OB - Chapter 16 : Nursing Managment During Postpartum Period
After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? "If the symptoms last more than a few days, I need to call my doctor." "I might feel like laughing one minute and crying the next." "I'll need to take medication to treat the anxiety and sadness." "I should call this support line only if I hear voices."
"I might feel like laughing one minute and crying the next." Explanation: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur.
A nurse visiting a postpartum client at home is reviewing the need for the woman to meet her own nutritional needs. The woman is breastfeeding her newborn. The nurse determines that the client understands her nutritional needs based on which statements? Select all that apply. -"I need to drink about 2 to 3 quarts of fluid each day." -"I should have about 4 servings of fruits each day." "I need to eat about 7 servings of vegetables daily." "I will have at least 4 to 5 servings of milk each day." "I need to cut way back on any fats and oils daily."
"I need to drink about 2 to 3 quarts of fluid each day." "I should have about 4 servings of fruits each day." "I will have at least 4 to 5 servings of milk each day." Explanation: Daily nutritional recommendations for the lactating woman include: 2 to 3 quarts of fluids, 4 servings each of fruits and vegetables, 4 to 5 servings of milk, 7 servings of meat, poultry, fish and eggs, and 5 servings of fats, oils and sweets.
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "I only eat a low-fiber diet." "I already have some pads with witch hazel at home." "My mom always used dibucaine." "Sitz baths worked the last time."
"I only eat a low-fiber diet." Explanation: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
A postpartum client has decided to bottle feed her newborn. After teaching the woman about it, the nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. "I will use warm water to mix the powdered formula." "I will be sure not to use the microwave to warm the formula." "I will make sure the nipple and neck of the bottle are filled with formula during a feeding." "I will store any formula left over from a feeding in the refrigerator." "I will get my newborn to suck by touching the nipple to the lips."
"I will be sure not to use the microwave to warm the formula." "I will make sure the nipple and neck of the bottle are filled with formula during a "I will get my newborn to suck by touching the nipple to the lips." Explanation: Teaching about bottle feeding should include the following: mixing powdered formula with room temperature water to allow better mixing and quicker dissolution of lumps; storing any formula prepared in advance in the refrigerator to keep bacteria from growing but discarding any formula not taken during a feeding; making sure that the nipple and neck of the bottle are always filled with formula to prevent the newborn from taking in too much air; and stimulating the sucking reflex by placing the nipple to the newborn's lips.
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your health care provider about this problem."
"It might take up to a week for your bowels to return to their normal pattern." Explanation: Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? "If you do not get up to walk you will not recover." "Walking is the best way to prevent complications such as blood clots." "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." "Maybe you will feel better after you take pain medication."
"Walking is the best way to prevent complications such as blood clots." Explanation: The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.
A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "Follow up with your health care provider within 3 weeks of being discharged." Notify the health care provider if your temperature is greater than 99° F (37.2° C)." "You should be seen by your health care provider if you have blurred vision." "Call your health care provider if you saturate a peri-pad in less than 4 hours."
"You should be seen by your health care provider if you have blurred vision." Explanation: The client needs to notify the health care provider for blurred vision, as this can indicate preeclampsia in the postpartum period. The client should also notify the health care provider if she has a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is within 2 weeks after hospital discharge.
A nurse is providing education to a client experiencing postpartum blues. The nurse determines client understanding when the client makes which of statements regarding factors that contribute to postpartum blues, signs and symptoms associated with postpartum blues, and collaborative care to treat symptoms? Contributing Factors Signs and Symptoms Collaborative Car
-Contributing Factors "Postpartum blues are due to changes in hormones." "Postpartum blues are due to fatigue." -Signs and Symptoms "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." -Collaborative Car "Sleep hygiene can help with postpartum blues." "Adequate nutrition can help with postpartum blues." "Regular physical exercise can help with postpartum blues." "Ensuring adequate support for newborn care can help with postpartum blues."
Rho(D) immune globulin is administered to which clients? Select all that apply. A client who is Rh-positive and gave birth to a 7-pound baby A newborn with type O-negative blood and a negative Coombs test An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood
An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood Explanation: Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate.
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? Vigorously massage the fundus. Immediately call the primary care provider. Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad.
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 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. Determine if this is the client's first baby. Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy.
Determine the newborn's blood type and rhesus. Explanation: 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 observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? Reassess the client in 1 hour. Document the lochia as scant. Stop using a peri-pad. Massage the client's fundus.
Document the lochia as scant. Explanation: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.
A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Apply ice packs directly to the perineal area. Apply ice packs for 40 minutes continuously. Ensure ice pack is changed frequently. Use ice packs for a week after birth.
Ensure ice pack is changed frequently. Explanation: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Provide breastfeeding newborns with pacifiers. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Explanation: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Provide breastfeeding newborns with pacifiers. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Explanation: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Provide breastfeeding newborns with pacifiers. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Explanation: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? Inspecting posture, color, and respiratory effort Checking for identifying birthmarks or skin injuries Auscultating bowel sounds, and measuring urine output Determining chest and head circumference
Inspecting posture, color, and respiratory effort Explanation: The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age.
Which assessment finding 1 hour after birth should be reported to the health care provider? Fundus of uterus is palpable at the level of the umbilicus. Fundus is displaced to the right, and bladder is hard. Large, bruised hemorrhoids are protruding from the anal opening. Lochia rubra is saturating a pad every 45 to 60 minutes.
Lochia rubra is saturating a pad every 45 to 60 minutes. Explanation: The nurse should ask the woman to turn over so her buttocks can be inspected in order to ensure that blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or the woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her health care provider to be certain there is no cervical or vaginal tear, or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is a normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist the client in emptying the bladder. The health care provider should be notified if a catheter needs to be inserted and there are no standing prescriptions for an in-and-out cath following birth.
A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action? Call the primary care provider. Massage the boggy fundus until it is firm. Document the findings. Nothing—excessive postpartum blood loss is normal.
Massage the boggy fundus until it is firm. Explanation: The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.
A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? Recommend a moisturizing soap to clean the nipples. Encourage use of breast pads with plastic liners. Offer suggestions based on observation to correct positioning or latching. Fasten nursing bra flaps immediately after feeding.
Offer suggestions based on observation to correct positioning or latching. Explanation: The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? Avoid use of water-based gel lubricants. Resume intercourse if bright red bleeding stops. Avoid performing pelvic floor exercises. Use oral contraceptive pills (OCPs) for contraception.
Resume intercourse if bright red bleeding stops. Explanation: The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs).
During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? Schedule home visits for high-risk families. Encourage frequent clinic visits for high-risk families. Provide phone numbers for call centers for questions. Ask family members to monitor the parents' progress.
Schedule home visits for high-risk families. Explanation: To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? The client is having a moderate amount of rubra lochia. The client requires assistance to ambulate in the hallway. The fundus is located 2 fingerbreadths above the umbilicus. The client is afebrile. Bowel sounds are active.
The fundus is located 2 fingerbreadths above the umbilicus. Explanation: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.
During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply. To identify client at risk for perinatal depressions To identify clients at risk for suicide To identify the client's attachment to the newborn To identify the need for additional support in the home To identify the client's need for antidepressant medications
To identify client at risk for perinatal depressions To identify clients at risk for suicide Explanation: The Edinburgh Depression Scale identifies the client at risk for perinatal depressions and identifies the client at risk for suicide. This scale does not assess maternal newborn attachment and the need for additional support in the home. If the scale identifies the client is at risk for depression, it does not identify the treatment modality.
A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? Avoid using soap for any perineal care. Wash her perineum with her daily shower. Use an alcohol wipe to wash her episiotomy line. Refrain from washing lochia from the suture line.
Wash her perineum with her daily shower. Explanation: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: inspect the perineum for lacerations. increase the flow of an IV. assess and massage the fundus. call the primary care provider or the nurse-midwife.
assess and massage the fundus. Explanation: 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.
A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? bonding attachment being spoiled none of the above
attachment Explanation: Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.
A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting: centrality. contact. individualization. reciprocity.
centrality. Explanation: Centrality, which is a component of commitment, is demonstrated when the parents place the infant at the center of their lives, acknowledging and accepting their responsibility to promote the infant's safety, growth and development. Contact, a dimension of proximity, refers to the sensory experiences of touching, holding, and gazing at the infant. Individualization, a dimension of proximity, reflects parental awareness of the need to differentiate the infant's needs from themselves and to recognize and respond to them appropriately. Reciprocity is the process by which the infant's abilities and behaviors elicit a parental response.
A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1commitment, attachment, and preparation for an infant 2acquaintance with and increasing attachment to the infant 3moving toward a new normal routine 4achievement of the parental role
commitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Explanation: Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.
A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1commitment, attachment, and preparation for an infant 2acquaintance with and increasing attachment to the infant 4achievement of the parental role 3moving toward a new normal routine
commitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Explanation: Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? first 30 to 60 minutes first 3 to 5 days first month first 6 months
first 30 to 60 minutes Explanation: Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage infection depression pulmonary emboli
infection Explanation: There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.
The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 3-in (7.5-cm) lochia stain. This amount should be documented as which type? moderate scant light heavy
light Explanation: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-in (2.5- to 5-cm) stain, and light or small an approximately 3- to 4-in (7.5- to 10-cm) stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: scant. light. moderate. heavy.
moderate. Explanation: Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.
A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? positive bonding negative bonding positive attachment negative attachment
negative attachment Explanation: Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.
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 above the umbilicus one fingerbreadth below the umbilicus at the level of the umbilicus below the symphysis pubis
one fingerbreadth below the umbilicus Explanation: 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.
When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? proximity reciprocity commitment all of the above
reciprocity Explanation: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.
Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means? Select all that apply. stasis altered coagulation decline in HGB localized vascular damage decline in WBCs
stasis altered coagulation localized vascular damage Explanation: Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during birthing process). All these increase the risk of clot formation.
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: the level of the umbilicus. between the umbilicus and symphysis pubis. 1 cm below the umbilicus. 2 cm below the umbilicus.
the level of the umbilicus. Explanation: Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? thromboembolic disorder of the lower extremities hormonal shifting of relaxin and estrogen infection normal response to the body converting back to prepregnancy state
thromboembolic disorder of the lower extremities Explanation: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
Which factor puts a client on her first postpartum day at risk for hemorrhage? hemoglobin level of 12 g/dl (120 g/L) uterine atony thrombophlebitis moderate amount of lochia rubra
uterine atony Explanation: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. vital signs of mother newborn's vital signs pain level head-to-toe assessment head-to-toe assessment of newborn
vital signs of mother pain level head-to-toe assessment Explanation: Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.
A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? Under 10 ml 10 to 25 ml 25 to 50 ml Over 50 ml
25 to 50 ml Explanation: Typically, the amount of lochia is described as follows: scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-ml loss light or small: an approximately 4-in (10-cm) stain or a 10- to 25-ml loss moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 ml large or heavy: a pad saturated within 1 hour after changing it or over 50-ml loss.
A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time? 3:30 a.m. 5:15 a.m. 7:45 a.m. 9:00 a.m.
9:00 a.m. Explanation: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? an absence of lochia red-colored lochia for the first 24 hours lochia that is the color of menstrual blood lochia appearing pinkish-brown on the fourth day
an absence of lochia Explanation: Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.
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? talking about how the nurse held her own newborn while on the birthing table showing a video of parents feeding their babies allowing the mother to pick the best time to hold her newborn bringing the newborn into the room
bringing the newborn into the room Explanation: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color? bluish white creamy yellow milky white gray liquid
creamy yellow Explanation: If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? delayed hemorrhage bladder distention extreme diaphoresis uterine atony
delayed hemorrhage Explanation: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.
Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? increasing oral fluid intake increasing intravenous fluids screening for bacteriuria in the urine encouraging the woman to empty her bladder completely every 2 to 4 hours
encouraging the woman to empty her bladder completely every 2 to 4 hours Explanation: The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.
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? first degree second degree third degree fourth degree
fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? infection hemorrhage fluid volume overload pulmonary emboli
hemorrhage Explanation: Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa, abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.
A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? normal findings in breastfeeding mothers an improperly positioned baby during feedings mastitis too much milk being retained
mastitis Explanation: Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.
A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition? infection hemorrhage pulmonary embolism hypertension
pulmonary embolism Explanation: Pulmonary embolism occurs in up to 3 per 1,000 births and is a major cause of maternal mortality.
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? Uterus is firm. Lochia is less than usual. Bladder is nonpalpable. Percussion reveals dullness.
Percussion reveals dullness. Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is inadequate suggestive of urinary retention. The urinary output is normal. The urinary output is above expected levels.
The urinary output is normal. Explanation: Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void.
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? nothing—it is normal hematoma infection DVT
hematoma Explanation: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? -redness -temperature -edema -drainage
temperature Explanation: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? touching talking looking feeding
touching Explanation: Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.
Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother? indirect Coombs test CBC with differential ANA titer screen
indirect Coombs test Explanation: The indirect Coombs test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh-positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to check for immunization and autoimmune disorders.
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 1 week 2 weeks 3 weeks 4 weeks
2 weeks Explanation: Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support Involving family in infant care
Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support Explanation: Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.
A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?
Massage the boggy fundus until it is firm. Explanation: The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.
A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? 97.5°F (36.9°C) 99.2°F (37.3°C) 100.1°F (37.8°C) 100.8°F (38.2°C)
100.8°F (38.2°C) Explanation: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that discourage unwrapping and exploring the infant policies that allow rooming the infant and mother together policies that allow visitors policies that allow flexibility for cultural differences
policies that discourage unwrapping and exploring the infant Explanation: Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? redness temperature edema drainage
temperature Explanation: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? Continue to monitor the woman's temperature every 4 hours; this finding is normal. Notify the health care provider about this elevation; this finding reflects infection. Obtain a urine culture; the woman most likely has a urinary tract infection. Inspect the perineum for hematoma formation.
Continue to monitor the woman's temperature every 4 hours; this finding is normal. Explanation: A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
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 transthoracic echocardiogram venogram of the right leg noninvasive arterial studies of the right leg
venous duplex ultrasound of the right leg Explanation: 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.