OB - Chapter 15
Which factor might result in a decreased supply of breast milk in a postpartum client?
supplemental feedings with formula
Which factor might result in a decreased supply of breast milk in a postpartum client?
supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.
The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: 7.25 or more. 7.21. 7.15 or less. 7.20.
7.15 or less.
The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women?
85%
The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? Evolution Involution Decrement Progression
Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she's most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? a) 85% b) 25% c) 100% d) 40%
85%
The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women? 40% 85% 25% 100%
85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? a. explain to her that women who have had several babies prior to this delivery often experience contracting and relaxing at intervals b. tell her that you will notify the doctor of the unusual pain and see what he wants to do c. recommend that the client ambulate more to help relieve the pain d. encourage the mother to breast- feed to help relax the uterus
A
A multigravida client admitted in active labor has progressed well and the client ane fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Contact the primary care provider. Time the contractions. Inspect the perineum. Auscultate the fetal heart tones.
Inspect the perineum.
The process by which the reproductive organs return to the nonpregnant size and function is termed what? a) Evolution b) Involution c) Decrement d) Progression
Involution
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? The urge to push occurs. Frequency of contractions are 5 to 6 minutes. Fetus is at -1 station. Emotions are calm and happy.
The urge to push occurs.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a scant amount of lochia serosa a moderate amount of lochia rubra a moderate amount of lochia alba
a moderate amount of lochia rubra
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors
A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?
"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction. Turn her or ask her to turn to her side.
Turn her or ask her to turn to her side.
A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?
"Be sure to change your pajamas to prevent you from chilling."
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?
"After birth it is easier to develop an infection in the urinary system; we need to see you today."
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response by the nurse is appropriate?
"After birth it is easier to develop an infection in the urinary system; we need to see you today." The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.
A woman who delivered her infant 1 week ago calls the clinic to complain of pain with urination and increased frequency. What response by the nurse is appropriate? a) "It is common for women to have yeast problems, try an over the counter cream and let us know if this continues." b) "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." c) "After delivery it is easier to develop an infection in the urinary system, we need to see you today." d) "This is normal, give it a few days and then call back."
"After delivery it is easier to develop an infection in the urinary system, we need to see you today."
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying ice b) Administering bromocriptine (Parlodel) c) Applying warm compresses d) Restricting fluids
Applying ice
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"
A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? a. wear a well- fitting bra b. A nurse is caring for a c. apply warm compressess d. apply hydrogel dressing
A
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
The nurse is preparing discharge training for a G2P2 client who will breast-feed her infant. The client mentions she wants more children but wants to wait a couple years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals?
when she resumes sexual activity
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
"I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue?
"Ovulation may return as soon as 3 weeks after birth."
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge teaching to address this issue? "You may have intercourse until next month with no fear of pregnancy." "Ovulation may return as soon as 3 weeks after birth." "You will not ovulate until your menstrual cycle returns." "Ovulation does not return for 6 months after birth."
"Ovulation may return as soon as 3 weeks after birth."
A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."
A postpartum client has called the unit reporting breast engorgement and asking for suggestions. Which instruction should the nurse prioritize for this client?
"Take a warm shower just before feeding your infant."
A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?
"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? a) "It takes a while to get your body back to its normal function after having a baby." b) "This is entirely normal, and many women go through it. It just takes time." c) "Try doing Kegel exercises to get your pelvic muscles back in shape." d) "You might try using a water-soluble lubricant to ease the discomfort."
"You might try using a water-soluble lubricant to ease the discomfort."
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum
A nurse is caring for a postpartum client who has a temperature. Which temperature protocols would the nurse use to indicate a possible infection?
100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4º F (38º C) on 2 postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
Five days after giving birth, a new mother tells her nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. She asks what the average weight loss at 5 days into the postpartal period is. Which of the following should the nurse mention? a) 24 lb b) 14 lb c) 9 lb d) 19 lb
19 lb
Mrs. Smith asks the nurse to compute her expected due date. Based on the fact that her last menstrual flow began on July 20, which due date would the nurse estimate?
A Following Nagel's Rule you would subtract 3 months Add 7 days and add 1 year. 7-3 = 4 20+7 = 27 4/27
The nurse is reviewing the health records of several client's who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage?
A client diagnosed with placenta succenturiate Placental succenturiate is a concern for maternal hemorrhage if the accessory lobes of the placenta are retained after delivery. The other conditions are not associated with a higher than usual concern for hemorrhage, although all postpartum clients are observed for hemorrhage.
Bonding between a mother and her infant can be defined how? a) A process of developing an attachment and becoming acquainted with each other b) An ongoing process in the year after delivery c) Family growing closer together after the birth of a new baby d) The skin to skin contact that occurs in the delivery room
A process of developing an attachment and becoming acquainted with each other
The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient?
Absence of lochia
The nurse is analyzing the readout on the EFM and determines the FHR pattern is reassuring based on which recording?
Acceleration of at least 15 bpm for 15 seconds A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.
At which time is it most important to monitor for umbilical cord prolapse? When the fetus is crowning At the onset of labor After rupture of membranes During transitional labor
After rupture of membranes
Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM?
Amniocentesis is an invasive procedure whereby a needle inserted into amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with RhD-negative blood, and she should receive RhoGam after the procedure. The CST, NST, and a biophysical profile are noninvasive tests Before administering Rho(D) immune globulin (RhoGAM), a nurse reviews a pregnant client's laboratory data. What combination of factors in the blood directs the need for RhoGAM? 1 Rh positivity and a positive Coombs test result Incorrect2 Rh negativity and a positive Coombs test result 3 Rh positivity and a negative Coombs test result Correct4 Rh negativity and a negative Coombs test result Rho(D) immune globulin (RhoGAM) is administered to prevent active formation of antibodies when an Rh-negative individual is at risk for sensitization. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells; it is never given to an individual with Rh antibodies. A positive Coombs test result indicates that the woman has Rh antibodies. RhoGAM never is given to an individual with Rh antibodies. RhoGAM is contraindicated in Rh-positive women because it will cause hemolysis of red blood cells.
Which statement is true regarding analgesia versus anesthesia? Decreased FHR variability is a common side effect when regional anesthesia is used. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. Hypotension is the most common side effect when systemic analgesia is used.
Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? a. postpartum blues b. postpartum depression c. anxiety disorders d. postpartum psychosis
B
A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? Decreased anxiety will increase trust in the nurse. Anxiety will increase blood pressure, increasing risk with an epidural. Anxiety can slow down labor and decrease oxygen to the fetus. Increased anxiety will increase the risk for needing anesthesia.
Anxiety can slow down labor and decrease oxygen to the fetus.
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused due to perineal edema? a) Use ointments locally b) Use a warm sitz bath or tub bath c) Apply moist heat d) Apply ice
Apply ice
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema? Use a warm sitz bath or tub bath. Use ointments locally. Apply moist heat. Apply ice.
Apply ice.
Louisa has just delivered her second child and will breast-feed. Although she wants "lots of kids," she doesn't want to become pregnant again until her second child is at least 2 years old. You counsel her to start using birth control at what point? a) Within 6 weeks b) As soon as she stops breast-feeding c) As soon as she resumes sexual activity d) Within 18 months
As soon as she resumes sexual activity
A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." Which of the following is the nurse's most appropriate response? a) Inform the physician that the client does not want to go home. b) Ask the client if she has any support in the home. c) Tell the client that she must go home as per hospital policy. d) Ask the client why she does not want to go home.
Ask the client why she does not want to go home.
The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize? Assess return of sensory and motor functions to the lower extremities. Make sure the client receives plenty of fluids. Help the client get up and walk around immediately. Let the client rest and recover while keeping her legs slightly elevated.
Assess return of sensory and motor functions to the lower extremities.
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts
The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? a. put on witch hazel pad b. place an ice pack c. notify a primary care provider d. apply a warm washcloth
B
A nurse is caring for a client who has just undergone delivery. What is the best method for the nurse to assess this client for postpartum hemorrhage? a) By assessing blood pressure b) By assessing skin turgor c) By monitoring hCG titers d) By frequently assessing uterine involution
By frequently assessing uterine involution
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. allowing the mother to pick the best time to hold her newborn b. talking about how the nurse held her own newborn while on the birthing table c. bringing the newborn into the room d. showing a video of parents feeding their babies
C
A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?
Empty the breasts frequently. The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.
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.
Encourage postpartum patients to participate in breast-feeding; Explain the importance of close observation to detect postpartum maternal hemorrhage; Provide information on reproductive life planning if requested
The nurse is assessing a breastfeeding mom 72 hours after delivery. When assessing her breast, the patient complains of bilateral breast pain around the entire breast. What is the most likely cause of the pain? a) Engorgement b) Blocked milk duct c) Mastitis d) Interductal yeast infection
Engorgement
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.
A woman who has just given birth seems to be bonding with her newborn, despite the fact that earlier in labor she had expressed an intent to give the baby up for adoption. In this case, the nurse should encourage the mother to keep her baby. a) False b) True
False
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Have the client void, and then massage the fundus until it is firm. Notify the primary care provider, and document the findings. Check and inspect the lochia, and document all findings. Assess a full set of vital signs.
Have the client void, and then massage the fundus until it is firm.
As the nurse caring for postpartum patients, what laboratory study would you expect to have ordered by the birth attendant the morning after delivery of the baby? a) Blood type b) Complete blood count (CBC) c) Hemoglobin and hematocrit (H&H) d) Iron level
Hemoglobin and hematocrit (H&H)
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with postpartum blues.
While caring for a new mother on her second day postpartum, the nurse notes the new mother handles her newborn tentatively, not kissing her child but appears afraid to interact with her baby. Which situation would the nurse suspect as the probable reason for this?
Normal reaction to accepting a new child.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next? Notify the healthcare provider. Perform urinary catheterization. Administer oxytocin IV. Insert a 20 gauge IV.
Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.
A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply.
Restlessness, feelings of worthlessness, and feeling overwhelmed
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?
Rooming-in allows increased maternal-newborn contact
A postpartum client delivered her infant 1 day ago and the nurse is monitoring her blood pressure. What position would the nurse place the client in to get the most accurate reading?
Sitting on the side of the bed for 2 to 3 minutes In order to get the most accurate reading on a client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.
While educating a class of postpartum clients before discharge home after birth, one woman asks when "will I stop bleeding?" How should the nurse respond?
The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks. The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week, but a white discharge may continue for up to 6 weeks after birth. Bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. The discharge may continue for up to six weeks, not just bleeding.
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?
To check for postpartum hemorrhage
The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which of the following? a) Increased white blood cell count b) Vessel damage during birth c) Episiotomy d) Decrease in coagulation factors
Vessel damage during birth
Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply. Wash her hands before and after caring for the client. Have the mother maintain a low activity level to allow the perineum to heal. Recommend that the mother change her peripads every 12 hours. Encourage intake of fluids following delivery and after discharge. Teach proper positioning of the infant for breast-feeding.
Wash her hands before and after caring for the client. Teach proper positioning of the infant for breast-feeding. Encourage intake of fluids following delivery and after discharge.
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra
The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care? a) Wear a tight, supportive bra b) Run warm water over the breast in the shower c) Express small amounts of milk when they are too full d) Massage the breast when they are painful
Wear a tight, supportive bra
There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain. Women report higher levels of satisfaction when regional anesthetics are used to control pain.
Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which of the following would the nurse interpret as an expected finding? a) Yellowish pink b) Yellowish white c) Red d) Pink
Yellowish white
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? administering bromocriptine applying ice restricting fluids applying warm compresses
applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the size of the fetus determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus determining the weight of the fetus
determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?
difficult to separate clots
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?
difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.
The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor?
discomfort due to hemorrhoids The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis
A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: acupressure. therapeutic touch. effleurage. patterned breathing.
effleurage.
The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? progesterone hCG prolactin estrogen
estrogen The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy. hCG and prolactin are not associated with postpartum diuresis.
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 10 minutes every 15 minutes every 20 minutes every 5 minutes
every 15 minutes
The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? external electronic fetal monitoring fetal oxygen saturation fetal blood pH fetal position
external electronic fetal monitoring
WWhen providing preconception care to a client, the nurse would identify which medication as being safe to continue during pregnancy?
famotidine Famotidine is a category B drug that has been used frequently during pregnancy and does not appear to cause major birth defects or other fetal problems. Isotretinoin and warfarin are category X drugs and should never be taken during pregnancy. Lithium is a category D drug with clear health risks for the fetus and should be avoided during pregnancy.
As a woman enters the second stage of labor, which would the nurse expect to assess? feelings of being frightened by the change in contractions reports of feeling hungry and unsatisfied expressions of satisfaction with her labor progress falling asleep from exhaustion
feelings of being frightened by the change in contractions
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?
hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inability of infant to empty breasts cracking of the nipple inadequate secretion of prolactin improper positioning of infant
inability of infant to empty breasts
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?
increased heart rate
The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply.
involution of the uterus contraction of the cervix decrease of pregnancy hormones return of blood volume to prepregnancy level Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.
The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: left lower quadrant. right lower quadrant. right upper quadrant. left upper quadrant.
left lower quadrant.
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?
lochia rubra
The nurse is making a home visit to a woman who is 5 days postpartum and has no reports. Which finding would concern the nurse and warrant further investigation?
lochia rubra
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?
lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartal period.
A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply.
moderate glycosuria mild ketonuria Occasional RBCs trace WBCs
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.
Which lochia pattern should be reported immediately?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.
The expected fetal heart rate response in an active fetus is:
of at least 15 bpm for 15 seconds. A reassuring active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and reassuring periodic change in fetal heart rates as a response to fetal movement.
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? trauma to pelvic muscles urinary overflow urinary tract infection postpartum diuresis
postpartum diuresis
Based on the incidence of disease in women, which assessment of lower extremities would be most important to make in a pregnant woman?
presence of varicosities Explanation: During pregnancy, women are prone to develop varicosities because of uterine pressure on lower-extremity veins.
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production?
prolactin
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? prolactin oxytocin progesterone estrogen
prolactin
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? prolonged decelerations accelerations early decelerations variable decelerations
prolonged decelerations
The nurse is caring for a client of Asian descent 1 day after she has given birth. Which foods will the client most likely refuse to eat when her meal tray is delivered? Select all that apply.
raw carrots and celery, ice cream, and orange slices
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?
redness in lower legs
The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?
rise in hematocrit
A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?
taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? writing pictures touching recognizing the meaning of words
touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.
While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:While caring for a woman in labor, the nurse notes that the fetal heart monitor demonstrates late decelerations. The most common cause for their occurrence is:
uteroplacental insufficiency. Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions. Maternal hypotension and fatigue would not be observed on the fetal heart monitor. Cord compression would be marked by fetal tachycardia.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? uterus 1 cm below umbilicus diaphoresis lochia serosa edematous vagina
uterus 1 cm below umbilicus
The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?
vessel damage during birth A woman's risk for thromboembolism increases due to her hypercoagulable state, vessel damage during birth, and immobility. The increase in white blood cell count is unrelated to her risk for thromboembolism. Coagulation factors remain elevated for 2 to 3 weeks postpartum. An episiotomy is not a risk factor for thromboembolism.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. a) Uterine infection b) Prolonged labor c) Empty bladder d) Early ambulation e) Breast-feeding f) Hydramnios
• Uterine infection • Prolonged labor • Hydramnios
When assessing a postpartum mother, the nurse asks the client how many peripads she has used over the last 4 hours. The mother responds that she has changed her pad 2 to 3 times per hour when they were saturated. What action should the nurse take
Notify the RN of the finding
Gestational diabetes occurs around the 24th week of gestation. When should every woman be screened for gestational diabetes?
24-28 weeks
The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus?
Supine
For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it.
True
Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding?
Two fingerbreadths below the umbilicus
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?
oxytocin
A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?
sim's position
A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. Which of the following should the nurse say in response to this request? a) "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." b) "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover." c) "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." d) "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? a) "I didn't realize all that went into being a dad. I wasn't prepared for this." b) "It'll be fun to have a baby in the house, but things shouldn't change too much." c) "I may not be a pro at helping out with the baby, but I enjoy being involved." d) "I've learned how to diaper and bathe the baby so I can be a really involved dad."
"I didn't realize all that went into being a dad. I wasn't prepared for this."
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? a. 1 cm above the umbilicus b. at the symphysis pubis c. at level of umbilicus d. 1 cm below the umbilicus
D
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? At the symphysis pubis 1 cm above the umbilicus At level of umbilicus 1 cm below the umbilicus
1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, which statement indicates the need for additional teaching? a) "I can't wait for these stretch marks to disappear after delivery." b) "My nipples won't be so dark after I give birth." c) "This line on my belly will go away over time." d) "I might lose some hair, but it will grow back."
"I can't wait for these stretch marks to disappear after delivery."
A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. What should the nurse say in response to this request?
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "I didn't realize all that went into being a dad. I wasn't prepared for this." "I may not be a pro at helping out with the baby, but I enjoy being involved." "It'll be fun to have a baby in the house, but things shouldn't change too much." "I've learned how to diaper and bathe the baby so I can be a really involved dad."
"I didn't realize all that went into being a dad. I wasn't prepared for this."
Which action would lead the nurse to assess that a postpartal woman is entering the taking-hold phase of the postpartal period?
She did her perineal care independently. During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.
A client gave birth vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?
"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after birth.
A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." "I need to get your vital signs and check your fundus to be sure you are not going into shock."
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.
Which instruction should the nurse provide to a breastfeeding woman experiencing breast engorgement?
"Take a warm shower just before feeding your infant." Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.
An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? "The client is experiencing lower back pain and I gave a backrub." "I changed the client position from her back to her side." "The client reports a pain level of 8. She has a low pain tolerance." "I instructed the client to ring if she felt the need to move her bowels."
"The client reports a pain level of 8. She has a low pain tolerance."
A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? a) "Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy." b) "Everyone is different, so it is difficult to say when your respirations will be back to normal." c) "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally." d) "You should notice a change in your respiratory status within the next 24 hours."
"Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before your pregnancy."
A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort."
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Bruising and swelling of the perineum often causes excessive urination."
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."
A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8
A postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8 mL The on-hand medication is morphine sulfate 10 mg/mL. The ordered dose is 8 mg, so the nurse would calculate the dose as follows: 10 mg/1 mL = 8 mg/X mL Cross multiply, 10X = 8 mL Divide 8 by 10 to get 0.8 mL
The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus. Use all options. 1 Cramping in the lower abdomen 2 Burning in the perineum 3 Pain noted in the lower back, buttocks and thighs 4 Intense contractions resulting in fetal movement
1 Cramping in the lower abdomen 3 Pain noted in the lower back, buttocks and thighs 4 Intense contractions resulting in fetal movement 2 Burning in the perineum
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? 1 cm above the umbilicus At level of umbilicus At the symphysis pubis 1 cm below the umbilicus
1 cm below the umbilicus
The nurse is assigned to a client on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?
1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.
If a delivering mother weighed 140 pounds at the time of delivery, how much weight should she have lost when she goes home 2 days later, based upon the average pattern? 5-10 pounds 17-29 pounds 10-15 pounds 15-22 pounds
17-29 pounds Normal expected weight loss is approximately 12-14 pounds with the delivery of the fetus, placenta and amniotic fluid then an additional 5-15 pounds in the early postpartum period from fluid loss.
The nurse is assessing a client who has just given birth and notes her prelabor vital signs reveal a temperature 98.8oF (37.1oC), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize? Shaking chills with a fever of 100.3° F (37.9° C) Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. Bradycardia and excessive, soaking diaphoresis Blood loss of 250 mL and WBC 25,000 cells/mL
Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? a. massage the breasts when they are painful b. run warm water over the breast in the shower c. express small amounts of milk when they are too full d. wear a tight, supportive bra
D
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?
Ask the client when she last changed her perineal pad. Explanation: If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.
A woman has just delivered a baby. Her prelabor vital signs were temperature: 98.8°F (37.1°C); blood pressure: 120/70 mmHg; pulse; 80 beats/min. and respirations: 20breaths/min. Which combination of findings during the early postpartum period are the most concerning? a) Shaking chills with a fever of 100.4°F (38°C) b) Blood pressure 90/50 mmHg, pulse 120 beats/min, respirations 24 breaths/min. c) Bradycardia and excessive, soaking diaphoresis d) Blood loss of 250 mL and WBC 25,000 cells/mL
Blood pressure 90/50 mmHg, pulse 120 beats/min, respirations 24 breaths/min.
A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client? Body secreting the excess fluids from pregnancy The body is trying to get rid of the extra blood made during pregnancy. Change in pregnancy hormone The patient may be drinking too much fluid.
Body secreting the excess fluids from pregnancy
A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration? a) Change in pregnancy hormone b) Body secreting the excess fluids from pregnancy c) The body is trying to get rid of the extra blood made during pregnancy d) The patient may be drinking too much fluid
Body secreting the excess fluids from pregnancy
A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration?
Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the patient drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.
The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her? a. a good meal for me is cream of chicken soap, cheese toast and ice cream for dessert b. it is all right to suppress the urge to have a stool for a few days to allow my stitches to heal c. i will avoid medications for constipation such as psyllium because it can upset the babys stomach d. i will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow
D
A client reports she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?
Encourage the client to eat more fiber rich foods. Encouraging fiber rich foods will help with prevention of constipation. The client needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.
The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? Risk factors Fetal status Maternal status Maternal obstetrical history
Fetal status
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?
Health-seeking behaviors related to care of newborn
During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus? a) Palpates the abdomen while feeling the uterine fundus b) Places index and middle fingers across the muscle c) Massaging the fundus carefully to expel any blood clots d) Placing a gloved hand just above the symphysis pubis
Placing a gloved hand just above the symphysis pubis
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
Showing increased confidence when caring for the newborn
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
While educating a class of postpartum patients before discharge home after delivery, one woman asks when "will I stop bleeding?" How should the nurse respond? a) The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks b) You should stop bleeding and have no discharge in the next 1 to 2 weeks c) The bleeding may continue for 6 weeks d) Bleeding may occur on and off for the next 2 to 3 weeks
The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a) Edematous vagina b) Diaphoresis c) Uterus 1 cm below umbilicus d) Lochia serosa
Uterus 1 cm below umbilicus
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a) Uterus 1 cm below umbilicus b) Diaphoresis c) Edematous vagina d) Lochia serosa
Uterus 1 cm below umbilicus
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Run warm water over the breast in the shower. Wear a tight, supportive bra. Massage the breasts when they are painful. Express small amounts of milk when they are too full.
Wear a tight, supportive bra.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a moderate amount of lochia rubra a scant amount of lochia serosa a moderate amount of lochia alba
a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased
On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?
bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.
breastfeeding and early ambulation
When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? increased progesterone levels use of anesthesia during birth decreased bladder pressure decreased intra-abdominal pressure
decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature
dehydration Explanation: 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.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? nausea blood loss diuresis lactation
diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.
If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? variable decelerations, too unpredictable to count fetal heart rate declining late with contractions and remaining depressed a shallow deceleration occurring with the beginning of contractions fetal baseline rate increasing at least 5 mm Hg with contractions
fetal heart rate declining late with contractions and remaining depressed
The nurse is caring for a client is who 24-hours post delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?
hemoglobin and hematocrit Explanation: The health care provider will order a hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia. A decreased result may indicate the woman has suffered post-delivery hemorrhage and is also common with cesarean deliveries. The maternal blood type will be determined before the delivery. The H&H may be ordered as part of the complete blood count or may be ordered separately. The complete blood count may be order to evaluate for infection if the client has a fever. The iron level may be ordered at a later date if the H&H continues to remain low after a few days, but is not a priority within the first 24 hours after delivery.
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
hemorrhage
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors The woman is showing signs of thromboembolism or deep vein thrombosis which is a risk for the postpartum client due to the increased hypercoagulable state which occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors which the body uses as a protective device, however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, then the client should be evaluated for anemia. The stirrups should not cause an injury.
A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. instruct the client or her partner to perform light fingertip repetitive abdominal massage. lead the client through a series of visualizations to aid in relaxation.
instruct the client or her partner to perform light fingertip repetitive abdominal massage.
The nurse is caring for a client who is gravida 3 para 2. The obstetric history reveals that all labors were uncomplicated with two vaginal deliveries. The client is 6 cm dilated and effaced. Which is the minimal acceptable amount of monitoring?
intermittent fetal heart rate auscultation
The process by which the reproductive organs return to the nonpregnant size and function is termed what?
involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which finding would the nurse expect to assess?
moderate lochia rubra with no clots During the first hour following birth, the nurse should find moderate lochia rubra with no clots. Lochia rubra with few clots or saturation of two or more pads within this first hour are not abnormal findings that require further investigation. Lochia alba appears around the 10th day postpartum.
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? progesterone prolactin estrogen oxytocin
oxytocin
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains?
oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.
During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?
peribottle and warm water
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?
perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?
postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?
postpartum depression
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? uterine contractions temperature pulse respiratory rate
respiratory rate
The nurse is caring for a client who is late in her pregnancy. What assessment finding should the nurse attribute to the role of prostaglandins?
softening of cervix
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? touching recognizing the meaning of words pictures writing
touching
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?
two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?
uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.
A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which of the following would the nurse expect to assess? a) Lochia alba saturating at least 3 pads b) Moderate lochia rubra with no clots c) Lochia rubra with few clots d) Lochia rubra saturating two pads
Moderate lochia rubra with no clots
Which lochia pattern should be reported immediately? a) Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 b) Moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 c) Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5 d) Lochia progresses from rubra to serosa to alba within 10 days
Moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
A client who gave birth 5 days ago complains to the nurse of profuse sweating during the night. What should the nurse recommend to the client in this regard? a) "Be sure to change your pajamas to prevent you from chilling." b) "I'm not sure why this is occurring since this usually doesn't occur until much later in the postpartum perio" c) "Drink plenty of cold fluids before you go to bed." d) "I would suggest that you speak with your physician about this."
"Be sure to change your pajamas to prevent you from chilling."
For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it. a) False b) True
True
A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is massaging the perineum as the fetal enlarges the vaginal opening." "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is the effect of a full bladder on fetal descent." "Effleurage is light abdominal massage used to displace pain."
"Effleurage is light abdominal massage used to displace pain."
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?
"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."
A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client? a) "It is normal for the discharge to be deep red since it consists of leukocytes, decidual tissue, RBCs, and serous fluid." b) "This discharge is called lochia, and it consists of leukocytes and decidual tissue." c) "The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." d) "The discharge at this point in the postpartum period consists of RBCs and leukocytes."
"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."
After describing continuous internal electronic fetal monitoring to a laboring woman and her partner, which statement by the woman would indicate the need for additional teaching?
"Unfortunately, I'm going to have to stay quite still in bed while it is in place." With continuous internal electronic monitoring, maternal position changes and movement do not interfere with the quality of the tracing. Continuous internal monitoring is considered the most accurate method, but it can be used only if certain criteria are met, such as rupture of membranes. A spiral electrode is inserted into the fetal presenting part, usually the head.
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? "You might try using a water-soluble lubricant to ease the discomfort." "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "Try doing Kegel exercises to get your pelvic muscles back in shape."
"You might try using a water-soluble lubricant to ease the discomfort."
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Bruising and swelling of the perineum often causes excessive urination."
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention.
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.
Be sure to engage in activity to aid in intestinal motility; This medication works the best when a high-fiber diet is consumed; and take each dose of the medication with a full glass of water or juice
The nurse is assigned to a patient on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus? a) At level of umbilicus b) 1cm above the umbilicus c) 1cm below the umbilicus d) At the symphysis pubis
1cm below the umbilicus
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? a. demonstrating how to do cord care on the newborn b. correcting the mother when she holds the newborn incorrectly c. telling the mother to feed the baby when it cries d. changing the infants diapers for the mother
A
A Chinese mother delivers her newborn and is ready to go home. The grandmother is present and will remain with the mother for 1 month. The grandmother tells the nurse that the mother will not be allowed to leave the house for the first month after delivery. How should the nurse respond to this statement?
Accept the grandmother's statement and do discharge teaching accordingly
A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours? Apply a cold pack to the perineum. Administer acetaminophen with codeine. Offer a hot pad for the abdomen. Assist the client to change position.
Administer acetaminophen with codeine.
The nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? a. evolution b. involution c. decrement d. progression
B
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a. administering bromcoriptine b. applying ice c. restriciting fluids d. applying warm compressess
B
The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation?
Beginning attachment and preparation for family
On assessment of a 2-day postpartum patient the nurses finds the fundus is boggy, at the umbilicus and slightly to the right. What is the most likely cause of this assessment finding? a) Bladder distention b) Full bowel c) Uteruine atony d) Poor bladder tone
Bladder distention
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation? Full bowel Poor bladder tone Bladder distention Uteruine atony
Bladder distention
A nurse is assessing a breastfeeding client in the third week postpartum. During assessment, the nurse observes that the rugae in the vagina have not reappeared. Which of the following should the nurse identify as the possible cause of delayed return of rugae? a) Low circulating progesterone level b) Low circulating oxytocin level c) High circulating estrogen level d) High circulating prolactin level
High circulating estrogen level
A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestions should the nurse give to the client's husband to resolve the issue? a) Recommend that she speak to the physician on her husband's behalf. b) Advise that her husband read up on parental care. c) Encourage the husband to speak to his friends who have children. d) Hold the baby frequently.
Hold the baby frequently
A client in her sixth week postpartum complains of general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which of the following? a) Hypovolemia b) Hypertension c) Hypothyroidism d) Hyperglycemia
Hypovolemia
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? Try to avoid carrying the baby for a few days. Maintain correct posture and positioning. Apply ice to the sore joints. Soak in a warm bath several times a day.
Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack
The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Put on a witch hazel pad. Apply a warm washcloth. Notify a primary care provider.
Place an ice pack.
A woman who delivered a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which of the following factors/conditions does the nurse believe is causing this experience? a) Postpartum depression. b) Postpartum anxiety. c) Postpartum baby blues. d) Postpartum reaction.
Postpartum baby blues.
What is the primary function of uterine contractions after delivery of the infant and placenta? a) Return the uterus to normal size b) Seal off the blood vessels at the site of the placenta c) Stop the flow of blood d) Close the cervix
Seal off the blood vessels at the site of the placenta
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Massage the breasts when they are painful. Express small amounts of milk when they are too full. Run warm water over the breast in the shower. Wear a tight, supportive bra.
Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
At what time is the laboring client encouraged to push? When the cervix is fully dilated When the health care provider has arrived When the fetal head can be seen When she feels the urge to push
When the cervix is fully dilated
When measuring the diagonal conjugate of a woman's pelvis, the distance between which anatomic landmarks would be used?
anterior surface of the sacral prominence and the anterior surface of the symphysis pubis
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying warm compresses administering bromocriptine restricting fluids applying ice
applying ice
The nurse is assessing a client who has given birth within the past hour. The nurse would expect to find the woman's fundus at which location
at the level of the umbilicus After birth, the fundus is located midline between the umbilicus and symphysis pubis but then slowly rises to the level of the umbilicus during the first hour after birth. Then the uterus contracts, approximately 1 cm (or fingerbreadth) each day after birth.
A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning?
blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.
The nurse is concerned with the interactions between a mother and her 2-day-old infant. The nurse observes signs of impaired bonding and attachment. Which action should the nurse document as a cause for concern?
calling the baby it or they Many new parents will need assistance with diaper changes; this is not a flag for concern; making eye contact and breastfeeding are positive interaction behaviors; if the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.
A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? green malodorous clear cloudy
clear
A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:A fetus is assessed at 2 cm above the ischial spines. The nurse would document fetal station as:
d) -2 Rationale: When the presenting part is above the ischial spines, it is noted as a negative station. Since the measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial spines.
When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?
decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.
When caring for postpartum clients, the nurse would expect the birth attendant to prescribe what laboratory study the morning after the birth of the baby?
hemoglobin and hematocrit H&H Monitor the H&H and note the H&H before birth. Most practitioners prescribe a postpartum H&H on the morning after birth. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a Rho(D) immune globulin workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?
inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inadequate secretion of prolactin improper positioning of infant cracking of the nipple inability of infant to empty breasts
inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? estrogen oxytocin progesterone prolactin
prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.
When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.
A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation?
suggest proper exercise
A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?
taking-in phase
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition
urinary tract infection
During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition? postpartum diaphoresis urinary tract infection uterine atony urinary retention
uterine atony Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? lochia serosa diaphoresis edematous vagina uterus 1 cm below umbilicus
uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which of the following are retrogressive changes? (Select all that apply.) a) Beginning of a parental role b) Involution of the uterus c) Formation of breast milk d) Return of blood volume to prepregnancy level e) Decrease of pregnancy hormones f) Contraction of the cervix
• Involution of the uterus • Return of blood volume to prepregnancy level • Decrease of pregnancy hormones • Contraction of the cervix
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which condition?
urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? stress incontinence urinary tract infection loss of pelvic muscle tone increased urine output
urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.
During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition?
uterine atony
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?
uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during postpartum, diuresis causes weight loss during the first postpartal week, whereas iron deficiency causes anemia in the puerperium.
A client who has given birth a week ago complains to the nurse of discomfort when defecating and ambulating. The birth involved an episiotomy. Which of the following should the nurse suggest to the client to provide local comfort? Select all that apply. a) Maintain correct posture b) Use of anesthetic sprays c) Use of warm sitz baths d) Use good body mechanics e) Use of witch hazel pads
• Use of warm sitz baths • Use of witch hazel pads • Use of anesthetic sprays
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?
taking-in
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? letting-go taking-hold taking-in acquaintance/attachment
taking-in
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?
taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which of the following does the nurse recognize as the phase the woman is experiencing? a) The taking hold phase. b) The taking in phase. c) The binding in phase. d) The letting go phase.
The taking hold phase.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
Bonding between a mother and her infant can be defined how?
a process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a year-long process, and the family growing closer together after the birth of a new baby is not bonding.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? a. apply cold compresses to the breasts b. feed the baby at least every two or three hours c. dry the nipples following feedings d. provide the infant oral nystatin
B
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings." "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break." "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover."
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "I need to let the doctor know if my lochia begins to have a foul smell." "I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know."
"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "I need to let the doctor know if my lochia begins to have a foul smell."
"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the doctor needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul smelling both indicate a possible infection and the doctor needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? "This line on my belly will go away over time." "I might lose some hair, but it will grow back." "I can't wait for these stretch marks to disappear after I give birth." "My nipples won't be so dark after I give birth."
"I can't wait for these stretch marks to disappear after I give birth."
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?
"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "It'll be fun to have a baby in the house, but things shouldn't change too much." "I didn't realize all that went into being a dad. I wasn't prepared for this." "I may not be a pro at helping out with the baby, but I enjoy being involved." "I've learned how to diaper and bathe the baby so I can be a really involved dad."
"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years."
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? "That's wonderful. Medication during labor is not good for the baby." "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." "Let me get you something for relaxation if you don't want anything for pain." "I respect your preference whether it is to have medication or not."
"I respect your preference whether it is to have medication or not."
A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breast-feeding, that will help make your uterus contract and get smaller." "There is really nothing you can do to speed along the progress, so just be patient." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "I would recommend that you rest for a few days to allow your body to heal and get back to normal."
"If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.
A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? "It distracts your brain from the sensations of pain." "It blocks the transmission of nerve messages of pain at the receptors." "It causes the release of endorphins." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."
"It distracts your brain from the sensations of pain."
A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? "It sounded like you had quite a time getting here. Would you like to continue your story?" "If you plan to breast-feed, you need to calm down." "You have a beautiful baby, why worry about that now?" "I need to assess your fundus now."
"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
A nurse is making an initial call on a new mother who gave birth to her third baby five days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
You are the home health nurse making an initial call on a new mother who delivered her third baby five days ago. The woman says to you "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? a) "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." b) "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the delivery. They will most likely go away in a day or two." c) "Tell me, are you seeing things that aren't there, or hearing voices?" d) "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the delivery. They will most likely go away in a day or two."
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming."
A new mother is concerned because it is 24 hours after childbirth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? a) "It takes about 3 days after birth for milk to begin forming." b) "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in." c) "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." d) "You may have developed mastitis. I'll ask the physician to examine you."
"It takes about 3 days after birth for milk to begin forming."
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming." The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy as, since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day post birth, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years." "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "You might try using a water-soluble lubricant to ease the discomfort." "Try doing Kegel exercises to get your pelvic muscles back in shape."
"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?
Administer pain medications. "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.
A client in labor has received a spinal epidural block. Which nursing intervention should the nurse prioritize after assessing maternal hypotension and changes in the fetal heart rate (FHR)?
Administer supplemental oxygen. Complications of a spinal epidural block include maternal hypotension, which affects the FHR. Supplemental oxygen should be administered to keep oxygenation levels appropriate for the mother and the fetus. The client should be placed in a semi-Fowler's position. Stopping the IV fluid may cause dehydration, and other positions may not have a positive effect on the blood pressure. Raising not lowering the woman's legs would be appropriate.
A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response?
Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.
A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? Ask the client why she does not want to go home. Inform the primary care provider that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client if she has any support in the home.
Ask the client why she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? a) Ask if she wants a breast pump to empty her breasts b) Explain to the woman that she should breastfeed because she is producing so much milk c) Assist the woman in placing ice packs on her breasts d) Assist the woman into the shower and have her run cold water over her breasts
Assist the woman in placing ice packs on her breasts
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? Assist the woman into the shower, and have her run cold water over her breasts. Assist the woman in placing ice packs on her breasts. Explain to the woman that she should breastfeed because she is producing so much milk. Ask if she wants a breast pump to empty her breasts.
Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.
A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which of the following? a) Attachment b) Involution c) Engorgement d) Engrossment
Attachment
A nurse is caring for a client who has been treated for a deep vein thrombosis (DVT). Which teaching point should the nurse stress when discharging the client? a) Avoid use of oral contraceptives. b) Avoid using compression stockings. c) Avoid using products containing aspirin. d) Plan long rest periods throughout the day.
Avoid use of oral contraceptives.
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? a. my episiotomy should begin to heal and feel better over the next few weeks b. i am breast feeding so i can anticipate that there will be reddened painful areas in my breasts c. i need to let the doctor know if my lochia begins to have a foul smell d. if i develop chills or my fever goes above 100.4 i need to let someone know
B
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min
The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.
Breasts feel slightly firm; Flattened nipple on the right breast; and breasts are non-painful
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? a. 99.1 at 12 hours postbirth and decreases after 18 hrs b. 100.3 at 24 hours postbirth and remains the same for the second postpartum day c. 100.5 at 48 hours postbirth and remains the same the third day postpartum d. 100.1 at 24 hours postbirth and decreases the second postpartum day
C
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? a. shaking chills with a fever of 100.4 b. hear rate of 70 and excessive soaking diaphoresis c. BP 90/50 heart rate 120 resp. 24 d. blood loss of 250 mL and WBC 25,000
C
The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning? Asking for assistance changing a diaper Making eye contact with the baby Calling the baby "it" or "they" Breastfeeding the infant on demand
Calling the baby "it" or "they" Many new parents will need assistance with diaper changes; this is not a flag for concern. Making eye contact and breastfeeding are positive interaction behaviors. If the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.
A nurse is caring for a client postpartum who complains of sore nipples. The nurse observes that the client's newborn is unable to suck properly although latched well. What intervention should the nurse perform to assist the baby to suck properly? a) Prolong the gap between feedings b) Check the baby's frenulum c) Position baby to face the nipple d) Suggest bottle feeding
Check the baby's frenulum
The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process? The client has the baby without any analgesic or anesthetic. The nurse suggests alternative methods of pain relief. Client priorities and preferences are incorporated into the plan. The health care provider decides the best pain relief for the mother and family
Client priorities and preferences are incorporated into the plan.
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?
Demonstrating how to do cord care on the newborn
The nurse will be performing the Leopold's maneuver to determine the position of the fetus. List in order the steps that the nurse would take. All options must be used.
Determine presentation. Determine position. Confirm presentation. Determine attitude.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next
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.
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which of the following observations would indicate the presence of tissue? a) Yellowish white lochia b) Easy to separate clots c) Foul-smelling lochia d) Difficult to separate clots
Difficult to separate clots
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? Decreased level of consciousness Difficulty breathing Staggering gait Intense pain
Difficulty breathing
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? Engagement of fetus Bloody show Dilation of cervix Rupture of amniotic membranes
Dilation of cervix
A client in the postpartum period complains of constipation. The nurse should inform the client of which of the following that contributes to postpartum constipation? a) Separation of rectus muscles b) Relaxation of abdominal muscles c) Distention of abdominal muscles d) Discomfort due to hemorrhoids
Discomfort due to hemorrhoids
While making a follow up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which of the following would be the most likely reason for the weight loss? a) Blood loss b) Diuresis c) Lactation d) Nausea
Diuresis
The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize? May experience rash, sore throat, headache, or general malaise within 2 to 4 weeks of the injection Advise the client that the vaccine is excreted in breast milk. Will prevent hemolytic disease of the infant in next pregnancy Do not to attempt another pregnancy for at least 3 months.
Do not to attempt another pregnancy for at least 3 months. The nurse should prioritize the fact that after the immunization, she needs to wait for at least 3 months before attempting to get pregnant again, if desired, so the fetus will not be exposed to the rubella vaccination. The rubella vaccine is a live virus and is considered teratogenic. The other choices are not priorities. Inform the breastfeeding woman that the rubella vaccine crosses over into the breast milk. The newborn benefits from short-term immunity but may become flushed, fussy, or develop a slight rash. Suggest that the woman speak to the pediatrician if she has concerns. The client may also experience a rash, sore throat, headache, and general malaise within 2 to 4 weeks after the injection. The nurse would not advise the new mother that the immunization will prevent hemolytic disease of the infant in her next pregnancy; this is incorrect information.
A nursing student is learning about intermittent fetal heart rate monitoring during labor. The student correctly chooses which of the following as used routinely for this procedure? (Select all that apply
Doppler fetoscope fetal monitor Intermittent fetal heart rate ascultation uses fetoscope, Doppler, or fetal monitor. An intrauterine pressure catheter is inserted into a pocket of amniotic fluid and is a continuous internal monitoring of contractions.
For several hours after delivery, Norah, a multigravida who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her this time. In fact, she's focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should you handle this situation? a) Redirect her attention to the baby by reminding her of the details of newborn care b) Encourage her to discuss her experience of the birth and answer any questions or concerns she may have c) Ask her to describe how she plans to integrate the newcomer into her existing family, including any actions she has taken to prepare the siblings d) Point out positive features of her baby and encourage her to hold and cuddle the baby
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have
For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation?
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.
The patient under your care is complaining she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement? a) Encourage the patient to eat more fiber rich foods b) Offer the patient a stimulant laxative c) Have her hold her feces until she really feels the need to defecate d) Add dairy products to the patient's diet
Encourage the patient to eat more fiber rich foods
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Excessive oxytocin Mastitis Engorgement Blocked milk duct
Engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding
When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement? a) Progesterone b) Human chorionic gonadotropin (hCG) c) Prolactin d) Estrogen
Estrogen
A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client?
Her bladder for distension
A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? Encourage the mother to breast-feed to help relax the uterus. Tell her that you will notify the doctor of the unusual pain and see what he wants to do. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain.
Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.
A woman who has just given birth seems to be bonding with her newborn, despite the fact that earlier in labor she had expressed an intent to give the baby up for adoption. In this case, the nurse should encourage the mother to keep her baby.
False Do not attempt to change a woman's mind about keeping her child or placing the child for adoption during the postpartal period as she is extremely vulnerable to suggestion at this time, and such decisions are too long range and too important to be made at such an emotional time. Her earlier conclusion may be the sound one. Instead, offer nonjudgmental support. Be especially aware of your own feelings about this issue, to avoid influencing a woman's decision making unnecessarily.
A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply.
Fatigue, discomfort, hormonal changes, and disrupted sleep patterns
A nurse is caring for a breastfeeding client who complains of engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which of the following should the nurse suggest to help her prevent engorgement? a) Apply cold compresses to the breasts b) Feed the baby at least every two or three hours c) Provide the infant oral nystatin d) Dry the nipples following feedings
Feed the baby at least every two or three hours
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Provide the infant oral nystatin. Dry the nipples following feedings. Feed the baby at least every two or three hours. Apply cold compresses to the breasts.
Feed the baby at least every two or three hours.
A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her episiotomy Her hematocrit
Her bladder for distension
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.
Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
Fourth-degree laceration. First-degree = only skin & superficial structures above muscle; second-degree extends through perineal muscles; third-degree extends through the anal sphincter muscle but not through the anterior rectal wall.
A woman presents to the clinic in the first trimester of pregnancy. She has three children living at home. One of them was born prematurely at 34 weeks. The other two were full-term at birth. She has a history of one miscarriage. How does the nurse record her obstetric history on the chart using the GTPAL format?
G5 T2 P1 A1 L3 One of the most common methods of recording the obstetric history is to use the acronym GTPAL. "G" stands for gravida, the total number of pregnancies including the current one. "T" stands for term, the number of pregnancies that ended at term (at or beyond 38 weeks' gestation); "P" is for preterm, the number of pregnancies that ended after 20 weeks and before the end of 37 weeks' gestation. "A" represents abortions, the number of pregnancies that ended before 20 weeks' gestation. "L" is for living, the number of children delivered who are alive at the time of history collection.
The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help Administer oxytocics to prevent uterine atony Teach the woman to perform periodic self-fundal massage Gently massage the fundus until it tones up
Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?
Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.
A nurse is caring for a client who is nursing her baby boy. The client complains of afterpains. Secretion of which of the following should the nurse identify as the cause of afterpains? a) Estrogen b) Prolactin c) Progesterone d) Oxytocin
Oxytocin
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.
Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.
A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Document the finding. Obtain assistance to check for a compressed umbilical cord. Prepare the woman for an emergency cesarean birth. Help the woman change positions.
Help the woman change positions.
The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? Start an oxytocic infusion and decrease the rate of IV fluids. Help the woman change positions. Position the woman on her side with a pillow under her left hip. Discontinue supplemental oxygen.
Help the woman change positions.
During contractions, the electronic fetal monitor (EFM) shows variable V-shaped decelerations in the FHR lasting about 30 seconds with accelerations of about 5 bpm before and after each deceleration. Overshoot is absent, and the baseline FHR is within normal limits. What should the nurse do first?When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem?
Help the woman change positions. Changing positions is a first intervention to determine if this will improve the oxygen to the fetus. Supplemental oxygen should be maintained until the mother is stable. Placing the client on her side may increase the work of breathing. Pharmacological interventions are premature.
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize?
Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 gm/dL and hematocrit of 42%. Which result should the nurse prioritize? Hemoglobin 11 gm/dL and hematocrit 34 percent in a woman who has given birth by cesarean Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean Hemoglobin 13 gm/dL and hematocrit 40 percent in a woman who has given birth vaginally Hemoglobin 12 gm/dL and hematocrit 38 percent in a woman who has given birth vaginally
Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 mL of blood lost during the delivery process, the hemoglobin should decrease by 1 gm/dL and the hematocrit by 2 percent. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 mL to 500 mL and for a cesarean delivery approximately 500 mL to 1000 mL. The loss of hemoglobin from 14 gm/dL to 9 gm/dL is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 mL of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.
A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her hematocrit Her episiotomy
Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.
Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) She experiences "pulling" pain while breastfeeding. b) Her uterus is at the level of the umbilicus. c) Her uterus is 2 cm above the symphysis pubis. d) Her uterus is three finger widths under the umbilicus.
Her uterus is at the level of the umbilicus.
A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?
Hold the baby frequently. The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.
The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out?
In approximately 10 days
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which of the following would the nurse identify as the most likely factor for this development? a) Cracking of the nipple b) Improper positioning of infant c) Inability of infant to empty breasts d) Inadequate secretion of prolactin
Inability of infant to empty breasts
The nurse is caring for a client who had been administered an anesthetic block during labor. Which of the following are risks that the nurse should watch for in the client? Select all that apply. a) Perineal laceration b) Incomplete emptying of bladder c) Bladder distention d) Urinary retention e) Ambulation difficulty
Incomplete emptying of bladder Bladder distention Urinary retention
When assessing a postpartum woman, which finding would be most significant in identifying possible postpartum hemorrhage? a) Increased hematocrit level b) Increased blood pressure c) Increased cardiac output d) Increase heart rate
Increase heart rate
A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which of the following should the nurse recommend to the client to improve pelvic floor tone? a) Sitz baths b) Kegel exercises c) Urinating immediately when the urge is felt d) Abdominal crunches
Kegel exercises
A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone? sitz baths Kegel exercises abdominal crunches urinating immediately when the urge is felt
Kegel exercises
Which assessment finding one hour after delivery should be reported to the health care provider?
Lochia rubra is saturating a pad every 45-60 minutes
What two elements play the biggest role in becoming a mother after delivery of her newborn?
Love and attachment to the child and engagement with the child
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?
Maintain correct posture and positioning
A client complains to the nurse of pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? a) Apply ice to the sore joints. b) Soak in a warm bath several times a day. c) Maintain correct posture and positioning. d) Try to avoid carrying the baby for a few days.
Maintain correct posture and positioning.
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?
Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.
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
Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged
The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. Note any hemorrhoids. Palpate the episiotomy for pain. Place the patient in Trendelenburg position for inspection. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Gently palpate for any hematomas.
Note any hemorrhoids. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Gently palpate for any hematomas.
A client's maternal serum alpha-fetoprotein (MSAFP) level was unusually elevated at 17 weeks. The nurse suspects which of the following?
Open spinal defects Elevated MSAFP levels are associated with open neural tube defects. Fetal hypoxia would be noted with fetal heart rate tracings and via nonstress and contraction stress testing. MSAFP in conjunction with marker screening tests would be more reliable for detecting Down syndrome. Maternal hypertension would be noted via serial blood pressure monitoring.
A client delivered vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond? a) You will not ovulate until your menstrual cycle returns b) Ovulation does not return for 6 months after delivery c) You may have intercourse until next month with no fear of pregnancy d) Ovulation may return as soon as 3 weeks after delivery
Ovulation may return as soon as 3 weeks after delivery
A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. The nurse would be accurate in identifying which hormone as the cause of these afterpains? a) Relaxin b) Prolactin c) Oxytocin d) Progesterone
Oxytocin
A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Instruct the woman to bend her knees and flex her hips. Have the woman lie completely flat on her back while auscultating. Ask the woman to hold her breath while assessing the FHR. Palpate the mother's radial pulse at the same time.
Palpate the mother's radial pulse at the same time.
A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?
Perform Kegel exercises. The nurse should ask the client to perform the Kegel exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?
Perform urinary catheterization
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?
Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.
You are used to working on the postpartum floor taking care of women who have had normal vaginal deliveries. Today, however, you have been assigned to help care for woman who are less than 24 hours post cesarean delivery. You know that in making your assessments you will have to change some things that you would not normally assess. What would you leave out of your patient assessments? a) Breasts b) Lower extremities c) Perineum d) Respiratory status
Perineum
During a postpartum exam on the day of delivery, the woman complains that she is still so sore that she can't sit comfortably. You examine her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point? a) Apply a warm washcloth b) Place an ice pack c) Put on a witch hazel pad. d) Notify a physician
Place an ice pack
A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse emphasize when teaching the patient about this treatment approach?
Sitz baths increase the blood supply to the perineal area
During a postpartum exam on the day of birth, the woman reports that she is still so sore that she cannot sit comfortably. The nurse examines her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point?
Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.
The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? Place an ice pack. Notify a primary care provider. Apply a warm washcloth. Put on a witch hazel pad.
Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.
A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which of the following conditions? a) Postpartum psychosis b) Postpartum blues c) Anxiety disorders d) Postpartum depression
Postpartum depression Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which of the following should the nurse identify as a potential cause for urinary frequency? a) Urinary overflow b) Trauma to pelvic muscles c) Postpartum diuresis d) Urinary tract infection
Postpartum diuresis
A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? Immersing the client in warm water in a pool or hot tub Administering an opioid such as meperidine or fentanyl Practicing effleurage on the abdomen Administering a sedative such as secobarbital or pentobarbital
Practicing effleurage on the abdomen
The nurse is assessing a postpartum client's vital signs 24 hours after the birth of her infant and notes: respirations 18, pulse 110 bpm, temperature 100.1°F (37.8°C), and blood pressure 128/88. Which assessment finding should the nurse prioritize for further attention?
Pulse (tachy)
Charting on the nursing care plan patient care, which nursing diagnosis has the highest priority for a postpartum patient? a) Acute pain related to afterpains or episiotomy discomfort b) Risk for infection related to multiple portals of entry for pathogens, including the former site of the placenta, episiotomy, bladder and breasts c) Risk for injury: postpartum hemorrhage related to uterine atony d) Risk for injury: falls related to postural hypotension and fainting
Risk for injury: postpartum hemorrhage related to uterine atony
The nurse would prepare a client for amnioinfusion when which action occurs?
Severe variable decelerations occur and are due to cord compression. Indications for amnioinfusion include severe variable decelerations resulting from cord compression, oligohydramnios (decreased amniotic fluid), postmaturity, preterm labor with rupture of the membranes, and thick meconium fluid. Failure of the fetal presenting part to rotate fully, descend in the pelvis, abnormal fetal heart rate patterns or acute pulmonary edema, and compromised maternal pushing sensations from anesthesia are indications for forceps-assisted birth, and not for amniofusion.
Which of the following actions would lead you to assess that a postpartal woman is entering the taking-hold phase of the postpartal period? a) She did her perineal care independently. b) She is eager to talk about her delivery experience. c) She has not asked for anything for pain all day. d) She sits and rocks her infant for long intervals.
She did her perineal care independently.
Which maternal reaction is the most concerning? a) She neglects to engage with or provide care for the baby and shows little interest in it b) She expresses doubt about her ability to care for the baby as well as the nurse can c) She hesitates to take her newborn when offered and expresses disappointment with the way the baby looks d) She is tearful for several days and has difficulty eating and sleeping
She neglects to engage with or provide care for the baby and shows little interest in it
Which maternal reaction is the most concerning?
She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues".
Which of the following actions would most make you believe that a postpartum woman is accepting a child well? a) She asks you to use her camera to take a photo of the child. b) She turns her face to meet the infant's eyes when she holds her. c) She states she has named the child after a well-loved friend. d) She comments that her baby has the most hair of any in the nursery.
She turns her face to meet the infant's eyes when she holds her.
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Talking about her labor experience to others around her Having feelings of grief or guilt Pointing out specific features in the newborn
Showing increased confidence when caring for the newborn
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Pointing out specific features in the newborn Having feelings of grief or guilt Talking about her labor experience to others around her
Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.
The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine? Slow respiration, less than 12 breaths per minute Abdominal distention and pain Intense itching manifested by scratching Difficulty coughing and turning
Slow respiration, less than 12 breaths per minute
Which of these cardiac variations, if found in the client who is pregnant, should the nurse recognize as a normal finding in pregnancy
Soft systolic murmur A soft systolic murmur is common in pregnancy secondary to the increased blood volume. The other findings are not normal and require further assessment by the nurse.
A nurse is caring for a client in the postpartum period. The nurse observes that distention of the abdominal muscles during pregnancy has resulted in separation of the rectus muscles. What intervention should the nurse perform to assist in healing the distended abdominal muscles? a) Suggesting proper exercise b) Applying warm compresses c) Massaging the muscles d) Applying moist heat
Suggesting proper exercise
Which factor might result in a decreased supply of breast milk in a postpartum client? a) Maternal diet high in vitamin C b) Supplemental feedings with formula c) An alcoholic drink d) Frequent feedings
Supplemental feedings with formula
A client is exhibiting signs of early engorgement, but her milk is still flowing easily. Which of the following suggestions would the nurse give to treat engorgement? a) Apply ice packs before a feeding. b) Restrict fluid intake. c) Have the baby nurse on both breasts with every feeding. d) Take a warm shower before a feeding.
Take a warm shower before a feeding
While caring for a client following a lengthy labor and delivery, the nurse notes that the client repeatedly reviews her labor and delivery and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? a) Taking-in b) Letting-go c) Taking-hold d) Acquaintance/attachment
Taking-in
A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in? a) Letting-go phase b) Taking-hold phase c) Taking-in phase d) Rooming-in phase
Taking-in phase
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is a) Taking-in, taking-hold, letting-go b) Taking-in, taking-on, letting-go c) Taking-in, holding-on, letting-go d) Taking, holding-on, letting-go
Taking-in, taking-hold, letting-go
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? Recommend rooming-in to foster attachment and confidence by the mother. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.
When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful? All pain is the same. Women innately know how to deal with labor pain. The characteristics of labor pain follow a pattern. If the woman is in too much pain, a cesarean section is an option.
The characteristics of labor pain follow a pattern.
The nurse is looking at the latest lab work for her postpartum client. The clent's pre-delivery hemoglobin and hematocrit (H & H) was 12.8 and 39. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?
The doctor needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the doctor needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The doctor will decide what measures to take.
roles of progesterone etc
The function of progesterone is to suppress uterine irritability throughout pregnancy. The function of estrogen is to promote oxytocin production and to sensitize the uterus to the effects of oxytocin. Prostaglandin, and not progesterone, stimulates the smooth muscle contractions in the uterus.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The parents explore the newborn's extremities, counting fingers and toes. The mother states that she has her father's eyes. The mother is reluctant to touch the newborn for fear of hurting her. The father holds the newborn en face and talks to her.
The mother is reluctant to touch the newborn for fear of hurting her.
Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? The father's coaching role may be disrupted at times. The mother may have continued memory loss postpartum. The infant may show increased drowsiness. The mother may have difficulty working effectively with contractions.
The mother may have difficulty working effectively with contractions.
The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?
The uterus contracts and squeezes the cord against the fetus. Explanation: Cord compression is not continuous when variable decelerations are occurring. The compression occurs when the uterus contracts and squeezes the cord against the fetus. It is relieved when the uterus relaxes between contractions. Prematurity and fetal sleep will cause decreased or absent variabilty.
The pain of labor is influenced by many factors. What is one of these factors? The woman is prepared for labor and birth. The woman has a high tolerance for pain. The woman has a high threshold for pain. The woman has lots of visitors during labor.
The woman is prepared for labor and birth.
The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? These methods are a technique to prevent the painful stimuli from entering the brain. Pain perception is decreased if anxiety is present. The gating mechanism is located at the pain site. The gating mechanism opens so all the stimuli pass through to the brain.
These methods are a technique to prevent the painful stimuli from entering the brain.
Which reason explains why women should be encouraged to perform Kegel exercises after delivery? a) They assist with lochia removal. b) They promote the return of normal bowel function. c) They assist the woman in burning calories for rapid postpartum weight loss. d) They promote blood flow, enabling healing and muscle strengthening.
They promote blood flow, enabling healing and muscle strengthening.
Which reason explains why women should be encouraged to perform Kegel exercises after birth?
They promote blood flow, enabling healing and muscle strengthening. Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.
The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic? This would cause fetal depression in utero. This can lead to maternal hypertension. The effects would wear off before delivery. This may prolong labor and increase complications.
This may prolong labor and increase complications.
Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which of the following? a) Hyperglycemia b) Varicose veins c) Thromboembolism d) Calcium depletion
Thromboembolism
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To determine if the mother's milk is coming in To answer questions the new parents may have To monitor the mother's blood pressure to note any elevations To check for postpartum hemorrhage
To check for postpartum hemorrhage
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To monitor the mother's blood pressure to note any elevations To check for postpartum hemorrhage To determine if the mother's milk is coming in To answer questions the new parents may have
To check for postpartum hemorrhage If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distension. There are no anticipated elevations in the mother's blood pressure, nor should the mother's milk come in this early.
If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first?
Turn her or ask her to turn to her side. The most common cause of uteroplacental insufficiency is compression of the vena cava; turning the woman to her side removes the compression.
A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. Ignore questions from the client. Reduce intravenous (IV) fluid rate.
Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.
Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? At the pubic bone One fingerbreadth below the umbilicus Two fingerbreadths below the umbilicus Level with the umbilicus
Two fingerbreadths below the umbilicus Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by Day 2, the fundal height is two fingerbreadths below the umbilicus.
Which finding would the nurse describe as "light" or "small" lochia?
Typically the amount of lochia is described as follows: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention will help the client most? a) Practicing good body mechanics b) Urinary catheterization c) A warm shower d) A warm compress
Urinary catheterization
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this?
Urinary elimination
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After delivery, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? a) Urinary elimination b) Being too tired to eat c) Elimination of solid wastes d) Breathing off fluid vapor
Urinary elimination
A postpartum client complains of urinary frequency and burning. Which of the following would the nurse suspect? a) Urinary tract infection b) Stress incontinence c) Subinvolution d) Uterine atony
Urinary tract infection
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which of the following? a) Stress incontinence b) Loss of pelvic muscle tone c) Increased urine output d) Urinary tract infection
Urinary tract infection
A nurse is caring for a client with postpartum hemorrhage. Which of the following should the nurse identify as the significant cause of postpartum hemorrhage? a) Iron deficiency b) Hemorrhoid c) Uterine atony d) Diuresis
Uterine atony
The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care?
Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client complains of engorgement. What suggestion should the nurse provide to alleviate breast discomfort? a) Wear a well-fitting bra b) Apply hydrogel dressing c) Apply warm compress d) Express milk frequently
Wear a well-fitting bra
A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A nurse is caring for a nonbreast-feeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing. Apply warm compresses.
Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartal blues? a 29-year-old mother who has lots of family visiting and offering to help her with meals and cleaning for the next few months a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 38-year-old G1 P1 who is constantly holding the baby and touching the baby's hands and fingers
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding During the postpartal period many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartal blues. The 38-year old-mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. acutely increased. slightly decreased. acutely decreased.
acutely decreased.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. acutely decreased. acutely increased. slightly decreased.
acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.
The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? tactile stimulation fetal scalp stimulation application of vibroacoustic stimulation administration of oxygen by mask
administration of oxygen by mask
Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:
assess and massage the fundus. 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.
AA client has just received combined spinal epidural. Which nursing assessment should be performed first? client has just received combined spinal epidural. Which nursing assessment should be performed first? A client has just received combined spinal epidural. Which nursing assessment should be performed first?
assess vital signs
A nA nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
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.
A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? engrossment engorgement attachment involution
attachment
A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?
attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.
A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? engorgement involution attachment engrossment
attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?
bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? bleeding postpartal gestational hypertension infection diabetes
bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding?
duration Explanation: Duration refers to how long a contraction lasts and is measured from the beginning of the increment to the end of the decrement for the same contraction. Intensity refers to the strength of the contraction determined by manual palpation or measured by an internal intrauterine catheter. Frequency refers to how often contractions occur and is measured from the increment of one contraction to the increment of the next contraction. The peak or acme of a contraction is the highest intensity of a contraction.
The nurse is assessing a breastfeeding mom 72 hours after birth. When assessing her breasts, the client reports bilateral breast pain around the entire breast. What is the most likely cause of the pain?
engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. The other problems do not typically develop until there is fully established breastfeeding
During a nonstress test, when monitoring the fetal heart rate, the nurse notes that when the expectant mother reports fetal movement, the heart rate increases 15 beats or more above the baseline. The nurse interprets this as:
reactive pattern. A reactive nonstress test indicates fetal activity, as evidenced by acceleration of the fetal heart rate by at least 15 bpm for at least 15 seconds within a 20-minute recording period. If this does not occur, the test is considered nonreactive. An increase in the fetal heart rate does not indicate variable decelerations. Fetal tachycardia would be noted as a heart rate greater than 160 bpm.
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? taking-hold letting-go acquaintance/attachment taking-in
taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.
A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? taking-hold phase attachment phase letting-go phase taking-in phase
taking-in phase
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking-in, taking-on, letting-go. taking-in, taking-hold, letting-go. taking-in, holding-on, letting-go. taking, holding-on, letting-go.
taking-in, taking-hold, letting-go.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
To assess the frequency of a woman's labor contractions, the nurse would time: the interval between the acme of two consecutive contractions. how many contractions occur in 5 minutes. the beginning of one contraction to the beginning of the next. the end of one contraction to the beginning of the next.
the beginning of one contraction to the beginning of the next.
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?
the taking-hold phase
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the letting-go phase the taking-hold phase the taking-in phase the binding-in phase
the taking-hold phase
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?
the taking-hold phase The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary tract infection postpartum diuresis trauma to pelvic muscles urinary overflow
trauma to pelvic muscles The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. uterine infection hydramnios early ambulation empty bladder breastfeeding prolonged labor
uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breast-feeding, early ambulation, and an empty bladder would facilitate uterine involution.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection; prolonged labor; and hydramnios