ob exam 5
The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client?
Expect that most visitors will be women. Uncover only the necessary skin when assessing.
The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective?
"I should see how my energy level is at home, and increase my activity slowly."
The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client?
Frequency Suprapubic pain
Which of the following would be considered a clinical sign of hemorrhage?
Increasing pulse
Which of the following conditions would predispose a client for thrombophlebitis?
Severe anemia
The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population?
When and how to contact their healthcare provider
The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be?
"Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple."
The client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond?
"Sometimes the uterus relaxes and excessive bleeding occurs."
The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective?
"My Beta-strep culture's being positive might have contributed to this problem."
The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?
"My bleeding will remain red for about a month."
The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness?
A nursing care model based on providing couplet care
How does the nurse assess for Homans' sign?
Dorsiflexing the foot and inquiring about calf pain
The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about?
Postpartum depression
The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching?
"If your incision becomes increasingly painful, call the doctor."
The nurse is instructing the parents of a newborn about car seat safety. Which statement indicates that the parents need additional information?
"We can bring the baby home from the hospital without a car seat as it is only a short drive home."
The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse?
"We can give the baby's bath together. I'll help you learn how to do it."
To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following?
Change peri-pads frequently
Which instructions should the nurse include when teaching parents of a newborn about caring for the umbilical cord?
Fold the diaper down to prevent covering the cord stump. Keep the umbilical stump clean and dry to avoid infection. Observe for signs of infection such as foul smell, redness, and drainage.
The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following?
Frequent breastfeedings
A postpartum woman is at increased risk for developing urinary tract problems because of which of the following?
Inhibited neural control of the bladder following the use of anesthetic agents
A client is preparing to take a sitz bath for the first time. What will the nurse do?
Place a call bell well within reach and check on the client frequently.
The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?
Postpartum hemorrhage
The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention?
The client appears anxious, and describes pressure in her chest.
The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care?
The baby's father should be encouraged to participate when the nurse is providing instruction.
A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include?
The baby's mouth should be examined for thrush.
The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion?
Tense tissues with severe pain
The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue?
"Voiding 2 or 3 times per day will help prevent a recurrence."
The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse?
Help the client back to bed to check the fundus
A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect?
Mastitis
At birth, an infant weighed 8 pounds 4 ounces. Three days later, the newborn is being discharged. The parents note that the baby now weighs 7 pounds 15 ounces. The nurse explains that the change in the newborn's weight is which of the following?
Within normal limits
The nurse is assessing clients after delivery. For which client is early discharge at 24 hours after delivery appropriate?
Woman and baby who have had two successful breastfeedings
The nurse is working with new parents who have recently immigrated to the United States. The nurse is not familiar with the family's cultural background. Which approach is most appropriate when discussing the newborn?
"Could you explain your preferences regarding childrearing?"
A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond?
"Everyone is different, and both responses are normal."
The nurse is discussing parent-infant attachment with a prenatal class. Which statement indicates that teaching was successful?
"Giving the baby his first bath can really give me a chance to get to know him."
The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best?
"You'll be wearing a sequential compression device until you start walking."
The nurse is planning home visits to the homes of new parents and their newborns. Which client should the nurse see first?
6-day-old female with greenish discharge from the umbilical cord site
A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make?
"I'm having significantly more pain this time than with my last birth."
Which statement by a new mother 1 week postpartum indicates maternal role attainment?
"It works better for me to undress the baby and to nurse in the chair rather than the bed."
The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response?
"It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception."
The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful?
"Taking baths will help my perineum feel less sore each day."
Which factors would the nurse observe that would indicate a new mother's early attachment to the newborn?
1)Pointing out familial traits of the newborn 2)Displaying satisfaction with the infant's sex 3)Face-to-face contact and eye contact
The nurse is instructing a new mother on circumcision care with a Plastibell. The nurse knows the mother understands when she states that the Plastibell should fall off within how long?
8 days
Which strategies would the nurse utilize to promote culturally competent care for the postpartum client?
Examine one's own cultural beliefs, biases, stereotypes, and prejudices Respect the values and beliefs of others. Incorporate the family's cultural practices into the care.
Which of the following symptoms would be an indication of postpartum blues?
Anger Mood swings Crying
The nurse teaches the parents of an infant who recently was circumcised to observe for bleeding. What should the parents be taught to do if bleeding does occur?
Apply gentle pressure to the site with gauze.
The nurse is providing postpartum care to an obese client. As part of care for this client, the nurse should do which of the following?
Apply sequential compression devices Have the mother ambulate as early as possible Supervise breastfeeding Instruct the client on signs of infection
The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?
Ask the client how much contact she would like with the baby, and whether she wants to feed it.
The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate?
Assess fundus and bladder status.
The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client?
Assist the client to the bathroom in 2 hours to void.
The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?
Assist the mother in identifying the baby's behavior cues.
The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1-10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient? A. Acute pain related to perineal trauma B. Risk for deficient fluid volume related to uterine bleeding and nausea C. Readiness for enhanced family coping D. Knowledge deficit related to newborn care
B. Risk for deficient fluid volume related to uterine bleeding and nausea Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority nursing diagnosis. Pain is a lower priority than is risk for fluid volume deficit. Family coping is a lower priority than is risk for fluid volume deficit. A knowledge deficit is a psychosocial issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.
On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be due to: A. The taking-hold phase B. Postpartum hemorrhage C. The taking-in phase D. Epidural anesthesia
C. The taking-in phase The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest. The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching. Postpartum hemorrhage is a serious complication and will need medical intervention. Epidural anesthesia is a pharmacological approach to pain control.
Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery?
Edema and bruising of perineum Fundus firm and midline
Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis?
Elevate the affected limb
A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate?
Encourage sitz baths.
The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care?
Encourage the client to express her emotions. Respect any special requests for the birth. Acknowledge the grieving process in the client. Allow access to the infant, if the client requests it.
To maintain a healthy temperature in the newborn, which of the following actions should be taken?
Encourage the mother to snuggle with the newborn under blankets. Keep the newborn's clothing and bedding dry. Reduce the newborn's exposure to drafts.
In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn?
Eye prophylaxis medication
A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included?
Gently massage the site after injection. Inject in the vastus lateralis muscle. Cleanse the site with alcohol prior to injection.
Before the newborn and mother are discharged from the birthing unit, the nurse teaches the parents about newborn screening tests that includes which of the following?
Hearing screening
The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following?
Help the new mother by allowing her to focus on resting and caring for the baby.
The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?
Offering the patient pre-medication 2 hours before the assessment
The nurse assesses a sleeping 1-hour-old, 39-weeks'-gestation newborn. The assessment data that would be of greatest concern would be which of the following?
Respirations 68 breaths/minute
The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage?
Leg exercises every 2 hours Abdominal tightening Ambulation
Risk factors associated with increased risk of thromboembolic disease include which of the following?
Malignancy Diabetes mellitus Varicose veins
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
Massage the uterine fundus until it is firm
A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications?
Misoprostol Methergine
What maternity unit policies promote postpartal family wellness and shared parenting?
Mother-baby care or couplet care on the postpartum unit Skin-to-skin contact between the mother and baby and the father and baby On-demand feeding schedule for both breastfed and bottle-fed infants
The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following?
Pain Urinary incontinence Changes in mental health status This is the correct answer. Sleep deprivation
The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following?
Prolonged labor Difficult birth Full bladder Infection
When caring for a new mother after cesarean birth, what complications would the nurse anticipate?
Pulmonary infection Deep vein thrombosis Pulmonary embolism
The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following?
Purulent, foul-smelling lochia
Which findings would indicate the presence of a perineal wound infection?
Redness Tender at the margins Hardened tissue Purulent drainage
Which of the following behaviors noted in the postpartum client would require the nurse to assess further?
Responds hesitantly to infant cries.
The nurse is analyzing various teaching strategies for teaching new mothers about newborn care. To enhance learning, which teaching method should the nurse implement?
Schedule time for one-to-one teaching in the mother's room.
A nurse suspects that a postpartum client has mastitis. Which data support this assessment?
Shooting pain between breastfeedings Late onset of nipple pain Pink, flaking, pruritic skin of the affected nipple
What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth?
The client feels a greater sense of control, and is less dependent on the nursing staff.
The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior?
The client is exhibiting normal behavior for her culture.
A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn?
The client who continues to touch her baby with only her fingertips
The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage?
The client who had oxytocin augmentation of labor
The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately?
The client who reports hearing voices talking about the baby
The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication?
The medication should be instilled in the lower conjunctival sac of each eye. The eyelids should be massaged gently to distribute the ointment. The medication can interfere with the baby's ability to focus.
The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action?
To assist the client to the bathroom
The nurse is caring for four newborns who have recently been admitted to the newborn nursery. Which labor event puts the newborn at risk for an alteration of health?
The infant's mother has group B streptococcal (GBS) disease.
On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following?
The taking-in period
The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first?
Woman day of delivery, fundus firm 2 cm above umbilicus
The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart?
"Cesarean birth after extended labor with ruptured membranes."
The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make?
"I am constantly tired. I feel like I could sleep for a week."
A newborn delivered at term is being discharged. The parents ask the nurse how to keep their baby warm. The nurse knows additional teaching is necessary if a parent states which of the following?
"A quick cool bath will help wake up my son for feedings."
The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client?
"Because of her age, this client will probably need extra teaching about the terminology for her anatomy."
The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response?
"Blood pooled in the vagina while you were in bed."
The parents of a newborn male ask the nurse whether they should circumcise their son. What is the best response by the nurse?
"Circumcision can sometimes cause complications. What questions do you have?"
A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond?
"Contact between parents and babies increases attachment."
A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following?
"I must avoid getting pregnant for 1 month."
Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate the need for further teaching?
"I will have to adjust some of my discharge instruction for this mother."
A postpartum mother is concerned that her newborn has not had a stool since birth. The newborn is 18 hours old. What is the nurse's best response?
"Passage of the first stool within 48 hours is normal."
The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching?
"Your infant should wet a diaper at least 6 times per day."
The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect?
1) Hematoma formation or bulging/shiny skin in the perineal area 2) Rise in the level of the fundus of the uterus 3) A boggy fundus that does not respond to massage
The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept?
1)"Talking to the baby is good because he'll recognize our voices." 2)"Holding the baby so we have direct face-to-face contact is good."
During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following?
1)Adapt to altered lifestyles and family structure resulting from the addition of a new member 2)Restore physical condition 3)Develop competence in caring for and meeting the needs of her infant
At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following?
1)Anticipatory guidance about the realities of being a parent. 2)Parenting literature and reference manuals. 3)Phone numbers and locations of local parenting groups. 4)Phone numbers and names of postpartum doulas.
When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do?
1)Ask the client to void before assessing the uterus. 2)Inform the client of the need for regular assessments. 3)Perform the procedures as gently as possible. 4)Take precautions to prevent exposure to body fluids.
Which interventions can the nurse utilize to provide continuity of care for the postpartal client who experienced a complication and is now ready to return home?
1)Encourage the client to take advantage of home visits. 2)Make telephone calls as a follow-up to check on the client and newborn. 3)Provide information about postpartal support groups. 4)Supply information about postpartum expectations designed to meet the specific needs of a variety of families.
What information should the nurse include when teaching the postpartal client and partner about resumption of sexual activity?
1)Maternal fatigue is often a significant factor limiting the resumption of sexual intercourse. 2)Couples should be encouraged to abstain from intercourse until the episiotomy is healed and the lochial flow has stopped. 3)Postpartum women often experience vaginal dryness, and should be encouraged to use some kind of lubrication initially during intercourse.
The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication?
1)Obtain blood specimens for hemoglobin and hematocrit. 2)Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina.
Nursing interventions that foster the process of becoming a mother include which of the following?
1)Promoting maternal-infant attachment 2)Building awareness of and responsiveness to infant interactive capabilities 3)Preparing the woman for the maternal social role
The postpartum nurse provides anticipatory guidance for the new mother as well as teaching on self-care and infant care before discharge. Which topics should be included?
1)Role changes brought on by the addition to the family unit 2)The realities of having a new baby, and how it affects previous lifestyle 3)Potential complications such as infant colic and postpartum issues 4)Sexuality and contraception
The nurse is teaching a new mother about ways to manage fatigue after she returns home. Which instructions should the nurse include?
1)Take frequent rest periods. 2)Nap when the newborn is sleeping. 3)Avoid overdoing housework and unnecessary chores. 4)Do not clean when infant is sleeping. 5)Utilize friends and family to provide help and support, such as cooking a meal.
What possible approaches should the nurse use to provide sensitive, holistic nursing care for the mother who is relinquishing her newborn?
1)Use active listening strategies to determine the client's needs. 2)Demonstrate empathy, concern, and compassion. 3)Provide nonjudgmental support and personalized care.
The nurse expects an initial weight loss for the average postpartum client to be which of the following?
10 to 12 pounds
The nurse is providing discharge teaching to the parents of a newborn. The nurse should instruct the parents to notify the healthcare provider in case of which of the following?
A bluish discoloration of the skin with or without a feeding. Refusal of two feedings in a row. Development of eye drainage. More than one episode of forceful vomiting.
The postpartum patient who delivered 2 days ago has developed endometritis. Which charting entry would the nurse expect to find in this patient's chart? A) "Cesarean birth performed secondary to arrest of dilation." B) "Rupture of membranes occurred 2 hours prior to delivery." C) "External fetal monitoring used throughout labor." D) "Patient has history of pregnancy-induced hypertension."
A) "Cesarean birth performed secondary to arrest of dilation." Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical exams necessary to assess for arrest of dilation are another risk factor for postpartum infection. Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis (2 hours are not prolonged). Internal (both internal fetal scalp electrode and intrauterine pressure catheter) NOT external fetal monitoring are risk factors for postpartum endometritis. Pregnancy-induced hypertension is not a risk factor for development of postpartum endometritis.
The postpartum multipara is breastfeeding her new baby. The patient states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. The best response of the nurse is: A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple to unblock that duct." B) "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." C) "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area." D) "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."
A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple to unblock that duct." A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. It is not unusual for mothers to develop complications similar to those experienced in prior pregnancies. Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened. The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for catching early onset of the infection. Massaging the area to unplug the duct and relieve milk stasis is much more effective.
The patient at 3 days postpartum has come to the maternity clinic with complaints of urinary urgency and dysuria. Which statement is most important for the nurse to make? A) "Void into this sterile cup without touching the inside of the cup." B) "Be sure to wipe from back to front after you have a bowel movement." C) "Call the clinic if you develop nausea and vomiting or constipation." D) "Decrease your fluid intake for a few days, but eat a lot of vegetables."
A) "Void into this sterile cup without touching the inside of the cup." A clean-catch urine sample will need to be obtained for urinalysis to determine if the patient has developed a urinary tract infection. Patients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora. A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections. Patients should increase their fluid intake but decrease their consumption of carbonated beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections.
The charge nurse is reviewing the plan of care for maternal patients currently admitted for postpartum care. During the course of her chart review, which intervention requires immediate consideration for revision? A) Daily prothrombin time (PT) measurements for coagulation assessment in a woman receiving heparin for treatment of thrombophlebitis. B) Use of the REEDA scale for assessment every 8 hours in the care of a patient diagnosed with puerperal infection. C) Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and bleeding after receiving oxytocic medications. D) Inserting a straight catheter to drain the overdistended bladder of a woman during the early postpartum period of her care.
A) Daily prothrombin time (PT) measurements for coagulation assessment in a woman receiving heparin for treatment of thrombophlebitis. Prothrombin time (PT) evaluates the anticoagulation effects of Coumadin; the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT). The nurse should inspect the woman's perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation Misoprostol (Cytotec) administration to a patient who demonstrates uterine atony and bleeding after receiving oxytocic medications Inserting a straight catheter to drain the overdistended bladder of a woman during the early postpartum period of her care.
A patient is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? (Select all that apply) A) Methergine B) Stadol C) Misoprostol D) Betamethasone
A) Methergine C) Misoprostol Methergine is a drug of choice for postpartum hemorrhage. Misoprostol is commonly administered rectally for postpartum hemorrhage Stadol is an analgesic and Bethamethasone is a glucocorticoid used for preterm labor in an attempt to decrease respiratory distress in preterm infant
A nurse suspects that a postpartum patient has mastitis. The following assessment provides what data to support this assessment? (Select all that apply) A) Shooting pain in her nipple during breastfeeding. B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple. D) Nipple soreness when the infant latches on.
A) Shooting pain in her nipple during breastfeeding. B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple. Mastitis is characterized by late-onset nipple pain, followed by shooting pain during and between feedings. The skin of the affected breast becomes pink, flaking, and pruritic Nipple soreness, engorgement, and the letdown reflex are not symptoms of Mastitis.
The community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother's statement suggests a need for further teaching? A. "Slow weaning should take place over a period of several months." B. "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace." C. "If I wean my baby slowly, I am less likely to develop breast engorgement." D. "Slowly weaning my baby is recommended to allow time for psychological adjustment."
A. "Slow weaning should take place over a period of several months." During slow weaning, over a period of several weeks the mother substitutes more cup feedings or bottle feedings for breast feedings. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychological adjustment.
The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time? (Select all that apply.) A. Administer analgesics as needed B. Encourage the patient to ambulate to the bathroom to void C. Encourage leg exercises every 2 hours D. Encourage the patient to cough and deep-breathe every 2-4 hours E. Encourage the use of breathing, relaxation, and distraction
A. Administer analgesics as needed Administering analgesics as needed, encouraging leg exercises every 2 hours, encouraging the patient to cough and deep-breathe every 2-4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient's nursing care needs, which are similar to those of other surgical patients. Encouraging her to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours.
During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? A. Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant B. Contact Social Services with concerns of neglect C. Provide the care the infant needs while continuing to evaluate the mother's actions D. Take the infant to the nursery so it can receive more consistent care
A. Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant Many primipara mothers will be hesitant to care for the infant because they feel inadequate. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention. The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction and the mother continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances. While this action does provide for the needs of the child while he or she is in the hospital, it does not help the mother know how to care for her child once she returns home. Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother's feelings of inadequacy.
Which of the following safety devices is most appropriate for the nurse making home visits? A. Cell phone B. Map of the area C. Personal handgun D. Can of mace
A. Cell phone Cell phones provide a means of contact, and are advisable for the nurse to carry.
The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction to Tylenol (acetaminophen). Which nursing action would be best? A. Offer the patient 800 mg Advil (ibuprofen) orally with food B. Provide two Percocet (oxycodone with acetaminophen) by mouth C. Encourage use of Dermoplast topical anesthetic spray D. Run very warm water into the tub and assist her into the bath
A. Offer the patient 800 mg Advil (ibuprofen) orally with food This is the best option, because the patient is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. This medication is contraindicated because of the patient's allergic reaction to acetaminophen. Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a patient has moderately severe pain. Ice packs would be better at this stage, because they will cause vasoconstriction to reduce edema and pain relief.
The nurse should inform the parents of a newborn that they should call their healthcare provider when which of the following occurs?
Absence of breathing longer than 20 seconds Lethargy Refusal of two feedings in a row continual increase in temperature
The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain?
Administer a mild analgesic to help with breastfeeding. Administer a mild analgesic at bedtime to ensure rest. Offer a warm water bottle for her abdomen.
The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time?
Administer analgesics as needed. Encourage leg exercises every 2 hours. Encourage the client to cough and deep-breathe every 2 to 4 hours. Encourage the use of breathing, relaxation, and distraction.
A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following?
Always place the infant in a supine position in the crib. Use a bulb syringe to suction mucus from the infant's nostrils as necessary.
The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client?
An appointment with a mental health counselor
On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following?
Apply cold packs to the breasts
A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client?
Avoid crossing the legs. Avoid prolonged standing or sitting. Take frequent walks.
New parents decide not to have their newborn circumcised. What should the nurse teach regarding care for the uncircumcised infant?
Avoid retracting the foreskin.
The postpartum patient has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? The patient: A) Develops pain and swelling in her left lower leg B) Appears anxious, and describes pressure in her chest. C) Becomes upset that she can't go home yet.
B) Appears anxious, and describes pressure in her chest. Anxiety and sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention.
Which method of initial assessment would best indicate whether a patient has a urinary complication? A) Urine pH B) Calculation of urine output C) Urine-specific gravity D) Calculation of intake
B) Calculation of urine output Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. Urine pH and urine-specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. Monitoring intake is an intervention that may help prevent urinary complications but calculating the intake itself would not indicate a complication.
The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The patient turns pale and feels weak. The first action of the nurse is to: A) Assist the patient to empty her bladder B) Help the patient back to bed to check her fundus. B) Assess her blood pressure and pulse. C) Begin an IV of Lactated Ringer's infusion.
B) Help the patient back to bed to check her fundus. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss.
The nurse is calling postpartum patients. Which patient should be seen immediately? The patient at 4 weeks postpartum who: A) Describes feeling sad all the time. B) Reports hearing voices talking about the baby. C) States she has no appetite and wants to sleep all day. D) Says she needs a refill on her sertraline (Zoloft) next week.
B) Reports hearing voices talking about the baby. This is an indication the patient is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby.
The nurse is revising the care plan of a 26-year-old woman who has developed mastitis. Which nursing diagnosis is most appropriate for inclusion in this patient's updated plan of care? A) Ineffective Peripheral Tissue Perfusion related to obstructed venous return B) Risk for Trauma related to lack of information about appropriate breastfeeding practices. C) Deficient Knowledge related to self-care after discharge on anticoagulant therapy D) Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction
B) Risk for Trauma related to lack of information about appropriate breastfeeding practices. In relation to the patient's mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices.
Put the following components specific to postpartum examination of a patient in the proper sequential order. A. L-lochia B. E-emotional C. H-Homans'/hemorrhoids D. B-breast E. E-episiotomy/laceration/edema F. U-uterus G. B-bowel H. B-bladder
B-breast U-uterus B-bladder B-bowel L-lochia E-episiotomy/laceration/edema H-Homan's/hemorrhoids E-emotional
The patient having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The patient states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best? A. "We'll take good care of you and your baby. You'll be home before you know it." B. "You'll be wearing long stockings to prevent blood clots from forming in your legs." C. "You will have a lot of pain, but there are medications that we give when it gets bad." D. "You won't be able to nurse until the baby is 12 hours old, because of your epidural."
B. "You'll be wearing long stockings to prevent blood clots from forming in your legs." Anti-embolism stockings are used until the patient is up and walking to prevent thrombus formation. This response focuses on the nurse, and does not provide specific information to answer the patient's question. This is a poor response. Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained. Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.
The nurse expects an initial weight loss for the average postpartum patient to be: A. 5-8 pounds B. 10-12 pounds C. 12-15 pounds D. 15-20 pounds
B. 10-12 pounds 10-12 pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid. 5-8 pounds might be the loss after a preterm birth. 12-15 pounds is close, but it does not match the usual weight of placenta, amniotic fluid, and full-term infant weight. 15-20 pounds might be the loss from a multiple birth.
The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care? (Select all that apply.) A. Encourage the patient to see and hold her infant B. Encourage the patient to express her emotions C. Respect any special requests for the birth D. Acknowledge the grieving process in the patient E. Allow for access to the infant if the patient requests it
B. Encourage the patient to express her emotions C. Respect any special requests for the birth D. Acknowledge the grieving process in the patient E. Allow for access to the infant if the patient requests it Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient's requests all are aspects of providing care for the patient who decides to relinquish her infant. Encouraging the patient to see and hold her infant does not respect the patient's right to refuse interaction, and might make her feel guilty for not wanting to see the infant.
The postpartum nurse is caring for a first-time mother who is unable to breastfeed her baby. While assessing the patient's breasts the day after birth, which teaching point should the nurse include? A. The let-down reflex B. Lactation suppression C. The purpose of fundal massage D. The cause of afterpains
B. Lactation suppression It is important to teach non-breastfeeding patients about lactation suppression after delivery but before discharge. The let-down reflex is an important teaching point for breastfeeding patients. The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts. Afterpains can be stimulated by breastfeeding, and they are more common in multiparas. Therefore, the nurse will likely not need to teach a non-breastfeeding primipara about afterpains.
The nurse is caring for a patient who delivered by cesarean birth. The patient received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention? (Select all that apply.) A. Increased intake of cold beverages B. Leg exercises every 2 hours C. Abdominal tightening D. Ambulation E. Eating a high-protein general diet
B. Leg exercises every 2 hours C. Abdominal tightening D. Ambulation Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or minimize abdominal distention in a surgical patient who received a general anesthetic. Increased intake of cold beverages and eating a high-protein general diet would increase the distention through increase of gas and constipation. Increased intake of cold beverages and eating a high-protein general diet would increase the distention through increase of gas and constipation.
The nurse has received an end of shift report on the postpartum unit. Which patient should she see first? A. Multip, second day post-cesarean, moderate lochia serosa B. Primip, day of delivery, fundus firm 2 cm above umbilicus C. Multip, first postpartum day, 4 cm diastasis recti abdominis D. Primip, first postpartum day, hypoactive bowel sounds all quadrants
B. Primip, day of delivery, fundus firm 2 cm above umbilicus This patient is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding. Bowel sounds are often decreased after delivery.
Every time the nurse enters the room of a postpartum patient who gave birth three hours ago, the patient asks something else about her birth experience. The nurse would: A. Answer questions quickly and try to divert her attention to other subjects B. Review documentation of the birth experience and discuss it with her C. Contact the physician to warn him the patient might want to file a lawsuit due to her preoccupation with her birth experience D. Submit a referral to Social Services because you are concerned about obsessive behavior
B. Review documentation of the birth experience and discuss it with her Review documentation of the birth experience and discuss it with her so the patient can integrate the experience. Three hours after birth, the mother needs to talk about her perceptions of her labor and delivery. Answering questions quickly and trying to divert her attention to other subjects trivializes her questions and does not allow her to sort out the reality from her subjective experience. Contacting the physician to warn him that the patient might want to file a lawsuit due to her preoccupation with her birth experiences is not warranted. Submitting a referral to Social Services because you are concerned about obsessive behavior is an incorrect action because this behavior is normal.
The maternal nurse educator is conducting a presentation for antepartum patients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in her teaching content? A) Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings. B) Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks. C) Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. D) Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.
C) Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. Women with a history of postpartum psychosis or depression or other risk factors should be referred to a mental health professional for counseling and biweekly visits between the second and sixth week postpartum for evaluation. As many as 50% to 70% of mothers develop adjustment reaction with depressed mood, which is also known as postpartum blues, or as maternal or baby blues. Unlike postpartum depression, this condition is characterized by mild depression interspersed with happier feelings. Post-traumatic stress disorder or PTSD (also called post-traumatic stress syndrome) is associated with exposure to an extremely traumatic event involving direct personal experience with actual or threatened death or serious injury, and evokes a reaction of intense fear, helplessness, or horror.
During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? A. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychological approach to family bonding." B. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach." C. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." D. "If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress."
C. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines.
The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal patients? A. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend patients by routinely bringing up the topic of postpartum depression." B. "For women with a history of depression, we include education about postpartum depression." C. "Teaching about postpartum depression is a routine part of education for all maternal patients." D. "If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic."
C. "Teaching about postpartum depression is a routine part of education for all maternal patients." Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.
On the second day postpartum, the patient experiences engorgement. To relieve her discomfort, the nurse should encourage the patient to: A. Remove her bra B. Apply heat to her breasts C. Apply ice packs to her breasts D. Limit breastfeeding to twice daily
C. Apply ice packs to her breasts Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. Removing her bra will only serve to increase breast milk production. Applying heat will promote breast milk production. Limiting breastfeeding to b.i.d. actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of mother or infant.
The nurse is observing a new graduate's assessment of a postpartum patient. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse? A. Ask the patient to void, and don clean gloves B. Discussing the effectiveness of patient comfort measures while performing the perineal assessment C. Instructing the patient's visitors to leave the room prior to beginning the assessment D. Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal assessment
C. Instructing the patient's visitors to leave the room prior to beginning the assessment The nurse should allow the patient to choose whether visitors leave or remain in the room during the assessment. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures. The supine position prevents a falsely high assessment of fundal height.
The nurse is performing an assessment of early attachment. During the assessment, the nurse needs to answer the question "Does the mother seem pleased with her baby's appearance and sex?" Which action of the mother might help answer this question? A. The mother enfolds the infant in her arms B. The mother feeds the infant every 2-3 hours as instructed C. The mother points out family traits she sees in the newborn D. The mother asks questions about how to properly bathe her infant
C. The mother points out family traits she sees in the newborn This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits.
The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? A. The patient's mother is included in all discussions and demonstrations B. The father of the baby is encouraged to change a diaper and give a bottle C. The nurse explains the characteristics and cues of the baby during the assessment D. A discussion on contraceptive methods is the first topic of teaching
C. The nurse explains the characteristics and cues of the baby during the assessment This helps the patient learn about her baby and understand him as an individual, and facilitates maternal-infant attachment. This is the highest priority. Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the patient desires to have her mother present for teaching and discussions. Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority. Young teens are statistically more likely to have another child during their adolescence, but establishing a rapport and facilitating understanding of and attachment to the newborn is a higher priority.
To promote infant security in the hospital, the nurse instructs the parents of a newborn to do which of the following?
Check the identification of all personnel who transport the newborn.
The nurse is performing a postpartum assessment on a newly delivered patient. When checking the fundus, there is a gush of blood. The patient asks why that is happening. The best response is: A. "We see this from time to time. It's not a big deal." B. "The gush is an indication that your fundus isn't contracting." C. "Don't worry. I'll make sure everything is fine." D. "Blood has pooled in the vagina while you were in bed."
D. "Blood has pooled in the vagina while you were in bed." Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semi-sitting in bed, which leads to a gush when fundal massage is undertaken. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not answer the patient's question. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse? A. "Apply an ice compress to your breast before nursing." B. "Encourage your baby to suckle for an average of 5 minutes per feeding." C. "Apply warm compresses to your breast after you finish feeding your baby." D. "When you aren't nursing, wear a well-fitted nursing bra at all times, even when you sleep."
D. "When you aren't nursing, wear a well-fitted nursing bra at all times, even when you sleep." The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension. Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother. For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours.
The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness? A. Normal newborn nursery centrally located to all patient rooms B. A kitchen with refrigerator stocked with juice and sandwiches C. Small, cozy rooms with a patient bed and rocking chair D. A nursing model based on providing couplet care
D. A nursing model based on providing couplet care Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered. Rooming-in better promotes family wellness than does having newborns in the nursery. Although having snacks is good for postpartum patients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness. Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better.
The nurse is preparing to receive a newly delivered patient. The patient is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important? A. Assign the patient a room on the GYN surgical floor instead of the postpartum floor B. Prepare to have teaching done in time for discharging the patient at 24 hours post-delivery C. Make an effort to not bring up the topic of the baby, and discuss the mother's health instead D. Ask the patient if she wants to feed her baby, and how much contact she wants to have
D. Ask the patient if she wants to feed her baby, and how much contact she wants to have Assess the patient's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother. Patients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead. Not all patients who relinquish their infants want early discharge. Make no assumptions, but assess instead. The patient's preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead.
The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? A. Describe the likely reaction of siblings to the new baby B. Discuss adaptation to grandparenthood by her parents C. Determine if father-infant attachment is taking place D. Assist the mother in identifying behavior cues of the baby
D. Assist the mother in identifying behavior cues of the baby Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment. Describe the likely reaction of siblings to the new baby. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching to the new mother. Although father-infant attachment is important, the mother is the main patient, and teaching her directly is a higher priority.
A new parent is concerned about spoiling her newborn. The home care nurse teaches the mother that: A. Spoiling occurs when an infant is rocked to sleep every night B. Newborns can be manipulative, so caution is advised C. Crying is good for a baby, and letting them cry it out is advised D. Meeting the infant's needs develops a trusting relationship
D. Meeting the infant's needs develops a trusting relationship Meeting the infant's needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind.
The nurse instructs the postpartum client that she can resume light housekeeping after the: A. Six-week postpartum checkup B. First week at home C. Second day at home D. Second week at home
D. Second week at home The postpartum client can resume light housekeeping after the second week at home. It's not necessary to wait until after the six-week postpartum checkup to resume light housekeeping. Within the first week is too early to resume even light housekeeping activity. The second day is too early to resume even light housekeeping activity.
During the first several months after birth, the mother and infant begin to know each other. This relationship progresses through several phases. Which of the following actions are to be expected in the phase of mutual regulation? A. The infant grasps his or her mother's finger while nursing B. The infant begins to seek out the mother over other individuals C. The mother spends more time making eye-to-eye contact with the infant D. The mother vocalizes feelings of frustration with her infant
D. The mother vocalizes feelings of frustration with her infant The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship. Actions that make the infant more attractive to the mother, such as grasping a finger, usually occurs during the acquaintance phase. When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more. Holding the infant in the en face position is likely to occur most often in the acquaintance phase.
To assess healing of the uterus at the placental site, the nurse assesses: A. Lab values B. Blood pressure C. Uterine size D. Type, amount, and consistency of lochia
D. Type, amount, and consistency of lochia Type, amount, and consistency of lochia determine the stage of healing of the placenta site, which occurs by a process of exfoliation. Lab values is incomplete as an answer because it does not indicate which lab values are in question. Blood pressure varies slightly in the normal postpartum woman and would not affect the placental site. Uterine size alone is not enough to assess the placenta site.
The postpartum client is about to go home. The nurse includes which subject in the teaching plan?
Diastasis of the recti muscles
Prior to conducting the initial assessment of a newborn, the nurse reviews the mother's prenatal record and the delivery record to obtain information concerning possible risk factors for the infant and to anticipate the impact of these factors on the infant's ability to successfully transition to the extrauterine environment. Which information is pertinent to this assessment?
Infectious disease screening results Maternal history of gestational diabetes Prolonged rupture of the membranes
To actively involve the postpartal client during discharge teaching, the postpartum nurse applies which learning principle?
Interactive nursed-patient relationships
Clinical features of posttraumatic stress disorder (PTSD) include which of the following?
Irritability Flashbacks Difficulty sleeping
The nurse is instructing parents of a newborn about voiding and stool characteristics. Which of the following would be considered an abnormal pattern?
Large amounts of uric acid crystals in the first days of life
Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following?
Massaging eyelids gently following application
The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?
Methylergonovine maleate (Methergine)
A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief?
Nonsteroidal anti-inflammatory agents
Which of the following is a risk factor for urinary retention after childbirth?
Not sufficiently recovering from the effects of anesthesia
The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure?
Observe for urine output.
The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?
Obtain an order for a stool softener.
The nurse assesses the newborn and notes the following behaviors: nasal flaring, facial grimacing, and excessive mucus. What is the nurse most concerned about?
Respiratory distress
The nurse initiates newborn admission procedures and evaluates the newborn's need to remain under observation by assessing which of the following?
Respiratory rate Airway clearance Ability to feed
Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take?
Review the documentation of the birth experience and discuss it with her
During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up?
Steady trickle of blood
The nurse has instructed a new mother on quieting activities for her newborn. The nurse knows that the mother understands when she overhears the mother telling the father to do what?
Swaddle the newborn in a blanket.
The nurse tells a mother that the doctor is preparing to circumcise her newborn. The mother expresses concern that the infant will be uncomfortable during the procedure. The nurse explains that the physician will numb the area before the procedure. Additional methods of comfort often used during the procedure include which of the following?
Talking to the infant Providing a pacifier Stroking the head
Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit?
Teach by example and role modeling when caring for the newborn in the client's room. Teach at every opportunity, even during the night shift, if the occasion arises. Teach using one-to-one instruction while in the client's room.
The nurse has just assisted the father in bathing the newborn 2 hours after birth. The nurse explains that the newborn must remain in the radiant warmer. This is based on which assessment data?
Temperature 96.8degreesF
The nurse has received the shift change report on infants born within the previous 4 hours. Which newborn should the nurse see first?
Term male, nasal flaring
A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action?
That the client would be placed on bed rest
The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?
The nurse explains the characteristics and cues of the baby when assessing him.
The nurse is planning discharge teaching for a postpartum woman. What information recommendations should the woman receive before being discharged?
To avoid overexertion To practice postpartum exercises To obtain adequate rest
To assess the healing of the uterus at the placental site, what does the nurse assess?
Type, amount, and consistency of lochia
The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate?
Use a 25-gauge, 5/8-inch needle for the injection. Protect the medication bottle from light. Give vitamin K prior to a circumcision procedure. Administer a dose of 0.5 to1 mg within 1 hour of birth.
Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated?
Within 1 hour of birth
The nurse is providing education to the new family. Which question by the nurse is best?
"How have your breastfeedings been going?"
The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?
"Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed."
The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?
"One minute I'm laughing and the next I'm crying."
A postpartum client calls the nursery to report that her newborn's umbilical cord stump is draining, and has a foul odor. What is the nurse's best response?
"Take your newborn to the pediatrician."
The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. What would the nurse suspect that the mother has?
Post-traumatic stress disorder