Chapter 16: Nursing Management During the postpartum period

Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother? A. indirect Coombs test B. CBC with differential C. ANA D. titer screen

A. indirect Coombs test The indirect Coombs test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh-positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to check for immunization and autoimmune disorders. p.g 565

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? A. redness B. temperature C. edema D. drainage

B. temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature. p.g 539

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? A. positive bonding B. negative bonding C. positive attachment D. negative attachment

D. negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors. p.g 547

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? A. 1 week B. 2 weeks C. 3 weeks D. 4 weeks

Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing. p.g 564

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? A. first degree B. second degree C. third degree D. fourth degree

The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall. p.g 543

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation (dilatation) and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is: A. At risk for postpartum depression due to inadequate rest. B. At risk for interruption of tissue integrity. C. At risk for safety due to low hemoglobin. D. At risk for inadequate healing due to decreased nutrition.

This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time. p.g 564-565

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? A. an absence of lochia B. red-colored lochia for the first 24 hours C. lochia that is the color of menstrual blood D. lochia appearing pinkish-brown on the fourth day

Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever. p.g 539

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? A. The client is having a moderate amount of rubra lochia. B. The client requires assistance to ambulate in the hallway. C. The fundus is located 2 fingerbreadths above the umbilicus. D. The client is afebrile. E. Bowel sounds are active.

C. The fundus is located 2 fingerbreadths above the umbilicus. The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. A. Low self-esteem' B. Feeling overwhelmed and out of control C. Low socioeconomic status D. Lack of social support E. Involving family in infant care

A, B, C, D Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression. p.g 564-565

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A. generally within 3 to 6 weeks B. whenever the couple wishes C. generally after 12 weeks D. usually within a couple weeks

A. generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum. p.g 555

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. A. abdominal pain B. active bowel sounds C. tender abdomen D. passing gas E. nondistended abdomen

B, D, E Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into. p.g 541-542

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for i Infection based on which factor? A. labor less than 3 hours B. hemoglobin of 11.5 mg/dl (115 g/L) C. placenta removed via manual extraction D. multiparity

C. placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage. p.g 538

The LVN/LPN will be assessing a postpartum client for danger signs of infection after a vaginal birth. What assessment finding would the nurse assess as a possible sign of infection for this client? A. presence of lochia rubra B. fever more than 100.4° F (38° C) C. fundus is above the umbilicus D. fundus is firm

B. fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection. p.g 539

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? A. Under 10 ml B. 10 to 25 ml C. 25 to 50 ml D. Over 50 ml

Typically, the amount of lochia is described as follows: * Scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-ml loss * light or small: an approximately 4-in (10-cm) stain or a 10- to 25-ml loss * moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 ml * large or heavy: a pad saturated within 1 hour after changing it or over 50-ml loss. p.g 542

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A. The flow contains large clots. B. The flow is over 500 mL. C. Her uterus is soft to your touch. D. The color of the flow is red.

A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted. p.g 542

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? A. proximity B. reciprocity C. commitment D. all of the above

B. reciprocity Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship. p.g 546

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Give newborns water and other foods to balance nutritional needs. B. Help the mother initiate breastfeeding within 30 minutes of birth. C. Encourage breastfeeding of the newborn infant on demand. D. Provide breastfeeding newborns with pacifiers. E. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

B, C, E The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns. p.g 558

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at: A. the level of the umbilicus. B. between the umbilicus and symphysis pubis. C. 1 cm below the umbilicus. D. 2 cm below the umbilicus.

B. between the umbilicus and symphysis pubis. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day. P.G 540

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? A. Uterus is firm. B. Lochia is less than usual. C. Bladder is nonpalpable. D. Percussion reveals dullness.

D. Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual. p.g 541

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: A. the level of the umbilicus. B. between the umbilicus and symphysis pubis. C. 1 cm below the umbilicus. D. 2 cm below the umbilicus.

A. the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day. p.g 540

When palpating for fundal height on a postpartum woman, which technique is preferable? A. placing one hand at the base of the uterus, one on the fundus B. placing one hand on the fundus, one on the perineum C. resting both hands on the fundus D. palpating the fundus with only fingertip pressure

A. placing one hand at the base of the uterus, one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation. p. 541

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A. women on antithyroid medications B. women on antineoplastic medications C. women using street drugs D. women with more than one infant E. women who had difficulties with breastfeeding in the past

A, B, C While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules. p.g 557

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. A. vital signs of mother B. newborn's vital signs C. pain level D. head-to-toe assessment E. head-to-toe assessment of newborn

A, C, D Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery. p.g 538

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? A. "I only eat a low-fiber diet." B. "I already have some pads with witch hazel at home." C. "My mom always used dibucaine." D. "Sitz baths worked the last time."

A. "I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function. p.g 551

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? A. Reassess the client in 1 hour. B. Document the lochia as scant. C. Stop using a peri-pad. D. Massage the client's fundus.

B. Document the lochia as scant. "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered. p.g 542

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. 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: A. inspect the perineum for lacerations. B. increase the flow of an IV. C. assess and massage the fundus. D. call the primary care provider or the nurse-midwife.

C. assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage. p.g 541

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: A. scant. B. light. C. moderate D. heavy.

C. moderate Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it. p.g 542

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time? A. 3:30 a.m. B. 5:15 a.m. C. 7:45 a.m. D. 9:00 a.m.

D. 9:00 a.m. If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame. P.G 551

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A. infection B. hemorrhage C. normal involution D. atony

D. atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? A. increasing oral fluid intake B. increasing intravenous fluids C. screening for bacteriuria in the urine D. encouraging the woman to empty her bladder completely every 2 to 4 hours

D. encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure. p.g 541

A nursing student is studying postpartum complications. Thromboembolic conditions have which risk factors? Select all that apply. A. A nursing student is studying postpartum complications. Thromboembolic conditions have which risk factors? Select all that apply. A. anemia B. diabetes C. cigarette smoking D. obesity E. irritable bowel F. multiparity

A, B, C, D, F Risk factors for developing thromboembolic conditions include anemia, diabetes, cigarette smoking, obesity, preeclampsia, hypertension, varicose veins, pregnancy, cesarean section, multiparity, inactivity, and advanced maternal age.

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths? A. Sitz baths cause perineal vasoconstriction and decreased bleeding. B. The longer a sitz bath is continued, the more therapeutic it becomes. C. Sitz baths increase the blood supply to the perineal area. D. Sitz baths may lead to increased postpartum infection.

C. Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum. p.g 549-550

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication? A. permanent urinary incontinence B. increased lochia drainage C. fluid volume overload D. ruptured bladder

B. increased lochia drainage If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder. p.g 541

A nurse is auscultating the lungs of a postpartum client and notices crackles and some dyspnea. The client's respiratory rate is 12 breaths/minute; she appears in some distress. What complication should the nurse suspect based on these data? A. pulmonary edema B. hemorrhage C. infection D. fluid volume deficit

A. pulmonary edema Any change in the respiratory rate of a postpartum woman might indicate pulmonary edema, atelectasis, or pulmonary embolism and must be reported. Lungs should be clear upon auscultation.

Thirty minutes after receiving pain medication, a postpartum woman states that she still 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? A. nothing—it is normal B. hematoma C. infection D. DVT

B. hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately. p.g 540

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? A. infection B. hemorrhage C. fluid volume overload D. pulmonary emboli

B. hemorrhage Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa, abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention. P.G 538

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A. touching B. talking C. looking D. feeding

A. touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process. p.g 545

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? A. 500 additional calories per day B. 1,000 additional calories per day C. 250 additional calories per day D. 750 additional calories per day

A. 500 additional calories per day The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting: A. centrality. B. contact. C. Individualization. D. reciprocity.

A. centrality. Centrality, which is a component of commitment, is demonstrated when the parents place the infant at the center of their lives, acknowledging and accepting their responsibility to promote the infant's safety, growth and development. Contact, a dimension of proximity, refers to the sensory experiences of touching, holding, and gazing at the infant. Individualization, a dimension of proximity, reflects parental awareness of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately. Reciprocity is the process by which the infant's abilities and behaviors elicit a parental response. p.g 546

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? A. first 30 to 60 minutes B. first 3 to 5 days C. first month D. first 6 months

A. first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth. p.g 545

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? A. "If the symptoms last more than a few days, I need to call my doctor." B. "I might feel like laughing one minute and crying the next." C. "I'll need to take medication to treat the anxiety and sadness." D. "I should call this support line only if I hear voices."

B. "I might feel like laughing one minute and crying the next." Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur. p.g 564

A client who had a cesarean birth of twins 6 hours ago reports shortness of breath and pain in the right calf. What complication should the nurse expect? A. infection B. hemorrhage C. pulmonary emboli D. fluid volume overload

C. pulmonary emboli One of the postpartum danger signs is calf pain with dorsiflexion of the foot. This would indicate a deep vein thrombosis. With the shortness of breath the client might have a pulmonary emboli. This scenario would require immediate interventions to prevent the client's death. p.g 539

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? A. Percussion reveals tympany. B. Uterus is boggy. C. Lochia is less than usual. D. Bladder is nonpalpable.

B. Uterus is boggy. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual. p.g 540

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? A. talking about how the nurse held her own newborn while on the birthing table B. showing a video of parents feeding their babies C. allowing the mother to pick the best time to hold her newborn D. bringing the newborn into the room

D. bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother. p.g 545

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel? A. fundus height 4 cm below umbilicus and midline B. fundus two fingerbreadths above symphysis pubis and hard C. fundus 4 cm above symphysis pubis and firm D. fundus two fingerbreadths below umbilicus and firm

D. fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm. p.g 541

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? A. thromboembolic disorder of the lower extremities B. hormonal shifting of relaxin and estrogen C. infection D. normal response to the body converting back to prepregnancy state

Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state. p.g 543

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? A. Schedule home visits for high-risk families. B. Encourage frequent clinic visits for high-risk families. C. Provide phone numbers for call centers for questions. D. Ask family members to monitor the parents' progress.

A. Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system. p.g 561

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? A. "It might take up to a week for your bowels to return to their normal pattern." B. "I'll get a laxative prescribed so that you can move your bowels." C. "That's unusual. Are you making sure to eat enough?" D. "Let me call your health care provider about this problem."

A. "It might take up to a week for your bowels to return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern. p.g 541

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? A. Recommend a moisturizing soap to clean the nipples. B. Encourage use of breast pads with plastic liners. C. Offer suggestions based on observation to correct positioning or latching. D. Fasten nursing bra flaps immediately after feeding.

C. Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? Select all that apply. A. resumption of intercourse B. activity C. resumption of prepregnancy environment D. signs and symptoms of infection E. infant formula selection

A. resumption of intercourse B. activity D. signs and symptoms of infection The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her prepregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician. p.g 565

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? A. Determine the newborn's blood type and rhesus. B. Determine if this is the client's first baby. C. Administer Rh immunoglobulins intramuscularly. D. Ask if the client received rH immunoglobulins during the pregnancy.

A. Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past. p.g 565

A client who gave birth by cesarean birth 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: A. encouraging the client to wear a supportive bra. B. having the client stand facing in a warm shower. C. informing the primary care provider that the client is showing early signs of breast infection. D. using a breast pump to facilitate removal of stagnant breast milk.

A. encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production. p.g 561

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? A. The urinary output is inadequate and the mother needs to drinks more fluids. B. The urinary output is inadequate suggestive of urinary retention. C. The urinary output is normal. D. The urinary output is above expected levels.

C. The urinary output is normal. Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void. p.g 541

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: A. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." B. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." C. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." D. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood."

B. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis. p.g 565

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? A. "Breastfeeding takes time and practice." B. "Some women just can't breastfeed. Maybe I'm one of these women." C. "Some babies latch on and catch on quickly; others take a little more time." D. "Maybe a lactation specialist can help me work through this."

B. "Some women just can't breastfeed. Maybe I'm one of these women." The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation. p.g 557

A nurse is assessing a postpartum client. Which measure is appropriate? A. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. B. Instruct the client to empty her bladder before the examination. C. Wear sterile gloves when assessing the pad and perineum. D. Perform the examination as quickly as possible.

B. Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth. p.g 540

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 birth? A. Avoid use of water-based gel lubricants. B. Resume intercourse if bright red bleeding stops. C. Avoid performing pelvic floor exercises. D. Use oral contraceptive pills (OCPs) for contraception.

B. Resume intercourse if bright red bleeding stops. The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs). p.g 555

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? A. Avoid getting out of bed for another 2 days. B. Walk with the nurse the length of her room. C. Walk the length of the hallway to regain her strength. D. Avoid elevating her feet when she rests in a chair.

B. Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged. p.g 553

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color? A. bluish white B. creamy yellow C. milky white D. gray liquid

B. creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A. infection B. dehydration C. change in the temperature from the birth room D. fluid volume overload

B. dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours. p.g 539

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a postpartum woman of Japanese descent, which action would be a priority? A. assigning a female nurse to care for her B. ensuring that the newborn receives a daily bath C. allowing time for the numerous visitors who come to see the woman and newborn D. providing time for prayers to be performed at the bedside

B. ensuring that the newborn receives a daily bath In the Japanese American culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino American culture because families are very close-knit. Bedside prayer is common due to the strong religious beliefs of the Filipino American culture. p.g 549

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider 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 client at risk for developing? A. hemorrhage B. infection C. depression D. pulmonary embol

B. infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV. p.g 538

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. A. moderate lochia rubra B. rounded mass over symphysis pubis C. dullness on percussion over symphysis pubis D. fundus boggy to the right of the umbilicus E. elevated oral temperature

B. rounded mass over symphysis pubis C. dullness on percussion over symphysis pubis D. fundus boggy to the right of the umbilicus If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4°F (38°C), infection is suggested. p.g 541

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs the client to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" A. saturating 1 pad in 3 hours B. saturating 1 pad in 1 hour C. saturating 1 pad in 6 hours D. saturating 1 pad in 8 hours

B. saturating 1 pad in 1 hour Bleeding is considered heavy when a client saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour. P.G 542

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? A. "Expect to see your 2-year-old become more independent when the baby gets home."' B. "Talk to your 2-year-old about the baby when you're driving him to day care."' C. "Ask your 2-year-old to pick out a special toy for his sister." D. "Have your 2-year-old stay at home while you're here in the hospital."

C. "Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn. p.g 563

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? A. "Follow up with your health care provider within 3 weeks of being discharged." B. Notify the health care provider if your temperature is greater than 99° F (37.2° C)." C. "You should be seen by your health care provider if you have blurred vision." D. "Call your health care provider if you saturate a peri-pad in less than 4 hours."

C. "You should be seen by your health care provider if you have blurred vision." The client needs to notify the health care provider for blurred vision, as this can indicate preeclampsia in the postpartum period. The client should also notify the health care provider if she has a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is within 2 weeks after hospital discharge. p.g 539

Rho(D) immune globulin is administered to which clients? Select all that apply. A. A client who is Rh-positive and gave birth to a 7-pound baby B. A newborn with type O-negative blood and a negative Coombs test C. An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday D. An Rh-negative woman following an ectopic pregnancy E. A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood

C. An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday D. An Rh-negative woman following an ectopic pregnancy E. A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate. p.g 565

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? A. Recommend a moisturizing soap to clean the nipples. B. Encourage use of breast pads with plastic liners. C. Offer suggestions based on observation to correct positioning or latching. D. Fasten nursing bra flaps immediately after feeding.

C. Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry. p.g 548

A nurse is providing education to a client experiencing postpartum blues. The nurse determines client understanding when the client makes which of statements regarding factors that contribute to postpartum blues, signs and symptoms associated with postpartum blues, and collaborative care to treat symptoms? Contributing Factors A. "Postpartum blues are due to changes in hormones." B. "Postpartum blues are due to being overweight." C. "Postpartum blues are due to dehydration." D. "Postpartum blues are due to fatigue."' Signs and Symptoms A. "A sign of postpartum blues is persistent depression beyond 10 days." B. "Postpartum blues can occur up to 1 year after giving birth." C. "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." D. "A symptom of postpartum blues is being unable to care for self or the infant weeks after giving birth." Collaborative Care A. "Sleep hygiene can help with postpartum blues." B. "Adequate nutrition can help with postpartum blues." C. "Regular physical exercise can help with postpartum blues." D. "Antidepressant medications can help with postpartum blues." E. "Ensuring adequate support for newborn care can help with postpartum blues."

Contributing Factors A. "Postpartum blues are due to changes in hormones." D. "Postpartum blues are due to fatigue." Signs and Symptoms C. "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." Collaborative Care A. "Sleep hygiene can help with postpartum blues." B. "Adequate nutrition can help with postpartum blues." C. "Regular physical exercise can help with postpartum blues." E. "Ensuring adequate support for newborn care can help with postpartum blues." p.g 561-564

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: A. the client will show no signs of infection. B. discussing methods that the woman will use to prevent infection. C. listing signs of infection that she will report to her health care provider. D. maintaining previous household routines to prevent infection.

D. maintaining previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman. p.g 565