ADN 240 Postpartum exam
A postpartum nurse is providing care for a client who is breastfeeding and has a perineal hematoma. The nurse should recommend that the client use which of the following breastfeeding positions? A. Side-lying B. Clutch hold C. Across-the-lap D. Cross-cradle
A. Side-lying The side-lying position allows the client to access her baby, facilitates latching, and reduces pressure on the hematoma. The client will be more comfortable while breastfeeding in this position.
A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Respiratory rate 52/min B. Weight 2500 grams (5.5 lb) C. Head circumference 28 cm (11 in) D. Blood glucose 48 mg/dL
C. Head circumference 28 cm (11 in) A head circumference of 28 cm (known as microcephaly) is below the expected reference range of 32 to 36.8 cm for a newborn. Microcephaly can indicate fused cranial sutures or prenatal infection with rubella, toxoplasmosis, or cytomegalovirus. The nurse should report this finding to the provider.
A postpartum nurse is caring for a client who has developed hemorrhagic shock. Which of the following manifestations should the nurse expect? A. Urinary output of 40 mL/hr B. Deep abdominal breathing C. Weak and irregular pulse D. Warm, dry hands with prompt capillary refill
C. Weak and irregular pulse A weak, irregular, and rapid pulse can indicate postpartum hemorrhagic shock due to decreased oxygenation and perfusion to the heart. The client will need fluid replacement and medical attention.
A nurse is teaching a client who is postpartum and breastfeeding. Which of the following statements should the nurse include? A. "You will need to wait 3 months before resuming sexual intercourse." B. "You don't need to use contraception until you are 4 months postpartum." C. "As long as you breastfeed, you will experience an overproduction of vaginal lubrication." D. "A reduction in sexual interest could indicate postpartum depression."
D. "A reduction in sexual interest could indicate postpartum depression." Manifestations of postpartum depression include decreased libido, feelings of sadness or anxiety, difficulty sleeping, or loss of appetite.
A nurse is teaching about mastitis to a client who is postpartum and breastfeeding her newborn. Which of the following statements by the client indicates an understanding of the teaching? A. "I will limit breastfeeding to 5 minutes per breast." B. "I will not breastfeed if I start to have flu-like symptoms." C. "I will shop for an underwire nursing bra today." D. "I will avoid any of my family members who are ill." Check Answer Question Feedback Show Explanation
D. "I will avoid any of my family members who are ill." The client should avoid ill family members to decrease the risk of mastitis. While the causative organisms of mastitis tend to be bacterial, exposure to viral illnesses can compromise the immune system and leave the client vulnerable to mastitis.
A nurse is providing teaching for a postpartum client who is breastfeeding. Which of the following statements indicates an understanding of the teaching? A. "I should feed my baby 8-12 times a day, based on feeding cues." B. "My baby should have 6 or 7 wet diapers a day during the first week." C. "I should switch my baby to the other breast after 15 minutes of feeding." D. "My nipple pain should go away after a few weeks of breastfeeding."
A. "I should feed my baby 8-12 times a day, based on feeding cues." For the first few days, parents might have to wake the newborn to feed every 2 to 3 hours. Once the infant is feeding well and gaining weight, feedings should be based on the infant displaying hunger cues, such as sucking on the fist and rooting.
A nurse is teaching a postpartum client how to swaddle her newborn. Which of the following statements by the parent demonstrates an understanding of the teaching? A."I should stop swaddling my baby once she is able to roll over by herself." B."My baby's legs should be extended straight out when I swaddle her." C."I should be able to slide just 1 finger between my baby's chest and the swaddled blanket." D. "After swaddling, I should place my baby on her side in her crib or bassinet."
A. "I should stop swaddling my baby once she is able to roll over by herself." The parent should discontinue swaddling the baby once the baby is able to roll over, which occurs around 2 months of age. Rolling over can tighten the swaddle and keep the baby from breathing properly.
A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."
A. "This will resolve in 3 to 6 weeks without treatment." This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks.
A nurse is reviewing risk factors for postpartum depression with a newly licensed nurse. Which of the following risk factors should the nurse include? A. Gestational diabetes B. Planned pregnancy C. Being married D. Post-term birth
A. Gestational diabetes Gestational diabetes increases the risk of postpartum depression. Other risk factors include infertility treatment, pregnancy complications, preterm birth, and a history of mood disorder.
A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL
A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL.
A nurse is assessing a newborn 1 hr after birth. Which of the following findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL
A. Jaundice of the sclera If the newborn has jaundice within the first 24 hours of life, this can indicate a potentially pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin, which can damage the neonatal brain.
A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk of uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn
A. Magnesium sulfate infusion B. Distended bladder D. Prolonged labor Magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. After birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics, which can result in a distended bladder. A distended bladder displaces the uterus and can prevent adequate contraction of the uterus. Also, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.
A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°
A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30 The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30°.
A nurse is caring for a newborn who is receiving treatment for jaundice with traditional phototherapy lights. Which of the following interventions should the nurse perform? A. Turn the newborn every 2 hr B. Supplement with 5% glucose water between scheduled feedings C. Dress the infant lightly in a t-shirt and diaper D. Apply lotion to the skin every 4 hr
A. Turn the newborn every 2 hr Phototherapy lowers serum bilirubin levels by converting bilirubin accumulated in the skin to a form that is excreted in the newborn's urine and stools. The infant must be turned every 2 to 3 hours to maximize skin exposure, which promotes bilirubin breakdown.
A nurse is preparing to massage the fundus of a client who is postpartum and experiencing uterine atony. In what order should the nurse take the following actions when performing a fundal massage? (Put them in the correct order) A. Rotate the upper hand to massage the client's uterus. B. Ask the client to lie on her back with her knees flexed. C. Place a hand just above the client's symphysis pubis. D. Use slight downward pressure to compress the client's fundus. E. Position a hand around the top of the client's fundus.
B,C,E,A,D Step 1: The nurse should gently massage the fundus to restore the muscle tone of the client's uterus. First, the nurse should place the client on her back with her knees flexed. Step 2: The nurse should place a hand just above the symphysis pubis. Step 3: Position the other hand around the top of the client's fundus. Step 4: The nurse should then rotate the upper hand to massage the client's uterus. Step 5: Use slight downward pressure to compress the client's fundus.
A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened by a gush of dark red blood from her vagina. Which of the following statements should the nurse make in response? A. "You might have retained placental fragments in your uterus." B. "Blood pools in the vagina when you are lying in bed." C. "You might have a damaged blood vessel." D. "Your blood flow will increase during the first few days after giving birth."
B. "Blood pools in the vagina when you are lying in bed." In the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow to a trickle of bright red lochia.
A nurse is providing postpartum discharge teaching to a client who is non-lactating about breast discomfort relief measures. Which of the following pieces of information should the nurse include? A. "Wear a loose-fitting bra to alleviate breast discomfort." B. "Place fresh cabbage leaves on your breasts." C. "Apply warm, moist compresses to your breasts." D. "Express small amounts of milk from your breasts frequently."
B. "Place fresh cabbage leaves on your breasts." After 3 days postpartum, the client's breasts can become swollen and distended because of congestion of the vascular structures of the breasts. Fresh cabbage leaves can be applied to engorged breasts to help relieve breast discomfort. The coolness of the leaves and the phytoestrogens exert a therapeutic effect on engorged breasts. Leaves should be replaced when they become wilted.
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse make? A. "This could indicate a possible uterine infection." B. "The bleeding is minimal until I discontinue your IV medication." C. "You might have retained some fragments of your placenta." D. "You will require additional medication to increase your bleeding."
B. "The bleeding is minimal until I discontinue your IV medication." The flow of lochia is often scant while receiving oxytocic medication until the effects of the medication wear off. This can be observed regardless of the administration route of the oxytocic medication.
The nurse is teaching a client who is postpartum about the rubella vaccine. Which of the followings statements should the nurse include? A. "You must not take this immunization if you've had the chickenpox." B. "You must not become pregnant for 28 days after receiving this immunization." C. "You must not breastfeed because the virus is passed in breastmilk." D. "You must not receive other vaccines at the same time as the rubella vaccine."
B. "You must not become pregnant for 28 days after receiving this immunization." Clients must not become pregnant for 28 days following rubella immunization. They should be educated about the possible side effects and risk of teratogenic effects on the developing fetus.
A nurse is caring for a client who had a vaginal delivery 24 hours ago. Which of the following findings should the nurse report to the provider? A. 2,000 mL urine since delivery B. 3+ deep tendon reflexes C. Fundus at umbilicus D. Soft breasts
B. 3+ deep tendon reflexes Deep tendon reflexes of 3+ or greater can indicate preeclampsia and should be reported to the provider.
A nurse is assessing a newborn who is 2 hr old. Which of the following findings should the nurse report to the provider? A. Overlapping suture lines B. Generalized petechiae C. Acrocyanosis D. Transient strabismus
B. Generalized petechiae The nurse should report generalized petechiae to the provider. This manifestation can be associated with an infection or a clotting-factor deficiency.
A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse perform first? A. Check for a full bladder B. Massage the fundus C. Measure vital signs D. Administer carboprost IM
B. Massage the fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The primary cause of early postpartum bleeding is uterine atony, which is manifested by a relaxed, boggy uterus. Thus, the greatest risk for this client is hemorrhage. The nurse should massage the client's fundus first. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client.
A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the following techniques should the nurse use? A. Press down and forward with the hand that is placed on the base of the uterus B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus C. Place the client in a semi-Fowler's position prior to checking the uterus D. Massage the fundus with gentle palpation until it becomes soft to touch.
B. Measure the height of the fundus in fingerbreadths in relation to the umbilicus The nurse should measure the height of the fundus in fingerbreadths and should expect the height to decrease 1 fingerbreadth in height daily after birth. The fundus should be about 3 fingerbreadths below the umbilicus by the third day postpartum.
A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse perform first? A. Perform a detailed physical assessment B. Place the newborn directly on the client's chest C. Give the newborn IM vitamin K D. Administer erythromycin ophthalmic ointment
B. Place the newborn directly on the client's chest the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. In this case, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature
A nurse is caring for a client who is postpartum and reports that her episiotomy incision is pulling and stinging. Which of the following actions should the nurse take? A. Encourage the client to ambulate B. Provide a sitz bath with warm water for the client C. Instruct the client to perform Kegel exercises D. Apply anesthetic cream topically each hour while the client is awake
B. Provide a sitz bath with warm water for the client The nurse should provide a client who is postpartum with a sitz bath to decrease episiotomy discomfort. The use of a sitz bath provides warm, moist, direct heat to the incision area, which helps relieve the pulling and stinging associated with the healing incision. The warm water increases blood flow to the area through vasodilatation, which also promotes healing and comfort.
A nurse is planning care for a client who is postpartum. Which of the following strategies should the nurse include in the plan to prevent bladder distention? A. Withhold analgesics to prevent urinary retention B. Run water in the sink while the client sits on the toilet C. Perform Credé's maneuver every 4 hours D. Restrict oral hydration
B. Run water in the sink while the client sits on the toilet Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle to run water over the client's perineum can assist with spontaneous voiding.
A nurse is providing education about continuous heparin therapy for a client who is 18 hours postpartum and has developed a deep vein thrombosis (DVT). Which of the following statements should the nurse include in the teaching? A. "An adverse effect of this medication is drowsiness." B. "This medication will require frequent monitoring of WBC levels." C. "Use a soft toothbrush to brush your teeth gently." D. "Avoid taking acetaminophen while receiving this medication."
C. "Use a soft toothbrush to brush your teeth gently." An adverse effect of heparin therapy is an increased risk of bleeding. The client should use a soft toothbrush to prevent trauma and bleeding.
A nurse is assessing a client who is 2 days postpartum. In which of the following locations should the nurse expect to locate the client's fundus? A. 3 cm above the umbilicus B. 1 cm above the umbilicus C. 3 cm below the umbilicus D. 1 cm below the umbilicus
C. 3 cm below the umbilicus The client's fundus should descend about 1 to 2 cm every 24 hours; therefore, at 2 days postpartum, the client's fundus should be located 3 cm below the umbilicus.
A postpartum nurse is caring for a client who is 4 hours postpartum and has a painful third-degree perineal laceration. Which of the following interventions should the nurse take? A. Prepare to initiate a warm water sitz bath for the client's perineum B. Encourage the client to sit on a soft pillow C. Apply cold ice packs to the client's perineum D. Administer an acetaminophen suppository rectally
C. Apply cold ice packs to the client's perineum A third-degree laceration extends from the perineum to the external sphincter of the rectum. This can cause severe discomfort. Cold ice packs are used on the perineal area during the first 24 hours to decrease edema, pain, and discomfort.
A nurse is assessing a client on the first postpartum day. Findings include the following: fundus firm and one fingerbreadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.3°C (99.2°F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider B. Massage the fundus C. Ask the client when she last voided D. Administer an oxytocic agent
C. Ask the client when she last voided Because the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be firm at the midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.
A nurse is caring for a client who is 2 hours postpartum and is exhibiting signs of hypovolemic shock. Which of the following actions should the nurse take? A. Saline lock the IV catheter B. Provide oxygen via nasal cannula C. Elevate the client's legs to a 30° angle D. Place the client in a semi-Fowler's position
C. Elevate the client's legs to a 30° angle The nurse should position the client on her side with her right hip elevated by a pillow or in a supine position with her legs elevated to at least a 30° angle. This improves blood flow and reduces manifestations of hypotension.
A nurse is providing teaching about breastfeeding to a client who is 4 hours postpartum. Which of the following pieces of information should the nurse include? A. Feed the newborn for 5 minutes on each breast B. Newborns are expected to lose up to 15% of their birth weight C. Ensure the newborn's mouth covers the nipple and areola D. Provide a pacifier to the newborn between feedings starting 3 days after birth
C. Ensure the newborn's mouth covers the nipple and areola The newborn's mouth should open wide prior to latching on to the breast. The client should ensure the newborn's mouth covers the nipple and areola to allow an adequate seal and prevent tissue damage.
A nurse is reviewing the electronic medical record of a newborn. Which of the following maternal factors may increase the risk of pathologic hyperbilirubinemia in the newborn? A. Placenta previa B. Multiple gestation C. Infection D. Anemia
C. Infection Blood group incompatibilities, maternal infection, maternal diabetes, and the administration of oxytocin during labor are potential risk factors for the development of hyperbilirubinemia in newborns.
A nurse is assessing a postpartum client and observes a steady trickle of bright red blood from the client's vagina. The uterus is palpated as firm, midline, and located 1 cm below the umbilicus. Which of the following actions should the nurse take? A. Massage the fundus B. Instruct the client to empty her bladder C. Notify the provider D. Teach the client to perform a sitz bath
C. Notify the provider Excessive vaginal bleeding in the presence of a contracted uterus is a sign of a vaginal or cervical laceration. The provider must be notified so the laceration can be repaired.
A nurse is assessing a postpartum client who has preeclampsia and notes a boggy uterus and excessive uterine bleeding. The nurse should plan to administer which of the following medications? A. Terbutaline B. Magnesium sulfate C. Oxytocin D. Methylergonovine
C. Oxytocin Oxytocin is a uterotonic medication that causes the uterus to contract and reduces excessive uterine bleeding.
A nurse is caring for a client who had a precipitous delivery. Which of the following assessments is the priority during the fourth stage of labor? A. Obtaining the client's temperature B. Inspecting the client's perineum C. Palpating the client's fundus D. Checking the client for hemorrhoids
C. Palpating the client's fundus The nurse should apply the safety and risk-reduction priority-setting framework, which assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority.
A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse perform? A. Prepare the client for an ultrasound examination B. Prepare the client for an emergency cesarean birth C. Prepare equipment needed for newborn resuscitation D. Perform endotracheal suctioning as soon as the fetal head is delivered
C. Prepare equipment needed for newborn resuscitation The nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. Continuous lochia flow and a flaccid uterus B. Report of increasing pain and pressure in the perineal area C. Slow trickle of bright vaginal bleeding and a firm fundus D. Gush of rubra lochia when the uterus is massaged
C. Slow trickle of bright vaginal bleeding and a firm fundus The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration.
A nurse is teaching a client who is postpartum about keeping the newborn safe. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I will put bumper pads in the crib." B. "I will warm my baby's formula in the microwave on a low setting." C. "I will place my baby on his stomach to sleep." D. "I will purchase a firm mattress for the crib."
D. "I will purchase a firm mattress for the crib." A firm mattress that leaves no gaps between it and the crib rails helps prevent suffocation and entrapment.
A nurse is assessing a postpartum client who reports strong contractions whenever she breastfeeds her newborn. The nurse should respond with which of the following statements? A. "Prolactin is increasing the blood supply to your uterus, and you are feeling blood vessel engorgement." B. "You probably have a small blood clot in your uterus, which is causing the uterus to contract in order to expel it." C. "Your breasts are secreting a hormone that enters the bloodstream and causes your abdominal muscles to contract." D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract."
D. "The same hormone that is released in response to the baby's sucking and causes milk to flow also makes the uterus contract." Oxytocin is released in response to breastfeeding. This hormone also causes the uterus to contract, which decreases the risk for postpartum hemorrhage and increases involution.
A postpartum nurse is caring for a client who reports excessive sweating during the first night after delivery. Which of the following statements should the nurse make? A. "This is an attempt by your body to retain the fluid gained during pregnancy." B. "This is caused by an increase in your estrogen hormonal levels." C. "This is caused by the increased pressure on your veins in your lower legs." D. "This is a source of your fluid loss after delivery."
D. "This is a source of your fluid loss after delivery." Postpartum diuresis is the loss of the remaining pregnancy-induced increase in blood volume. The loss of excess tissue fluid begins within 12 hours after birth. Fluid loss by urination and perspiration results in a weight loss of approximately 2.27 kg (5 lb) during the early postpartum period.
A nurse in a newborn nursery has received reports on 4 newborns. Which of the following newborns should the nurse identify as requiring intervention? A. A newborn who has acrocyanosis B. A newborn who has a macular, papular, vesicular rash on the torso C. A newborn who has a blood glucose level of 54 mg/dL D. A newborn whose axillary temperature is 36.1°C (96.9°F)
D. A newborn whose axillary temperature is 36.1°C (96.9°F) This temperature places the newborn at risk for cold stress, which can diminish pulmonary perfusion. The nurse should place the newborn under a radiant heat warmer, monitor the temperature of the newborn, and continue to assess the newborn's respiratory and cardiovascular status.
A nurse is assessing a female client 24 hr after delivery and notes the fundus is 2 cm above the umbilicus. Which of the following actions should the nurse take? A. Administer a tocolytic medication B. Apply a heating pad to the mid-abdominal area C. Reassess the fundus in 2 hr D. Ambulate the client to the bathroom
D. Ambulate the client to the bathroom An increased fundal height in the postpartum period is a sign of a non-contracted uterus, which increases the risk for hemorrhage. The most common postpartum cause of an elevated fundal height is an over-distended bladder.
A nurse is caring for a client who is postpartum and is having difficulty voiding. Which of the following actions should the nurse take first? A. Place the client's hands in warm water B. Administer an analgesic to the client C. Pour water from a squeeze bottle over the client's perineum D. Assist the client to the bathroom
D. Assist the client to the bathroom The greatest risk to this client is an injury from a distended bladder; therefore, the first action the nurse should take is to assist the client to the bathroom to encourage spontaneous voiding. If this is unsuccessful, the nurse can try other techniques to promote voiding.
A nurse is preparing to provide umbilical cord care for a newborn 12 hours after delivery. Upon inspection, the nurse notes moderate bleeding from a blood vessel. Which of the following actions should the nurse take? A. Check the newborn's heart rate B. Place a pressure dressing on the cord stump C. Administer vitamin K D. Check the integrity of the cord clamp
D. Check the integrity of the cord clamp The nurse should apply the clamp to the umbilical cord while detaching it from the placenta to stop blood flow from the cord to the placenta. When the placenta is no longer attached, the blood vessels in the cord will atrophy as the cord stump dries and shrivels. If blood is coming from a vessel prior to the cord stump necrotizing, the nurse should ensure the cord clamp has not loosened or opened. If it has, the nurse should apply a new clamp immediately.
A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? A. Teach the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn
D. Encourage the client to interact with the newborn Interacting with the baby can help provide a distraction and decrease the discomfort of uterine contractions. While it is important to let the parent know that afterpains are more intense during and after breastfeeding, it is also necessary to encourage the planning of methods that provide the most effective and timely relief. Other nonpharmacological interventions can include distraction, therapeutic touch, imagery, hydrotherapy, acupressure, aromatherapy, music therapy, massage therapy, and transcutaneous electrical nerve stimulation (TENS).
A nurse is caring for a client who is 3 days postpartum and has chosen to formula-feed her newborn. During an examination of the client's breasts, the nurse notes that they are warm and firm. Which of the following actions should the nurse plan to take? A.Encourage the client to pump the breasts B. Instruct the client to take a warm shower twice per day C. Tell the client to massage the breasts D. Instruct the client to apply cold compresses
D. Instruct the client to apply cold compresses To help relieve breast engorgement, the client should apply cold compresses for about 15 minutes every hour. The client can also try applying fresh, cold cabbage leaves to the breasts.
A nurse at a clinic is preparing to teach the process of involution to a group of antenatal clients. Which of the following information should the nurse provide? A. The fundus is approximately 2 cm (0.79 in) above the level of the umbilicus at the end of the third stage of labor. B. The fundus is approximately 3 cm (1.18 in) above the umbilicus within 12 hours after delivery. C. The fundus is located halfway between the umbilicus and mons pubis on the sixth day postpartum. D. The fundus is not palpable abdominally at 2 weeks postpartum.
D. The fundus is not palpable abdominally at 2 weeks postpartum. Involution is the return of the uterus to its normal pre-pregnancy state, which occurs after the delivery of the placenta. By the end of the third stage of labor, the fundus is 2 cm below the umbilicus. Within 12 hours after delivery, the fundus rises 1 cm above the umbilicus. The fundus descends 1 to 2 cm (0.39 to 0.79 in) every 24 hours. The fundus is not palpable after the sixth postpartum day.
