Chapter 12: The Postpartum Woman
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover." "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break."
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "It'll be fun to have a baby in the house, but things shouldn't change too much." "I've learned how to diaper and bathe the baby so I can be a really involved dad." "I may not be a pro at helping out with the baby, but I enjoy being involved." "I didn't realize all that went into being a dad. I wasn't prepared for this."
"I didn't realize all that went into being a dad. I wasn't prepared for this."
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? "It takes about 3 days after birth for milk to begin forming." "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." "You may have developed mastitis. I'll ask the primary care provider to examine you." "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in."
"It takes about 3 days after birth for milk to begin forming."
A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? "It's difficult to say, but it will probably return in about 2 to 3 weeks." "It varies, but you can estimate it returning in about 7 to 9 weeks." "You won't have to worry about it returning for at least 3 months." "You don't have to worry about that now. It'll be quite a while."
"It varies, but you can estimate it returning in about 7 to 9 weeks."
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Let me show you how to calm him down. I've been doing this for many years." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?"
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best? "It doesn't hurt when the midwife takes out the stitches. You will only feel a little tugging and pulling sensation." "It is very important for you to go to your checkup visit. Besides, the stitches do not have to be removed." "Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed." "Oh, you must not miss your follow-up appointment. Don't worry. Your midwife will be very gentle."
"Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed."
A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "I need to get your vital signs and check your fundus to be sure you are not going into shock." "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."
A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? "Your uterus is still shrinking in size; that's why you're feeling this pain." "Let me check your vaginal discharge just to make sure everything is fine." "Your body is responding to the events of labor, just like after a tough workout." "The baby's sucking releases a hormone that causes the uterus to contract."
"The baby's sucking releases a hormone that causes the uterus to contract."
A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? "You must have an infection, so let me get a urine specimen." "Your body is undergoing many changes that cause your bladder to fill quickly." "Your uterus is not contracting as quickly as it should." "The anesthesia that you received is wearing off and your bladder is working again."
"Your body is undergoing many changes that cause your bladder to fill quickly."
A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
A nurse is providing care to a woman who is 6 hours postpartum. The nurse suspects urinary retention based on which finding? fundus at the level of the umbilicus moderate amount of lochia rubra 50 to 70 mL urine per void every hour urine clear yellow in color
50 to 70 mL urine per void every hour
A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first? Call the Medical Response Team to her room. Notify the health care provider of the findings. Have another nurse come listen to the client's respirations and count the rate. Ask the charge nurse to look in on the client before the end of the shift.
Notify the health care provider of the findings
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles
Postpartum diuresis
A postpartum client is experiencing painful hemorrhoids. Which position should the nurse suggest the client use when resting? supine Sims position knee-chest position Trendelenburg position
Sims position
Identification of appropriate psychological adaptations to the postpartum period is necessary to detect maladaptive behaviors. Which behavior would indicate the need for further assessment of a new mother's adaptation? tentative fingertip touching immediately after delivery staring off into the distance while holding the newborn calling the infant by the name of the older sibling staring into the baby's eyes
Staring off into the distance while holding the newborn
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. Recommend rooming-in to foster attachment and confidence by the mother.
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action? The fundus is firm and located at the level of the umbilicus. The fundus is firm and located one fingerbreadth below the level of the umbilicus. The fundus is firm and deviated sharply to the right side of the abdomen. The fundus is firm and located 1 fingerbreadth above the level of the umbilicus.
The fundus is firm and deviated sharply to the right side of the abdomen.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The mother states that she has her father's eyes. The father holds the newborn en face and talks to her. The mother is reluctant to touch the newborn for fear of hurting her. The parents explore the newborn's extremities, counting fingers and toes.
The mother is reluctant to touch the newborn for fear of hurting her.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding? The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is inadequate suggestive of urinary retention. The urinary output is normal. The urinary output is above expected levels.
The urinary output is normal.
Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? Level with the umbilicus One fingerbreadth below the umbilicus Two fingerbreadths below the umbilicus At the pubic bone
Two fingerbreadths below the umbilicus
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? Urinary elimination Elimination of solid wastes Being too tired to eat Breathing off fluid vapor
Urinary elimination
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Apply warm compresses. Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing.
Wear a well-fitting bra
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? You should be able to resume normal activities after 2 weeks. You should not lift anything heavier than your infant in its carrier. Only clean half of the house per day to allow yourself more rest. You need to hire a maid for the first month after delivery to help out around the house.
You should not lift anything heavier than your infant in its carrier.
The nurse is reviewing the health records of several clients who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage? a client who birthed an 8 lb 6 oz (3799 g) neonate a client diagnosed with placenta succenturiate a client who showered 12 hours after birth of a healthy term neonate a client with a pulse rate of 88 beats/min and a blood pressure of 102/64 mm Hg
a client diagnosed with placenta succenturiate
The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this client? absence of lochia red-colored lochia for the first 24 hours lochia that is the color of menstrual blood lochia appearing pinkish-brown on the fourth day
absence of lochia
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine
applying ice
A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? two fingerbreadths above the umbilicus at the level of the umbilicus two fingerbreadths below the umbilicus four fingerbreadths below the umbilicus
at the level of the umbilicus
When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? deep red, fleshy-smelling lochia voiding of 350 cc blood pressure 90/50 mm Hg profuse sweating
blood pressure 90/50 mm Hg
A Chinese mother delivers her newborn and is ready to go home. The grandmother is present and will remain with the mother for 1 month. The grandmother tells the nurse that the mother will not be allowed to leave the house for the first month after delivery. How should the nurse respond to this statement? Remind the grandmother that the mother needs to get out and get fresh air and sunshine over the next month. Ask the grandmother why she is putting such restrictions on her daughter. Accept the grandmother's statement and do discharge teaching accordingly. Explain that new mothers may have to go places in caring for their newborn.
Accept the grandmother's statement and do discharge teaching accordingly.
One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as mother by going through a series of four developmental stages. What is one of them? Achieving a maternal identity Finding a way to get the new baby to conform to existing family interrelationships Physical restoration and learning to get help in caring for the infant Preparing for the infant before she conceives
Achieving a maternal identity
The night shift LPN is checking on a woman who had a cesarean delivery with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first? Administer naloxone per the preprinted orders. Awaken the woman and instruct her to breathe more rapidly. Call the anesthesiologist from the room for orders. Perform bag-to-mouth rescue breathing at a rate of 12 per minute.
Administer naloxone per the preprinted orders.
The nurse is doing discharge teaching with the parents of a baby. It is their second child. The nurse explains about sibling regression and offers ways to deal with regressive behavior. What is this called? reinforcement anticipatory guidance preparatory instructions parenting suggestions
Anticipatory guidance
A postpartum client has a history of thrombophlebitis. What should the nurse do to determine if the client is developing this after delivery? Assess for warmth in the legs. Assess temperature every 4 hours. Assess for calf redness and edema. Palpate the feet for tingling or numbness.
Assess for calf redness and edema.
An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as: attachment. engrossment. involution. engorgement.
Attachment
During the assessment, the nurse observes a separation of the rectus muscle that is more than two fingerbreadths wide. Which instruction should the nurse offer the client? Perform regular exercises. Avoid lifting heavy objects. Sleep on a firm mattress. Avoid sleeping on back.
Avoid lifting heavy objects
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? shaking chills with a fever of 99° F (37.2° C) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. heart rate 70 bpm and excessive, soaking diaphoresis blood loss of 250 mL and WBC 25,000 cells/mL
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. heart rate 70 bpm and excessive, soaking diaphoresis
A postpartum client is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the client about this medication? Select all that apply. This medication has no adverse effects. Be sure to engage in activity to aid in intestinal motility. One pill should be taken after every meal for the first week. This medication works the best when a high-fiber diet is consumed. Take each dose of the medication with a full glass of water or juice.
Be sure to engage in activity to aid in intestinal motility. This medication works the best when a high-fiber diet is consumed. Take each dose of the medication with a full glass of water or juice.
The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor? discomfort due to hemorrhoids distention of abdominal muscles separation of rectus muscles relaxation of abdominal muscles
discomfort due to hemorrhoids
The nurse is assessing the fundus of a client on postpartum day 2. What should the nurse expect when palpating the fundus? fundus 4 cm above symphysis pubis and firm fundus height 4 cm below umbilicus and midline fundus two fingerbreadths below umbilicus and firm fundus two fingerbreadths above symphysis pubis and hard
fundus two fingerbreadths below umbilicus and firm
While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time? health-seeking behaviors related to care of newborn ineffective coping related to expectation to provide newborn care risk for altered family coping related to an additional family member risk for impaired parenting related to disappointment in the sex of the child
health-seeking behaviors related to care of newborn
The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? blood type folic acid level hemoglobin and hematocrit iron level
hemoglobin and hematocrit
A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? demonstrates pleasure when touching or holding the newborn identifies imperfections in the newborn's appearance is able to distinguish his newborn from others in the nursery shows feelings of pride with the birth of the newborn
identifies imperfections in the newborn's appearance
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? reduces lochia promotes uterine involution improves pelvic floor tone alleviates perineal pain
improves pelvic floor tone
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? increased blood pressure increased cardiac output increased hematocrit level increased heart rate
increased heart rate
The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation? encouraging the woman to manually express milk suggesting that she take frequent warm showers to soothe her breasts telling her to limit the amount of fluids that she drinks instructing her to apply ice packs to both breasts every other hour
instructing her to apply ice packs to both breasts every other hour
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: greater than after a vaginal birth. about the same as after a vaginal birth. less than after a vaginal birth. saturated with clots and mucus.
less than after a vaginal birth.
The nurse assesses a postpartum client's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? lochia alba lochia rubra lochia serosa lochia normalia
lochia rubra
The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? uterus 5 cm below umbilicus lochia rubra edematous vagina diaphoresis
lochia rubra
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately? moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? prolactin progesterone oxytocin estrogen
oxytocin
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments? breasts perineum lower extremities respiratory status
perineum
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum blues postpartum depression postpartum psychosis anxiety disorders
postpartum depression
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis? edema in perineal area redness in lower legs diaphoresis increased lochia
redness in lower legs
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? two fingerbreadths above the umbilicus at the level of the umbilicus two fingerbreadths below the umbilicus four fingerbreadths below the umbilicus
two fingerbreadths below the umbilicus
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? uterine atony hemorrhoid diuresis iron deficiency
uterine atony
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. uterine infection prolonged labor hydramnios breastfeeding early ambulation empty bladder
uterine infection prolonged labor hydramnios
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? lochia serosa edematous vagina uterus 1 cm below umbilicus diaphoresis
uterus 1 cm below umbilicus
The nurse is preparing discharge training for a G2P2 client who will breastfeed her infant. The client mentions she wants more children but wants to wait a couple of years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals? when she stops breastfeeding within 18 months within 6 weeks when she resumes sexual activity
when she resumes sexual activity
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? hematocrit 42% (0.42) white blood cell count 14,000/mm3 (14 ×109/L) hemoglobin 12.5 g/dL (125 g/L) platelets 350,000/µL (350 ×109/L)
white blood cell count 14,000/mm3 (14 ×109/L)
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be? red pink yellowish white yellowish pink
yellowish white
When assessing a client's uterine fundus during the fourth stage of labor, the nurse palpates a soft, uncontracted fundus. Which of the following would the nurse do next? Instruct the client to exercise. Gently massage the boggy fundus. Suggest complete bed rest. Suggest avoiding lifting weight.
Gently massage the boggy fundus
The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help Gently massage the fundus until it tones up Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage
Gently massage the fundus until it tones up
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed? Harm to self Lack of a social network Withdrawal from others Poor nutrition
Harm to self
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.
Have the client void, and then massage the fundus until it is firm.
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize? Hemoglobin 13 g/dl (130 g/L) and hematocrit 40% (0.40) in a woman who has given birth vaginally Hemoglobin 12 g/dl (120 g/L) and hematocrit 38% (0.38) in a woman who has given birth vaginally Hemoglobin 11 g/dl (110 g/L) and hematocrit 34% (0.34) in a woman who has given birth by cesarean Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean
Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean
A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breast-feeding, that will help make your uterus contract and get smaller." "I would recommend that you rest for a few days to allow your body to heal and get back to normal." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "There is really nothing you can do to speed along the progress, so just be patient."
"If you are breast-feeding, that will help make your uterus contract and get smaller."
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Tell me, are you seeing things that aren't there, or hearing voices?"
"It sounds like you have the 'baby blues'. They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? cannot be palpated 2 cm below the umbilicus 6 cm below the umbilicus 10 cm below the umbilicus
Cannot be palpated
A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to? Increased thyroid hormone levels Increased estrogen levels Decreased hemoglobin levels Decreased progesterone levels
Decreased progesterone levels
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? Changing the infant's diapers for the mother Demonstrating how to do cord care on the newborn Correcting the mother when she holds the newborn incorrectly. Telling the mother to feed the baby when it cries.
Demonstrating how to do cord care on the newborn
A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client? Redirect her attention to the baby by reminding her of the details of newborn care. Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings. Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. Point out positive features of her baby, and encourage her to hold and cuddle the baby.
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? Restrict fluid intake to 2 L each day. Ensure the baby empties the breasts at each feeding Apply ice packs before a feeding. Wear a tight fitting bra at all times.
Ensure the baby empties the breasts at each feeding
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain. Encourage the mother to breast-feed to help relax the uterus.
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. Lochia rubra Fundal height level of one fingerbreadth above the umbilicus Episiotomy appears edematous Temperature of 101.8°F (38.8°C) White blood cell count of 28,000/mm3
Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C)
A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? Her hematocrit The size of her infant Her bladder for distension Her episiotomy
Her bladder for distension
After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take? Call the client's family. Let the health care provider know the condition of the incision. Since everything appears normal, continue to monitor the incision every 4 hours. Re-apply a dressing over the incision line.
Let the health care provider know the condition of the incision.
What two elements play the biggest role in becoming a mother after delivery of her newborn? Confidence and happiness with the pregnancy Love and attachment to the child and engagement with the child Planned and desired pregnancy and previous experience with infants Interactions with the child and support systems
Love and attachment to the child and engagement with the child
