Chapter 17: Nursing Care of a Postpartal Family

5. A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? A) Avoid using soap for any perineal care. B) Wash her perineum with her daily shower. C) Use an alcohol wipe to wash her episiotomy line. D) Refrain from washing lochia from the suture line.

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 413 Feedback: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.

20. The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum patient. Which outcome indicates that teaching has been effective? A) Patient performs perineal care independently with every morning shower. B) Patient explains the purpose of performing perineal care at least once a day. C) Patient flushes the commode before standing when performing perineal care. D) Patient washes the perineum from back to front when performing perineal care.

Ans: A Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 413 Feedback: The nurse should instruct the postpartum patient to include perineal care as part of a daily bath or shower and after every voiding or bowel movement. The patient should stand before flushing the commode when performing perineal care because water from the commode can splash the perineum and cause an infection. The patient should be instructed to wash the perineum from front to back to reduce the potential for contamination from the rectal area.

2. The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? A) lochia rubra B) lochia serosa C) lochia normalia D) lochia alba

Ans: A Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Remember Page: 404 Feedback: Lochia rubra is red; it lasts for the first few days of the postpartal period.

25. A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting? A) Supine B) Sims position C) Knee-chest position D) Trendelenburg position

Ans: B Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 416 Feedback: Assuming a Sims position several times a day aids in good venous return to the rectal area and reduces the discomfort of hemorrhoids. Supine, knee-chest, and Trendelenburg are not recommended positions to aid in the pain of hemorrhoids.

28. A new mother asks if it is possible to have rooming-in with the newborn. How should the nurse respond to this patient's request? A) It depends on whether the patient plans to breastfeed. B) Rooming-in allows increased maternal-newborn contact. C) This puts too much responsibility on a first-time mother. D) Resting for the first 3 days postpartum will be better for the patient.

Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 401 Feedback: The more time a woman has to spend with her baby, the sooner she can become better acquainted with her child, feel more confident in her ability to care for her baby, and more likely form a sound mother-child relationship. Rooming-in is when the mother and child are together 24 hours a day. Rooming-in does not depend on whether the patient is planning to breastfeed the infant. Rooming-in helps the new mother become confident in abilities to care for the baby. Resting for 3 postpartum days is not recommended.

27. A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery? A) Assess for warmth in the legs. B) Assess temperature every 4 hours. C) Assess for calf redness and edema. D) Palpate the feet for tingling or numbness.

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 416 Feedback: Assess for thrombophlebitis by dorsiflexing the ankle and asking if pain occurs in the calf region. Assess also for redness in the calf area and edema of the ankle. Warmth is not an indication of a thrombophlebitis. Body temperature is not used to assess for thrombophlebitis. Feet numbness and tingling are not indications of thrombophlebitis.

6. 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

Ans: A Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 404 Feedback: Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

14. A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period? A) She sits and rocks her infant for long intervals. B) She is eager to talk about her birth experience. C) She has not asked for anything for pain all day. D) She did her perineal care independently.

Ans: D Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 399 Feedback: During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

8. When palpating for fundal height on a postpartal 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

Ans: A Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 411 Feedback: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

26. The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective? A) "I should limit stair climbing to four times a day." B) "I can have coitus at any time after returning home." C) "I should plan to return to my full-time job after 6 weeks." D) "I should notify the physician if my discharge decreases in amount."

Ans: C Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 420 Feedback: It is usually advised that a woman not return to an outside job for at least 3 to 6 weeks, not only for her own health but also for enjoyment of the early weeks with the newborn. Stair climbing should be limited to one flight/day for the first week at home. Coitus is safe as soon as the patient's lochia has turned to alba and, if present, an episiotomy is healed. The patient should notify the primary care provider if there is an increase, not a decrease, in lochial discharge.

29. The nurse is concerned that a new mother is ambivalent about the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at this time? A) Contact the Social Services department. B) Schedule home care for the mother and infant. C) Assess who is going to take care of the baby at home. D) Ask the patient if it would be better that the baby is put up for adoption.

Ans: A Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 422 Feedback: Some patients do not openly voice a wish to give up a child, but their actions demonstrate they feel little attachment to their newborn. A woman who has doubts about wanting the baby is slow to make contact, barely touching the baby even by the time of discharge, and asking few questions about newborn care. When this happens, the hospital social service department can be of assistance in helping the patient plan the child's future. The nurse needs to do more than schedule home care for the mother and infant. The nurse should consult with Social Services that will assess who is going to care for the infant at home and find out if the patient wants to give the baby up for adoption. This is not the nurse's role.

18. While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time? A) Health-seeking behaviors related to care of newborn B) Ineffective coping related to expectation to provide newborn care C) Risk for altered family coping related to an additional family member D) Risk for impaired parenting related to disappointment in the sex of the child

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Analyze Page: 416 Feedback: The new mother is asking the nurse to validate actions being performed while providing newborn care. The nursing diagnosis most appropriate for the new mother at this time would be health-seeking behaviors related to care of the newborn. The new mother is not demonstrating signs of ineffective coping. There is no information to support a risk for altered family coping or risk for impaired parenting.

21. The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient? A) 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

Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analyze Page: 404 Feedback: Lochia should never be absent during the first 1 to 3 weeks because absence of lochia may indicate postpartal infection. Red-colored lochia for the first 24 hours is normal. Lochia that is the color of menstrual blood is normal. Lochia appearing pinkish-brown on the fourth postpartum day is normal.

4. Which information would the nurse emphasize in the teaching plan for a postpartal 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 postpartal infection.

Ans: C Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 412 Feedback: Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

23. The nurse manager of a postpartum care area is planning educational sessions for the nursing staff to support the 2020 National Health Goals for postpartum care. Which information should be included in this staff training? Select all that apply. A) Encourage postpartum patients to participate in breast-feeding. B) Provide information on reproductive life planning if requested. C) Suggest postpartum patients remain on bed rest for at least 2 postpartum days. D) Recommend new mothers to attend prenatal classes to learn infant care after delivery. E) Explain the importance of close observation to detect postpartum maternal hemorrhage.

Ans: A, B, E Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 397 Feedback: Nurses can help the nation achieve the 2020 National Health Goals for postpartum care by maintaining close observation in the immediate postpartal period to detect maternal hemorrhage, encouraging and supporting women as they begin breastfeeding, and ensuring women receive reproductive life planning information if desired. Bed rest and attending prenatal classes to learn newborn care are not strategies to support the 2020 National Health Goals for postpartum care.

24. A postpartum patient is concerned about loose tissue around the abdominal area. Which exercise should the nurse recommend that the patient begin on postpartum day 2 to strengthen and tighten these muscles? A) Sit-ups B) Chin-to-chest C) Pelvic rocking D) Kegel exercises

Ans: B Client Needs: Health Promotion and Maintenance Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 417 Feedback: The chin-to-chest exercise is excellent for the second day to tighten abdominal muscles. The exercise can be done 3 or 4 times a day, and the patient should feel the abdominal muscles pull and tighten if it is being done correctly. Sit-ups, pelvic rocking, and Kegel exercises are not identified to assist with tightening the muscles of the abdominal region.

17. The nurse assesses a postpartum patient's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? A) Lochia alba B) Lochia rubra C) Lochia serosa D) Lochia normalia

Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 404 Feedback: Lochia that is red in color, or bloody, is termed lochia rubra. Lochia alba is colorless flow that occurs around postpartum day 10. Lochia serosa is pink or brown in color and appears around postpartum day 4. Lochia normalia is not a term used to describe lochia.

11. A woman states that she still feels exhausted on her second postpartal 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.

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 407 Feedback: Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

19. A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse emphasize when teaching the patient about this treatment approach? A) Sitz baths may lead to increased postpartal infection. B) Sitz baths increase the blood supply to the perineal area. C) Sitz baths cause perineal vasoconstriction and decreased bleeding. D) The longer a sitz bath is continued, the more therapeutic it becomes.

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 412 Feedback: Moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. Sitz baths do not cause postpartal infections. Sitz baths do not cause perineal vasoconstriction and decreased bleeding. Every use of a sitz bath is therapeutic.

10. A woman who is two days postpartum has painful hemorrhoids postpartally. Which of the following positions would you suggest she use for resting? A) Spine with uterus pressed to the side B) Sims' position C) Knee-chest position D) Trendelenburg position

Ans: B Client Needs: Physiological Integrity: Basic Care and Comfort Cognitive Level: Apply Page: 417 Feedback: A Sims' position relieves pressure on rectal veins, thus reducing the size and pain of hemorrhoids. A knee-chest position is not recommended.

12. A postpartal woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartally? A) Ask her if she feels any warmth in her legs. B) Assess for calf redness and edema. C) Take her temperature every 4 hours. D) Palpate her feet for tingling or numbness.

Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 416 Feedback: Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

1. Which action would most make the nurse believe that a postpartum woman is accepting a child well? A) She states she has named the child after a well-loved friend. B) She turns her face to meet the infant's eyes when she holds her. C) She comments that her baby has the most hair of any in the nursery. D) She asks the nurse to use her camera to take a photo of the child.

Ans: B Client Needs: Psychosocial Integrity Cognitive Level: Apply Page: 400 Feedback: An "enface" position is a mark of a woman who is interacting warmly with a newborn.

30. A postpartum patient is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the patient about this medication? Select all that apply. A) This medication has no adverse effects. B) Be sure to engage in activity to aid in intestinal motility. C) One pill should be taken after every meal for the first week. D) This medication works the best when a high-fiber diet is consumed. E) Take each dose of the medication with a full glass of water or juice.

Ans: B, D, E Client Needs: Physiological Integrity: Basic Care and Comfort Client Needs 2: Physiological Integrity: Pharmacological and Parenteral Therapies Cognitive Level: Apply Page: 415 Feedback: Docusate sodium (Colace) is used in the postpartal period to prevent constipation. It works by lowering the surface tension of feces, allowing water and lipids to penetrate the stool and soften it. The nurse should instruct the patient to engage in activity to promote intestinal motility, consume a diet high in fiber, and take each dose of the medication with a full glass of water or juice. This medication has abdominal pain and diarrhea as potential adverse effects. This medication is not taken after every meal but rather one dose per day.

15. The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior? A) Disappointment with the child's sex B) Difficulty accepting the role changes C) Reacting normally to accepting a new child D) Cultural customs do not include kissing children

Ans: C Client Needs: Psychosocial Integrity Client Needs 2: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 400 Feedback: More often, a woman enters into a relationship with her newborn tentatively and with qualms and conflicts that must be addressed before the relationship can be meaningful. This is because parental love is only partly instinctive. The tentative behavior does not indicate disappointment with the child's sex, difficulty accepting role changes, or cultural customs that do not include kissing children.

16. While documenting patient care, the nurse notes that a postpartum patient is accepting the birth of the child well. What did the nurse most likely observe to come to this conclusion? A) Names the child after a well-loved friend B) Asks the nurse to take a photo of the child C) Turns the face to meet the infant's eyes when holding the baby D) Comments that the baby has the most hair of any in the nursery

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 400 Feedback: Looking directly at the newborn's face, with direct eye contact or the en face position, is a sign a woman is beginning effective attachment. Naming the child after a well-loved friend, taking a photo of the child, or commenting on the child's hair are not indications that the postpartum patient is accepting the birth of the child well.

13. A postpartal woman (gravida 1, para 1) asks immediately after delivery if she should request rooming-in with her infant. Your best response would be that: A) this puts too much responsibility on a first-time mother. B) it depends on whether she will breastfeed or not. C) rooming-in allows increased maternal-newborn contact. D) resting for the first 3 days postpartum will be better for her.

Ans: C Client Needs: Psychosocial Integrity Cognitive Level: Analyze Page: 401 Feedback: Rooming-in (having the baby with her for the majority of the day) encourages bonding and is recommended whether a woman will breastfeed or not.

22. The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus? A) Fundus 4 cm above symphysis pubis and firm B) Fundus height 4 cm below umbilicus and midline C) Fundus two fingerbreadths below umbilicus and firm D) Fundus two fingerbreadths above symphysis pubis and hard

Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Physiological Integrity: Basic Care and Comfort Cognitive Level: Analyze Page: 403 Feedback: Because uterine contraction begins immediately after placental delivery, the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases one fingerbreadth or centimeter per day and will be palpable 1 cm below the umbilicus. For the second postpartal day, the uterus will be two fingerbreadths or centimeters below the umbilicus. The fundus should not be palpated 4 cm above the symphysis pubis, 4 cm below the umbilicus, or two fingerbreadths above the symphysis pubis on the second postpartum day. The fundus should not be hard.

9. A postpartal woman is concerned that her abdomen is extremely lax. Which exercise would the nurse suggest she start on the second day postpartum to tighten her abdominal muscles? A) Sit-ups B) Pelvic rocking C) Kegel exercises D) Chin-to-chest

Ans: D Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 417 Feedback: Chin-to-chest exercises strengthen abdominal muscles yet are not exhausting and can be started on the second day. Sit-ups can be started after a few more days. Kegel exercises strengthen the perineal, not abdominal, muscles.

3. A nurse helps a postpartum woman out of bed for the first time postpartally 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.

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 404 Feedback: 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.

7. When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal 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

Ans: D Client Needs: Physiological Integrity: Physiological Adaptation Cognitive Level: Apply Page: 411 Feedback: 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.