Chapter 16

Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by

Bringing the newborn into the room

Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to

Assess and massage the fundus

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm?

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100°F (37.8°C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal

Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

During the first 24 hours after delivery owing to dehydration from exertion

A client who gave birth by cesarean delivery 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

Encouraging the client to wear a supportive bra.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal delivery. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth-degree

A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient?

Increased intake will rehydrate the patient and decrease her skin temperature.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following?

Long term obesity

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

One fingerbreadth below the umbilicus

Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection?

Placenta removed via manual extraction

When palpating for fundal height on a postpartal woman, which technique is preferable?

Placing one hand at the base of the uterus, one on the fundus

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after childbirth?

Resume intercourse if bright-red bleeding stops

You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits?

The color of the flow is red

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth

True

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

Venous duplex ultrasound of the right leg

A newly delivered mother has difficulty sleeping despite her exhaustion from labor. This inability to rest is due to Select all that apply.

• The baby's crying • Inability to get adequate pain relief • Frequent trips to the bathroom due to diuresis • Excess fatigue and overstimulation by visitors

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following?

atony

Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration

Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma

A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

• Encourage breastfeeding of the newborn infant on demand. • Place baby in uninterrupted skin-to-skin contact with the mother. • Help the mother initiate breastfeeding within 30 minutes of birth.

Hypercoagulability during pregnancy protects the mother against excessive blood loss during childbirth. It also can increase a woman's risk of developing a blood clot. It does this by which of the following ways? (Select all that apply.)

• stasis • altered coagulation • localized vascular damage

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications?

Increased lochia drainage

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing?

Infection

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus?

Placing a gloved hand just above the symphysis pubis

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

The level of the umbilicus

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

• Nondistended abdomen • Active bowel sounds • Passing gas

Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge?

• Resumption of intercourse • Activity • Signs and symptoms of infection