to 102 beats/min C. An increase in respiratory rate from 18 to 22 breaths/min D. A blood pressure change from 130/88 to 120/80 mm Hg

B (During the postpartum period, maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to increase the supply of blood. A body temperature of 100.4º F is a normal finding. A respiratory rate of 22 breaths/min indicates that the patient has no internal bleeding. A blood pressure of 120/80 mm Hg does not indicate that the patient has hemorrhage.)

A patient who has had a cesarean birth has been on bed rest for 8 hours after surgery and has warmth and redness in the left lower limb. Which interventions taken by the nurse would be most beneficial to the patient? Select all that apply. A. Advise the patient to apply a hot compress at the reddened site. B. Inform the primary health care provider (PHP) about the patient's condition immediately. C. Advise the patient to apply an antinflammatory ointment at the reddened site. D. Have the patient sit upright and lower the reddened leg. E. Have the patient remain in bed with reddened limb elevated on pillows.

B, E (A patient who has had a cesarean birth and has remained in the bed for more than 8 hours is at risk of venous thromboembolism. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the leg, the nurse should notify the PHP immediately. Meanwhile, the patient should remain in bed with the affected limb elevated on pillows. Applying heat increases discomfort because the affected limb is already warm. Applying antiinflammatory ointment to the leg at the reddened site would not be useful because the redness is caused by embolism, not inflammation.)

The nurse is caring for a 24-hour-postpartum patient who had a cesarean birth with general anesthesia. The patient complains of abdominal discomfort and gas pains. What would be the most suitable nursing intervention in this situation? A. Encourage the patient to drink coffee. B. Administer analgesic medications to patient. C. Encourage the patient to use a rocking chair. D. Offer soups and beverages to the patient

C (A patient who complains of abdominal discomfort and gas pains should be encouraged to use a rocking chair because it stimulates the passage of flatus and relieves discomfort. The patient should not be encouraged to drink coffee because the caffeine present in it intensifies the pain by increasing bowel movements. Analgesic medication does not relieve gas, but the administration of antigas or antiflatulent medications may help relieve gas. Offering soups and beverages may cause more discomfort and gas in the patient.)

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is: a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

C (Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A "fleshy" odor, not a foul odor, is within normal limits.)

Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas b) Unrepaired lacerations of the vagina or cervix c) Failure of the uterine muscle to contract firmly d) Retained placental fragments

C (Failure of the uterine muscle to contract firmly)

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. Discusses her labor and birth experience excessively. b. Believes that her baby is more attractive and clever than any others. c. Has not given the baby a name. d. Has a partner or family members who react very positively about the baby.

C (If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby's sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.)

Postpartal overdistention of the bladder and urinary retention can lead to which complications? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

C (Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.)

The nurse is caring for a postpartum patient who has an episiotomy wound. The nurse finds that the patient has soreness at the incision site and lower back pain. What does the nurse tell the patient? A. Avoid using sitz baths. B. Avoid cleaning the perineal area frequently. C. Place a covered ice pack on the affected area. D. Drink plenty of water and eat foods containing fiber

C (Patients with episiotomy may have soreness and back pain. To relieve soreness and back pain, the nurse should advise the patient to place an ice pack on the affected area. This provides comfort and reduces the inflammation and pain. A sitz bath helps relieve lower back pain and discomfort, so the patient should be encouraged to use sitz baths at a temperature of 38° to 40° C (100° to 104° F) at least twice a day to prevent edema. Not cleaning the perineal area may cause infection, so the nurse should advise the patient to clean her perineum frequently. Drinking plenty of water and eating foods such as fresh fruit and vegetables that contain fibers can relieve constipation or hemorrhoids but does not help reduce soreness.)

The nurse is preparing to administer rubella vaccine to a patient during the postpartum period. At the follow-up visit, the patient reports to the nurse that she has rashes on her skin. What does the nurse expect the primary health care provider (PHP) to prescribe in this situation? A. Oxytocin (Pitocin) B. Rh immune globulin C. Adrenaline (Epinephrine) D. Magnesium sulfate

C (Rubella vaccine is made from duck eggs; therefore women who are allergic to duck eggs can develop a hypersensitivity reaction to the vaccine. As a result, the patient might develop rashes on her skin. The PHP would prescribe adrenaline to combat hypersensitivity reactions. Oxytocin is injected to increase the tone of the uterine muscles but not to combat hypersensitivity. Rh immune globulin suppresses the immune system, which would worsen the condition; therefore this medication is unlikely to be prescribed. Magnesium sulfate is used for preeclampsia and is not used to minimize hypersensitivity reactions caused by rubella vaccine.)

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having the patient flex, extend, and rotate her feet, ankles, and legs. c. Having the patient sit in a chair. d. Notifying the physician immediately if a positive Homans' sign occurs.

C (Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans' sign (calf muscle pain or warmth, redness, or tenderness) requires the physician's immediate attention.)

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A. Massage the fundus. B. Administer Methergine, 0.2 mg PO, that has been ordered prn. C. Assist the woman to empty her bladder. D. Recognize this as an expected finding during the first 24 hours following birth.

C (The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action is to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. This is not an expected finding, and emptying the bladder is required.)

Which measure is least effective in preventing postpartum hemorrhage? A. Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered B. Encouraging the woman to void every 2 hours C. Massaging the fundus every hour for the first 24 hours following birth D. Teaching the woman the importance of rest and nutrition to enhance healing

C (The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage. )

A lactating patient who gave birth to twins 1 month earlier approaches the primary health care provider (PHP) for a general checkup. What suggestion does the nurse give to the patient about the recommended calorie intake? A. Less than 1800 kcal/day B. Less than 2200 kcal/day C. More than 2700 kcal/day D. Should be 1800 to 2200 kcal/day

C (The recommended caloric intake for a lactating mother who breastfeeds more than one infant is more than 2700 kcal/day. If a lactating mother of twins takes less than 2200 kcal/day, she may not produce enough milk. An intake of 1800 to 2200 kcal/day is recommended for nonlactating mothers.)

Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 b. 24, 96 c. 48, 96 d. 48, 120

C (The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.)

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: a. Retained placental fragments. b. Unrepaired vaginal lacerations. c. Uterine atony. d. Puerperal infection

C (This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.)

Excessive blood loss after childbirth can have several causes; however, the most common is: A. Vaginal or vulvar hematomas. B. Unrepaired lacerations of the vagina or cervix. C. Failure of the uterine muscle to contract firmly. D. Retained placental fragments.

C (Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.)

Excessive blood loss after childbirth can have several causes; the most common is: a. Vaginal or vulvar hematomas. b. Unrepaired lacerations of the vagina or cervix. c. Failure of the uterine muscle to contract firmly. d. Retained placental fragments.

C (Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.)

The nurse is caring for a 2-day postpartum patient who is breastfeeding. The patient reports breast irritation. Which intervention would be beneficial to the patient? A. Apply ice packs to the breasts between feedings. B. Place hydrogel pads to the breasts between feedings. C. Tell the patient to wear breast shells. D. Apply cold cabbage leaves to the breasts between the feedings.

C (To reduce breast irritation, the nurse advises the patient to wear breast shells. This will increase comfort during breastfeeding. Application of ice packs between feedings reduces breast engorgement. Hydrogel pads can be applied if the patient has sore nipples between feedings. Cold cabbage leaves applied to the breasts for 15 to 20 minutes between feedings can reduce breast engorgement by reducing tissue swelling and facilitating the flow of milk.)

A postpartum patient has chosen not to breastfeed. What instructions should the nurse provide to the patient to prevent discomfort caused by breast engorgement? Select all that apply. A. Express the milk from both breasts. B. Perform regular breast stimulation. C. Wear a well-fitted support bra. D. Use a breast binder. E. Apply ice packs on the breasts

C, D, E (Patients who choose not to breastfeed may experience breast engorgement and related discomfort. The nurse should instruct the patient to wear a well-fitted support bra or use a breast binder to support the breasts, which can relieve discomfort. Applying ice packs with a 15-minutes-on, 45-minutes-off schedule also helps relieve breast engorgement and reduce discomfort. Expressing milk from the breast or performing nipple stimulation may increase milk production and may worsen breast engorgement.)

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

D ("I'll warm the soup in the microwave for you" shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. "What is that anyway?" does not show cultural sensitivity.)

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts and glands. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

D (Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.)

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a) Bladder distention b) Uterine atony c) Constipation d) Hematoma formation

D (Hematoma formation)

On reviewing the medical reports of a postpartum patient, the nurse finds that the patient has Homans' sign. What does the nurse interpret from this finding? A. Risk of uterine atony B. Hypotensive shock C. Risk of developing mastitis D. Venous thromboembolism (VTE)

D (Homans' sign is an assessment test used to determine whether the patient has VTE. Presence of Homans' sign indicates that the patient may have VTE. Uterine atony can be assessed by palpating the uterine fundus. Hypotensive shock can be assessed by checking the patient's vitals. Mastitis can be assessed by the examining the patient's breasts.)

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises? A. To prevent urine retention B. To provide relief of lower back pain C. To tone the abdominal muscles D. To strengthen the perineal muscles

D (Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles.)

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. Formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby.") b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there.") c. Including other family members in the teaching of self-care and child care. ("We're all in this together.") d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

D (Many professionals believe that the nurse's nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. "Mothering the mother" is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.)

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a) Begin an IV infusion of Ringer's lactate solution b) Assess the woman's vital signs c) Call the woman's primary health care provider d) Massage the woman's fundus

D (Massage the woman's fundus)

Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? a) Postural hypotension b) Temperature of 38 C c) Bradycardia- pulse rate of 55 beats/min d) Pain in left calf with dorsiflexion of left foot

D (Pain in left calf with dorsiflexion of left foot)

What intervention does the nurse perform to suppress lactation in a patient who had a stillbirth? A. Run warm water over the patient's breasts. B. Administer strong analgesics. C. Administer oral and intravenous fluids. D. Advise the patient to wear a breast binder for the first 72 hours after giving birth.

D (Suppression of lactation is recommended in cases of neonatal death. To suppress lactation, the nurse should advise the patient to wear a breast binder continuously for the first 72 hours after delivery. Running warm water over the breast stimulates lactation. Mild analgesics can be administered to reduce breast engorgement, but they are not used to suppress lactation. Administration of oral or intravenous fluids may stimulate lactation.)

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a. Begin an intravenous (IV) infusion of Ringer's lactate solution. b. Assess the woman's vital signs. c. Call the woman's primary health care provider. d. Massage the woman's fundus.

D (The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician would be notified after the nurse completes the assessment of the woman.)

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient? A. "The vaccine is safe even if you have an egg allergy." B. "You cannot breastfeed for 5 days after taking the vaccine." C. "You will not have joint pains or skin rashes after the vaccination." D. "You should use proper contraception for 3 months after the vaccination."

D (The patient must not become pregnant for 3 months after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.)

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse recognizes the need for additional instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from the symphysis pubis back to the episiotomy. C. Changes her perineal pad every 2 to 3 hours. D. Uses the peribottle to rinse upward into her vagina.

D (The peribottle should be used in a backward direction over the perineum . The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash is appropriate. Washing from the symphysis pubis back to the episiotomy is appropriate. Changing the perineal pad every 2 to 3 hours is appropriate.)

The nurse is caring for a postpartum patient who gave birth recently. The nurse is evaluating the parent's behavior toward the new baby. Which parent-infant behaviors should the nurse investigate further? A. Change the baby's diapers when needed. B. Position the baby comfortably. C. Demonstrate eye-to-eye contact with the baby. D. Complete the child care activities silently, without looking at the baby.

D (The psychosocial assessment includes evaluating adaptation to parenthood, as evidenced by the parents' reactions to the baby and interactions with the new baby. Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning baby comfortably, and maintaining eye-to-eye contact are appropriate behaviors that increase parent-infant attachment.)

The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding? A. Hand the father the newborn and instruct him to change the diaper. B. Ask the father why he is so anxious and nervous. C. Tell the father that he will get used to the newborn in time. D. Provide education about newborn care when the father is present.

D (To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn)

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

D (Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder.)

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

D (These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.)

Perineal care is an important infection control measure. When evaluation a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a) Uses soap and warm water to wash the vulva and perineum b) Washes from symphysis pubis back to the episiotomy c) Changes her perineal pad every 2 to 3 hours d) Uses the peribottle to rinse upward into her vagina

D (Uses the peribottle to rinse upward into her vagina)