Chapter 15: Postpartum Adaptations (PrepU)

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: "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." "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."

"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." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? "You should notice a change in your respiratory status within the next 24 hours." "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." "Everyone is different, so it is difficult to say when your respirations will be back to normal." "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally."

"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." The abdominal organs, including the diaphragm, typically return to prepregnancy state within 1 to 3 weeks after birth. Discomforts such as shortness of breath and rib aches lessen, and tidal volume and vital capacity return to normal values.

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? 1 cm above the umbilicus 1 cm below the umbilicus At the symphysis pubis At level of umbilicus

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Run warm water over the breast in the shower. Express small amounts of milk when they are too full. Massage the breasts when they are painful. Wear a tight, supportive bra.

Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

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 hydrogel dressing. Apply warm compresses. Wear a well-fitting bra. Express milk frequently.

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

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: engrossment. involution. engorgement. attachment.

attachment. When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smooths the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply. uterine infection prolonged labor hydramnios breastfeeding early ambulation

breastfeeding early ambulation Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? increased progesterone levels decreased intra-abdominal pressure decreased bladder pressure use of anesthesia during birth

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

A young mother is at the office for her 6-week visit. She is still experiencing mild lochia alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion? creamy discharge foul odor fleshy smell light brown discharge

foul odor At 3 to 6 weeks, the lochia alba is in the final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? hyperglycemia hypovolemia hypothyroidism hypertension

hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inability of infant to empty breasts inadequate secretion of prolactin improper positioning of infant cracking of the nipple

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? postpartum depression postpartum reaction postpartum baby blues postpartum anxiety

postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

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 tract infection urinary overflow trauma to pelvic muscles postpartum diuresis

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest? keeping the baby in the same room at all times sleeping with the infant playing a recording of their voices at all times promoting skin-to-skin contact (kangaroo care) on the chest

promoting skin-to-skin contact (kangaroo care) on the chest Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.

Which factor might result in a decreased supply of breast milk in a postpartum client? supplemental feedings with formula maternal diet high in vitamin C frequent feedings an alcoholic drink

supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? letting-go phase taking-hold phase attachment phase taking-in phase

taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client? The body is trying to get rid of the extra blood made during pregnancy. The patient may be drinking too much fluid. Body secreting the excess fluids from pregnancy Change in pregnancy hormone

Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

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? 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. Notify the primary care provider, and document the findings.

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? yellowish-white lochia easy to separate clots foul-smelling lochia difficult to separate clots

difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? "It takes a while to get your body back to its normal function after having a baby." "Try doing Kegel exercises to get your pelvic muscles back in shape." "You might try using a water-soluble lubricant to ease the discomfort." "This is entirely normal, and many women go through it. It just takes time."

"You might try using a water-soluble lubricant to ease the discomfort." Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

During the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply. Needing assistance with changing her peripad Changing her newborn's diaper with guidance from the nurse. Asking the nurse to take the newborn away so she can rest. Desiring to hold her infant Telling the nurse about her delivery experience.

Needing assistance with changing her peripad Telling the nurse about her delivery experience. Asking the nurse to take the newborn away so she can rest. In the early postpartum period, the new mother is focused upon herself and concerned about her needs. She is very dependent, having difficulty making decisions and requesting help with self-care. She relives the delivery experience and wants to share it with others. This period may last several hours or several days.

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Notify a health care provider. Put on a witch hazel pad. Apply a warm washcloth.

Place an ice pack. The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.

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 need to hire a maid for the first month after delivery to help out around the house. Only clean half of the house per day to allow yourself more rest. You should not lift anything heavier than your infant in its carrier.

You should not lift anything heavier than your infant in its carrier. New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with.

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? "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." "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." "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?"

"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?"' Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard? "Be sure to change your pajamas to prevent you from chilling." "I would suggest that you speak with your primary care provider about this." "Drink plenty of cold fluids before you go to bed." "I'm not sure why this is occurring since this usually doesn't occur until much later in the postpartum period."

"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell." "My episiotomy should begin to heal and feel better over the next few weeks"

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the health care provider needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul-smelling both indicate a possible infection and the physician needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her? "I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." "I will avoid medications for constipation such as psyllium because it can upset the baby's stomach." "A good meal for me is cream of chicken soup, cheese toast, and ice cream for dessert." "It is all right to suppress the urge to have a stool for a few days to allow my stitches to heal."

"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." The objective of preventing constipation is to increase the mother's intake of fruits, vegetables, and fiber. The offered meal is comprised of low fiber foods. The mother is discouraged from suppressing the urge to pass stool, although the mother is often frightened it will hurt. Bulk-forming medications such as psyllium are excellent to help the mother not become constipated. There is no problem with the medication interfering with breastfeeding.

What two elements play the biggest role in becoming a mother after delivery of her newborn? Planned and desired pregnancy and previous experience with infants Confidence and happiness with the pregnancy Love and attachment to the child and engagement with the child Interactions with the child and support systems

Love and attachment to the child and engagement with the child A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.

The nurse is monitoring a client who is 3 hours postpartum. On assessment the nurse notes a temperature of 102.4 oF. Which action should the LPN prioritize? Notify the RN who will notify the provider. Continue to monitor for another hour. Assist the client in ambulation. Administer an antipyretic.

Notify the RN who will notify the provider. A temperature elevated above 100.4°F is a sign of possible infection. The LPN should notify the RN. The RN will then notify the provider and receive further care orders for the patient. Administering an antipyretic can only be done at the physician's order. Assisting in ambulation and continuing to monitor the patient for another hour are not indicated interventions for this patient.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia rubra a moderate amount of lochia alba a scant amount of lochia serosa

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: acutely decreased. slightly decreased. acutely increased. slightly increased.

acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

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 cardiac output increased blood pressure increased heart rate increased hematocrit level

increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? rooming-in phase letting-go phase taking-hold phase taking-in phase

taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period.

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. empty bladder early ambulation uterine infection prolonged labor hydramnios breastfeeding

uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

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: "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."

"If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia alba a scant amount of lochia serosa a moderate amount of lochia rubra

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

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 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.1ºF (37.8ºC) at 24 hours postbirth and decreases 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 temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema? Apply moist heat. Use a warm sitz bath or tub bath. Apply ice. Use ointments locally.

Apply ice. Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation? Bladder distention Full bowel Poor bladder tone Uterine atony

Bladder distention Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced 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? Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage Put on the call button to summon help Gently massage the fundus until it tones up

Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? infection bleeding postpartum gestational hypertension diabetes

bleeding Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking, holding-on, letting-go. taking-in, taking-on, letting-go. taking-in, taking-hold, letting-go. taking-in, holding-on, letting-go.

taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? iron deficiency diuresis uterine atony hemorrhoid

uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.

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? "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "You would probably be more successful if you wrapped him in on a warm blanket." "Let me show you how to calm him down. I've been doing this for many years."

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.

The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding? Family growing closer together after the birth of a new baby An ongoing process in the year after birth The skin-to-skin contact that occurs in the birth room A process of developing an attachment and becoming acquainted with each other

A process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? "If you plan to breastfeed, you need to calm down." "It sounded like you had quite a time getting here. Would you like to continue your story?" "I need to assess your fundus now." "You have a beautiful baby, why worry about that now?"

"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

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." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "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 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." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue? "Ovulation may return as soon as 3 weeks after birth." "You may have intercourse until next month with no fear of pregnancy." "Ovulation does not return for 6 months after birth." "You will not ovulate until your menstrual cycle returns."

"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Dry the nipples following feedings. Apply cold compresses to the breasts. Feed the baby at least every two or three hours. Provide the infant oral nystatin.

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. What was the birth weight of the infant? Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions? Has she delivered by cesarean section or vaginally?

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions? An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, abortion or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do? Assist the client to the bathroom. Suggest catheterizing her this time to prevent the possibility of fainting. Have the client sit dangling her legs off the side of the bed for 5 minutes. Ask the client to lie back down and get her a bedpan.

Have the client sit dangling her legs off the side of the bed for 5 minutes. The first time a woman gets up following delivery, it is recommended that she sit up on the side of the bed, dangling her legs for 5 minutes to prevent postural hypotension and lightheadedness. If the woman then feels fine, the nurse will accompany her to the bathroom and back to bed.

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? Acute pain related to afterpains or episiotomy discomfort Risk for infection related to multiple portals of entry for pathogens Risk for injury: postpartum hemorrhage related to uterine atony Risk for injury: falls related to postural hypotension and fainting

Risk for injury: postpartum hemorrhage related to uterine atony The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.

The primigravida client is surprised by the continued uterine contractions while holding her new baby. Which explanation by the nurse will best explain these contractions? Closes the cervix Returns the uterus to normal size Seals off the blood vessels at the site of the placenta Stops the flow of blood

Seals off the blood vessels at the site of the placenta The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, the other options are secondary to the constriction of blood vessels at the placental site.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice applying warm compresses administering bromocriptine restricting fluids

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? increased white blood cell count decreased red blood cell count increased coagulation factors stirrup injury during birth

increased coagulation factors The woman is showing signs of thromboembolism or deep vein thrombosis, which is a risk for the postpartum client due to the increased hypercoagulable state that occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors that the body uses as a protective device; however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, the client should be evaluated for anemia. The stirrups should not cause an injury.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? having feelings of grief or guilt pointing out specific features in the newborn showing increased confidence when caring for the newborn talking about her labor experience to others around her

showing increased confidence when caring for the newborn Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the taking-in phase the taking-hold phase the letting-go phase the binding-in phase

the taking-hold phase The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? touching pictures recognizing the meaning of words writing

touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.

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? estrogen progesterone oxytocin prolactin

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.

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? Encourage the mother to breast-feed to help relax the uterus. Recommend that the client ambulate more to help relieve the pain. 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.

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. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

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 bladder for distension The size of her infant Her episiotomy Her hematocrit

Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.

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. 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. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge.

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

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 depression postpartum blues postpartum psychosis anxiety disorders

postpartum depression The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? acquaintance/attachment letting-go taking-in taking-hold

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.