M: Ch 17

36. The postpartum nurse is administering ibuprofen (Advil) to a client with episiotomy discomfort. The prescribed order is 400 mg of Advil by mouth every 6 to 8 hours PRN for discomfort. The Advil sent by the pharmacy is 200 mg/tablet. How many tablet(s) should the nurse administer to the client? Record your answer as a whole number. _____ tab(s)

ANS: 2 Use the medication calculation formula to calculate the correct dose. Formula: Desired/available ´ volume = mg/dose 400 mg/200 mg ´ 1 tab = 2 tabs PTS: 1 DIF: Cognitive Level: Application REF: 340 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Formal b. Informal c. Personal d. Anticipatory

ANS: A A major task of the formal stage of role attainment is getting acquainted with the infant. The informal stage begins once the parents have learned appropriate responses to their infant's cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.

11. Rho(D) immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

ANS: A An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's. PTS: 1 DIF: Cognitive Level: Analysis REF: 334 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity

If the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.

ANS: A An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated. PTS: 1 DIF: Cognitive Level: Application REF: 331 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

20. Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth

ANS: A Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent. PTS: 1 DIF: Cognitive Level: Analysis REF: 329, 330 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

28. The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold c. Patient reports she took two sitz baths in 12 hours d. Edges of the perineal laceration are well approximated

ANS: A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma. PTS: 1 DIF: Cognitive Level: Evaluating REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Client who is bottle feeding her first child d. Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

ANS: A The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus. PTS: 1 DIF: Cognitive Level: Understanding REF: 340 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold

ANS: A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. In the taking-in phase, the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment. During the taking-hold phase, the mother assumes responsibility for her own care and shifts her attention to the infant.

Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources. b. Recommends employing babysitters frequently. c. Tells the parents about the realities of parenthood. d. Offers a home phone number and tells parents to call if they have a question.

ANS: A Available resources within the community can assist the parents in role transition. Some parents may not be able to afford babysitters. Also, this removes them from the parenthood role. Each adult sees parenthood in a different light. They cannot be compared. Searching out resources for the parents is an important task; however, the nurse should not give her personal number to patients.

A new father calls the nurse's station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, "She was never like this before the baby was born." How should the nurse best respond? a. Reassure him that this behavior is normal. b. Advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: A Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. Postpartum blues are a normal process that is short-lived; no medical intervention is needed. Telling him to ignore the moods blocks communication and may belittle the husband's concerns. Patient teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching.

The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time? a. Hand the baby to the woman. b. Explain "taking-in" to the woman. c. Offer to hand the baby to the woman. d. No action, because this situation is perfectly acceptable

ANS: A During the taking-in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. She learns best during the taking-hold phase. The woman is dependent and passive at this stage and may have difficulty making a decision. This is expected behavior during the taking-in phase; however, interventions that facilitate infant bonding can be taken

The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks? a. Making the birth experience "real" b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. Taking hold of the events leading to her labor and birth

ANS: A Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. She is in the taking-in phase, trying to make the birth experience seem real. This is to satisfy her needs, not the needs of others

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold. c. Patient reports she took two sitz baths in 12 hours. d. Edges of the perineal laceration are well approximated.

ANS: A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitates wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma.

The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture? a. Special foods brought from home. b. Preference for fresh fruits. c. Preference for "cold" foods. d. Request for ice water instead of hot water.

ANS: A Specific foods brought from home are a welcome sign of caring in many cultures. Some Asians believe that after childbirth the woman should eat only "hot" foods such as chicken, meat, and fish. Fresh fruit would be considered a "cold" food. Although ice water is commonly given to hospital patients, it is not acceptable to many Asians. For example, Southeast Asian women may refuse cold or ice water and prefer hot water or other warm beverages to keep warm.

Which patient is more likely to have less stress adjusting to her role as a mother? a. A 26-year-old woman who is returning to work in 10 weeks b. A 35-year-old anxious mother who has had no contact with babies or children c. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

ANS: A The woman who has the least amount of stress in her life will adjust more quickly to her role as a mother. The anxious mother with no real experience with babies may have a difficult time adjusting to motherhood. The teenager has a significant amount of stress in her life, which could make adjusting to her role as a mother more difficult. The 25-year-old mother has the added stress of twins, which may make motherhood adjustment more difficult.

Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM e. Varicella

ANS: A, B, C, E If a patient who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, Tdap, and varicella should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.

Which description best explains the term reciprocal attachment behavior? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback that the infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

ANS: B In this definition, reciprocal refers to the feedback from the infant during the attachment process. The quiet alert state is a good time for bonding; however, does not define reciprocal attachment. Reciprocal attachment deals with feedback behavior and is not unidirectional.

32. The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas

ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks. PTS: 1 DIF: Cognitive Level: Application REF: 339 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity *33. The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.) a. The client has not voided but the bladder cannot be palpated. b. The fundus is displaced from the midline and the client has been unable to void. c. The client has been medicated for pain but she has not voided; the fundus is midline. d. The amount voided is less than 150 mL and the fundus is displaced from the midline. *ANS: B, D The nurse makes the decision to perform an intermittent sterile catheterization if the client is unable to void, the amount is less than 150 mL, and the fundus is displaced. A nonpalpable bladder and firm fundus at or below the umbilicus and in the midline confirm that the bladder is empty and rule out urinary retention with overflow. PTS: 1 DIF: Cognitive Level: Analysis REF: 340 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a. Provide comfort and ample time for rest. b. Keep the baby wrapped to avoid cold stress. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way. e. Limit the amount of modeling so the mother doesn't feel insecure.

ANS: A, C, D Provide comfort and ample time for rest, because the mother must replenish her energy and be relatively free of discomfort before she can progress to initiating care of the infant. Position the infant in an en face position and discuss the infant's ability to see the parent's face. Face to face and eye to eye contact is a first step in establishing mutual interaction between the infant and parent. Point out the characteristics of the infant in a positive way: "She has such pretty little hands and beautiful eyes." The baby should be kept warm, but parents should be assisted to unwrap the baby (keeping or rewrapping the body part not being inspected) to inspect the toes, fingers, and body. The nurse should model behaviors by holding the infant close, making eye contact with the infant, and speaking in high-pitched, soothing tones.

31. The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a. "I will gently pat the perineum dry rather than wipe." b. "I will only use the perineal bottle after bowel movements." c. "I will use cold water in the perineal bottle as I cleanse." d. "I will use the perineal bottle without touching the perineum."

ANS: A, D The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements. PTS: 1 DIF: Cognitive Level: Analysis REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

34. The nurse is teaching a non-breastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended . d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production. PTS: 1 DIF: Cognitive Level: Application REF: 344 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

23. In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth? a. Quantity of lochia rubra b. Pain management techniques c. Frequency of vital signs and fundal checks d. Assessment of infection risk from loss of skin integrity

ANS: B A cesarean section is major surgery. Pain relief is provided in various ways, including patient-controlled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 341 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad

ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: · Scant—less than a 1-inch stain on the peripad · Light—1- to 4-inch stain · Moderate—4- to 6-inch stain · Heavy—saturated peripad · Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. "I may not have a bowel movement until the 2nd postpartum day." b. "If I breastfeed and supplement with formula, I won't need any birth control." c. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." d. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

4. Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum, but is still appropriate. PTS: 1 DIF: Cognitive Level: Application REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

An example of binding in during the postpartum period is a a. new mother telling her friends all about her labor and birth experience. b. father looking at his newborn and stating that he "looks like I did when I was a baby." c. mother reporting increasing anxiety during the postpartum period because she feels like she is without support. d. mother wanting some time alone so that she can catch up on needed sleep.

ANS: B A new mother telling her friends all about her labor and birth experience is an example of binding in or claiming. A new mother telling her friends all about her labor and birth experience is an example of the taking-in phase of maternal adaptation. A mother who reports increasing anxiety during the postpartum period because she feels like she is all alone may be problematic and indicates that the patient is experiencing significant stressors during the postpartum period. A mother wanting some time alone so that she can catch up on needed sleep is a normal reaction to the demands of the newborn and reflects that the patient may need additional support during this time.

35. The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

ANS: B, D, E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa). PTS: 1 DIF: Cognitive Level: Application REF: 348 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity SHORT ANSWER

Which measure is optimal in order to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles

ANS: C Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention.

1. A postpartum client overhears the nurse tell the health care provider that she has a positive Homans sign and asks what it means. Which is the nurse's best response? a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A fleshy odor, not a foul odor, is within normal limits. PTS: 1 DIF: Cognitive Level: Application REF: 338 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38° C (100.4° F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38° C (100.4° F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.

24. When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage. PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate. b. Document the finding. c. Encourage the use of an incentive spirometer. d. Ambulate the client around the nurses' station.

ANS: C Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses' station should not be done at this time. PTS: 1 DIF: Cognitive Level: Application REF: 342 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The Centers for Disease Control and Prevention (CDC) recommends the use of which personal protective equipment with which the nurse is likely to come into contact? a. Any body fluids b. Any client at any time c. Blood and blood products d. Any client suspected of being HIV-positive

ANS: C Possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids. Only certain body fluids can cause contamination. It is not necessary to wear protective equipment continually with all clients. Protective equipment is important with a client if the nurse is at risk for contamination with blood or certain body fluids. The equipment does not have to be worn with casual contact. PTS: 1 DIF: Cognitive Level: Understanding REF: 334 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Safe and Effective Care Environment

A postpartum client asks, "Will these stretch marks go away?" Which is the nurse's best response? a. "No, never." b. "Yes, eventually." c. "They will fade to silvery lines but won't disappear completely." d. "They will continue to fade and should be gone by your 6-week checkup."

ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear. PTS: 1 DIF: Cognitive Level: Application REF: 333 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

27. The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 330 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

The nurse is developing a plan of care for the patient's fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? a. Encourage the patient to call the baby by his or her first name. b. Stimulate the grasp reflex by placing the patient's finger in the infant's palm. c. Ask the patient if she wants her baby placed on her chest immediately after birth. d. Assess for familial characteristics and remark on the resemblance to the patient or the father.

ANS: C Bonding refers to the rapid initial attraction felt by parents for their infant. It is unidirectional, from parent to child, and is enhanced when parents and infants are permitted to touch and interact during the first 30 to 60 minutes after birth. During this time, the infant is in a quiet, alert state and seems to gaze directly at the parents. Infants are often placed skin to skin on the mother's chest or abdomen for bonding time immediately after birth. Nurses frequently delay procedures such as measurements and medication administration that would interfere with this time, so that parents can focus on their newborn baby. Attachment follows a progressive or developmental course that changes over time. It is rarely instantaneous. Unlike bonding, attachment is reciprocal—it occurs in both directions between parent and infant.

Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting? a. En face behavior is observed between father and infant. b. Mother relates that she feels exhilarated postbirth. c. Mother states that she feels excessive fatigue as a result of the childbirth experience. d. Father displays finger tipping behavior toward infant.

ANS: C Fatigue can contribute to altered parenting, because it may affect the level of interaction between parent and child. En face behavior acknowledges maternal-paternal attachment. A feeling of exhilaration is normal following a changing life cycle event such as childbirth. Finger tipping behavior conveys a sense of identification or claiming behavior.

When assessing the A of the acronym REEDA, the nurse should evaluate the a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis D = drainage.

Which action should the nurse take in order to provide support and encouragement to the new postpartum patient? a. Recount how she solved her own problems. b. Correct the new mother at every opportunity. c. Praise the mother's early attempts at infant care. d. Explain to the new mother that everything will be fine.

ANS: C Positive reinforcement of the mother's attempt to provide care to the newborn will promote a healthy self-concept. The mother needs to learn how to solve problems on her own. Each person may use different techniques that work for that person. Correcting her actions would be discouraging to a new mother. She needs encouragement. Saying everything will be fine is blocking communication and further teaching.

A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment? a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role. d. Observe the son's reaction to the baby and let him decide when he wants to be introduced to his new sibling.

ANS: C Providing the older son with a special role designation and involving him in the care of the baby will facilitate sibling attachment. Spending individual time with the older child is recommended but will not facilitate sibling attachment. Although the older child should be supervised because of his age in terms of infant safety, this level of overprotection may inhibit sibling attachment. Observation of his behavior may be warranted; however, the age of the child (2 years) does not warrant this type of control.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

ANS: C The lochia of the cesarean birth mother will go through the same phases as that of the woman who had a vaginal birth; however, the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and an indication of hemorrhage. The health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss; but, this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. What should the nurse do next? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

ANS: C The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate. This is normal for an adjusting family

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked. PTS: 1 DIF: Cognitive Level: Application REF: 336 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

25. Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client. PTS: 1 DIF: Cognitive Level: Analysis REF: 336 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

29. The nurse is performing a postpartum assessment on a client and concludes with the assessment depicted in the figure. Which is the rationale for performing the depicted assessment? a. Check for edema. b. Check for range of motion. c. Check for adequate reflexes. d. Check for deep vein thrombosis.

ANS: D Discomfort in the calf with sharp dorsiflexion of the foot is a positive Homans sign and may indicate deep vein thrombosis. Edema is checked by palpating and pressing on the top of the foot, range of motion is not a postpartum assessment, and reflexes are checked at the patellar area. PTS: 1 DIF: Cognitive Level: Analysis REF: 338 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE

22. To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion. b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence.

ANS: D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the client is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period. PTS: 1 DIF: Cognitive Level: Application REF: 332 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

3. Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

A pregnant client asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after birth because of: a. increased estrogen. b. increased progesterone. c. decreased human placental lactogen. d. decreased melanocyte-stimulating hormone.

ANS: D Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation. PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

ANS: D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 334 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

14. Which documentation in the client's chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow d. Fundus below the symphysis and not palpable

ANS: D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

26. The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart.

ANS: D The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed. PTS: 1 DIF: Cognitive Level: Application REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history? a. Client has not been pregnant. b. Client has had a C section as a method of birth. c. Client has been treated for an STD with resultant scarring of the cervix. d. Client has a history of pregnancy.

ANS: D With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is not associated with cervical changes. PTS: 1 DIF: Cognitive Level: Application REF: 330 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth? a. Discuss child care arrangements with her. b. Allow her to solve the problem on her own c. Reassure her that she'll get used to leaving her baby. d. Allow her to express her positive and negative feelings freely

ANS: D Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. Discussing child care arrangements is an important step in anticipatory guidance, although this is not the best way to offer support. The new mother should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision. Reassuring her that she will get used to leaving the baby blocks communication and belittles the patient's feelings.

To promote bonding and attachment immediately after birth, which action should the nurse take? a. Assist the mother in feeding her baby. b. Allow the mother quiet time with her infant. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newborn.

ANS: D Assisting the mother in assuming an en face position with her newborn will support the bonding process. After birth is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time.

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum patient.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care? a. Have the patient drink carbonated beverages to promote urinary excretion. b. Tell the patient that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence.

ANS: D Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen pelvic floor muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"

ANS: D Postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management for full recovery. Nurses need to assess the depression to ascertain if she is unable to cope with daily life. Postpartum blues are self-limiting and frequently occur by the fifth postpartum day and resolve in 2 weeks. The response "Sounds like postpartum depression" does not offer the patient any help or encouragement through this challenging time. Asking if she is getting enough sleep does not add to the assessments already identified in the stem. Enough information exists to determine that she has the signs and symptoms of postpartum blues. The nurse must differentiate between postpartum blues and depression.

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart.

ANS: D The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed.