OB Lippincott Postpartal Care - The Postpartal Client with a Vaginal Birth

42. A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following? 1. Orange juice. 2. Herbal tea. 3. Milk. 4. Grape juice.

1. 1. Orange juice. Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption.

8. A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which of the following actions in the infant's plan of care? 1. Urine toxicology screening. 2. Notifying hospital security. 3. Limiting contact with visitors. 4. Contacting local law enforcement.

1. Urine toxicology screening. A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal system will be activated to provide and ensure protective custody for this child. Hospital security would not become involved unless the mother is obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any hospitalized clients unless the safety of the infant is jeopardized; thus, limiting contact with visitors would not be appropriate. Local law enforcement agencies would be contacted

16. A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate? 1. "Your menstrual cycle will return in 3 to 4 weeks." 2. "It will probably be 6 to 10 weeks before it starts again." 3. "You can expect your menses to start in 12 to 14 weeks." 4. "Your menses will return in 16 to 18 weeks."

2. "It will probably be 6 to 10 weeks before it starts again." For clients who are bottle-feeding, the menstrual flow should return in 6 to 10 weeks, after a rise in the production of folliclestimulating hormone by the pituitary gland. Nonlactating mothers rarely ovulate before 4 to 6 weeks postpartum. Therefore, 3 to 4 weeks is too early for the menstrual cycle to resume. For women who are breast-feeding, the menstrual flow may not return for 3 to 4 months (12 to 16 weeks) or, in some women, for the entire period of lactation, because ovulation is suppressed.

5. A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is having pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time? 1. Begin sitz baths. 2. Administer pain medication per prescription. 3. Replace ice packs to the perineum. 4. Initiate anesthetic sprays to the perineum.

2. Administer pain medication per prescription. Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.

25. A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which of the following? 1. Fatigue. 2. Fainting. 3. Diuresis. 4. Hygiene needs.

2. Fainting Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.

33. A newly postpartum primiparous client asks the nurse, "Can my baby see?" Which of the following statements about neonatal vision should the nurse include in the explanation? 1. Neonates primarily focus on moving objects. 2. They can see objects up to 12 inches (30.5 cm) away. 3. Usually they see clearly by about 2 days after birth. 4. Neonates primarily distinguish light from dark.

2. They can see objects up to 12 inches (30.5 cm) away. The neonate has immature oculomotor coordination, an inability to accommodate for distance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see objects clearly within a range of 9 to 12 inches (22.9 to 30.5 cm), whether or not they are moving. Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood. Newborns can distinguish colors as well as light from dark.

12. The physician prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following? 1. Hypoglycemia. 2. Hyperbilirubinemia. 3. Hemorrhage. 4. Polycythemia.

3. Hemorrhage Vitamin K acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal flora to produce vitamin K, which is necessary for coagulation. Hypoglycemia is prevented and treated by feeding the infant. Hyperbilirubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy. Polycythemia may occur in neonates who are large for gestational age or postterm. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe.

43. The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to: 1. Bottle-feed the twins to prevent exhaustion and fatigue. 2. Plan for each parent to spend equal amounts of time with each twin. 3. Avoid assistance from other family members until attachment occurs. 4. Relate to each twin individually to enhance the attachment process.

4. Relate to each twin individually to enhance the attachment process. It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individually, rather than as a unit, to enhance the attachment process. Mothers of twins are usually able to breast-feed successfully because the milk supply increases on demand. However, possible fatigue and exhaustion require that the mother rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends, because caring for twins or other multiple births (eg, triplets) can be exhausting for the family.

38. In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The nurse should instruct the client that she can resume sexual intercourse: 1. In 6 weeks when the episiotomy is completely healed. 2. After a postpartum check by the health care provider. 3. Whenever the client is feeling amorous and desirable. 4. When lochia flow and episiotomy pain have stopped

4. When lochia flow and episiotomy pain have stopped For most clients, sexual intercourse can be resumed when the lochia has stopped flowing and episiotomy pain has ceased, usually about 3 weeks postpartum. Sexual intercourse may be painful until the episiotomy has healed. The client also needs instructions about the possibility that pregnancy may occur before the return of the client's menstrual flow. The postpartum check by the health care provider typically occurs 4 to 6 weeks after birth and most women have already had intercourse by this time. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while. In addition, the mother's physiologic responses may be diminished because of low hormonal levels, adjustments to the maternal role, and fatigue due to lack of rest and sleep.

29. An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold her baby without "spoiling" him. Which of the following responses would be most appropriate? 1. "Hold him when he is fussy or crying." 2. "Hold him as much as you want to hold him." 3. "Try to hold him infrequently to avoid overstimulation." 4. "You can hold him periodically throughout the day."

2. "Hold him as much as you want to hold him." According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, singing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.

40. While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which of the following client statements indicates the need for additional teaching? 1. "I should try to gently manually replace the hemorrhoid." 2. "Analgesic sprays and witch hazel pads can relieve the pain." 3. "I should lie on my back as much as possible to relieve the pain." 4. "I should drink lots of water and eat foods that have a lot of roughage."

3. "I should lie on my back as much as possible to relieve the pain." The client needs more teaching when she states, "I should lie on my back as much as possible to relieve the pain." Instead, the client should lie in the Sims position as much as possible to aid venous return to the rectal area and to reduce discomfort. Gentle manual replacement of the hemorrhoid is an appropriate measure to help relieve the discomfort and prevent enlargement. Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids. Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining and subsequent hemorrhoidal development or enlargement.

35. A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first? 1. Administer ibuprofen. 2. Reassess in 1 hour. 3. Catheterize the client. 4. Obtain a prescription for a fluid bolus.

3. Catheterize the client. A uterine fundus located off to one side and above the level of the umbilicus is commonly the result of a full bladder. Although the client had voided, the client may be experiencing urinary retention with overflow. If anesthesia has been used for birth, the inability to void may be related to the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a one-time order for catheterization, after which, typically, enough edema has subsided to make it easier and less painful for the client to void and completely empty her bladder. Administering ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be detrimental since the client's distended bladder is interfering with uterine involution, predisposing her to possible hemorrhage. Administering a bolus of fluid would be inappropriate because it would only add to the client's full bladder.

9. The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the prescriptions sheet would be the most appropriate for this client? 1. Aspirin 1,000 mg PO every 4 to 6 hour PRN. 2. Ibuprofen 800 mg PO every 6 to 8 hour PRN. 3. Ducosate 100 mg PO twice a day. 4. Acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN.

4. Acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN. Acetaminophen and hydrocodone would be the drug of choice for this situation because the pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use. Although ibuprofen would typically be a good choice because it inhibits the prostaglandin synthesis associated with a multiparous client breast-feeding, the pain level is too high for this drug to have an acceptable effect. Docusate is used as a stool softener postpartum but does not provide pain relief.

13. A grand-multiparous client has just given birth to a large-for-gestational-age infant. The nurse determines the client's primary risk is for: 1. Knowledge deficit. 2. Acute pain. 3. Ineffective breast-feeding. 4. Fluid volume deficit.

4. Fluid volume deficit. The primary risk is for fluid volume deficit related to blood loss. The client is at increased risk for uterine atony and therefore increased blood loss due to having given birth to five or more children and for having a large infant. The client may be at risk for pain, ineffective breast-feeding, and knowledge deficit, but there is not enough information to indicate that these are priority problems at this time.

20. At a postpartum checkup 11 days after childbirth, the nurse asks the client about the color of her lochia. Which of the following colors is expected? 1. Dark red. 2. Pink. 3. Brown. 4. White.

4. White On about the eleventh postpartum day, the lochia should be lochia alba, clear or white in color. Lochia rubra, which is dark red to red, may persist for the first 2 to 3 days postpartum. From day 3 to about day 10, lochia serosa, which is pink or brown, is normal.

10. At which of the following locations would the nurse expect to palpate the fundus of a primiparous client immediately after birth of a neonate? 1. Halfway between the umbilicus and the symphysis pubis. 2. At the level of the umbilicus. 3. Just below the level of the umbilicus. 4. Above the level of the umbilicus.

1. Halfway between the umbilicus and the symphysis pubis. Immediately after delivery of the placenta, the nurse would expect to palpate the fundus halfway between the umbilicus and the symphysis pubis. Within 2 hours postpartum, the fundus should be palpated at the level of the umbilicus. The fundus remains at this level or may rise slightly above the umbilicus for approximately 12 hours. After the first 12 hours

27. Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate? 1. Maintain eye contact while talking to the baby. 2. Paint the baby's room in bright colors accented with teddy bears. 3. Use brightly colored animals and cartoon figures on the wall. 4. Move a brightly colored rattle in front of the baby's eyes.

1. Maintain eye contact while talking to the baby. Neonates like to look at eyes, and eye-to-eye contact is a highly effective way to provide visual stimulation. The parent's eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fix on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric figures are appropriate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimulation as eye-to-eye contact with talking. Brightly colored animals and cartoon figures are more appropriate at approximately 1 year of age.

21. After instructing a primiparous client about episiotomy care, which of the following client statements indicates successful teaching? 1. "I'll use hot, sudsy water to clean the episiotomy area." 2. "I wipe the area from front to back using a blotting motion." 3. "Before bedtime, I'll use a cold water sitz bath." 4. "I can use ice packs for 3 to 4 days after birth."

2. "I wipe the area from front to back using a blotting motion." The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours.

28. A primiparous client has just given birth to a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following? 1. Thanking Allah for giving him a male heir. 2. Singing to his son from the Koran in praise of Allah. 3. Expressing appreciation that his wife and son are healthy. 4. Performing a ritual similar to baptism in other religions.

2. Singing to his son from the Koran in praise of Allah The father is praying to Allah because of the Muslim belief that the first sounds a child hears should be from the Koran in praise of and supplication to Allah. Although male children are revered in this culture, this practice is performed by Muslims whether the child is male or female. The father's actions are unrelated to his wife and son's being healthy. The nurse should allow the practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the family. The Muslim faith does not have a baptism rite whereby the child becomes a member of the faith.

44. Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the following would the nurse do next? 1. Document this as a normal finding in the client's record. 2. Contact the physician for a prescription for oxytocin. 3. Encourage the client to ambulate to the bathroom and void. 4. Gently massage the fundus to expel the clots.

3. Encourage the client to ambulate to the bathroom and void At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return it to midline, it should be reported to the physician. Oxytocin is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.

22. A primiparous client, 20 hours after childbirth, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions? 1. Start in a sitting position, then lie back, and return to a sitting position, repeating this five times. 2. Assume a prone position, and then do push-ups by using the arms to lift the upper body. 3. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. 4. Flex the knees while supine, and then bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling.

3. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks.

1. The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which of the following next to ensure the safest transition of the infant to the mother? 1. Assess whether the mother is able to ambulate to care for the infant. 2. Ask the mother if there is anything else she needs for the care of her baby. 3. Check the crib to determine if there are enough diapers and formula. 4. Complete the hospital identification procedure with mother and infant.

4. Complete the hospital identification procedure with mother and infant. The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.

19. Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further? 1. Retained placental tissue. 2. Uterine inversion. 3. Bladder distention. 4. Perineal lacerations.

4. Perineal lacerations. A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.

14. The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next: 1. Apply an ice pack to the perineal area. 2. Assess the client's temperature. 3. Have the client take a warm sitz bath. 4. Contact the physician for prescriptions for an antibiotic.

1. Apply an ice pack to the perineal area. The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours. Although vital signs, including temperature, are important assessments, taking the client's temperature is unrelated to the hematoma and would provide no additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the physician of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection.

37. A primiparous client who gave vaginal birth to a viable term neonate 48 hours ago has a midline episiotomy and repair of a third degree laceration. When preparing the client for discharge, which of the following assessments would be most important? 1. Constipation. 2. Diarrhea. 3. Excessive bleeding. 4. Rectal fistulas.

1. Constipation The client with a third-degree laceration should be assessed for constipation, because a third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fistulas may develop at a later time, but not at 48 hours postpartum.

26. A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate? 1. "Ask for some pain medication before you sit down." 2. "Squeeze your buttock muscles together before sitting down." 3. "Keep a relaxed posture before sitting down with your full weight." 4. "Ask the physician for some analgesic cream or spray."

2. "Squeeze your buttock muscles together before sitting down." The nurse should instruct the client to squeeze or contract the muscles of the buttocks together before sitting down in the chair; this contracts the pelvic floor muscles, which reduces the tension on the tender perineal area. Then the client should put her full weight slowly down on the chair. Pain medication may only be prescribed for every 3 to 4 hours, so the client may not be able to receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades by the fifth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the pelvic floor muscles. Most physicians prescribe an analgesic cream or spray when a client has an episiotomy, but they provide only temporary relief.

36. While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate? 1. "As long as you don't get pregnant again, the marks will disappear completely." 2. "They usually fade to a silvery-white color over a period of time." 3. "You'll need to use a specially prescribed cream to help them disappear." 4. "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."

2. "They usually fade to a silvery-white color over a period of time." Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.

41. A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds based on the understanding about which of the following? 1. Foods from home are generally discouraged on the postpartum unit. 2. The mother can bring the daughter any foods that she desires. 3. This is permissible as long as the foods are nutritious and high in iron. 4. The client's physician needs to give permission for the foods.

2. The mother can bring the daughter any foods that she desires. On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the physician's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease; certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.

2. A client is in the first hour of her recovery after a vaginal birth. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicus; it is firm and midline with no palpable bladder. The client's vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions? 1. Increase the IV rate. 2. Recheck the admission hematocrit and hemoglobin levels. 3. Report the findings to the health care provider. 4. Document the findings as normal.

3. Report the findings to the health care provider. At any point in the postpartum period, the lochia should be dark in color, rather than bright red. The volume should not be great enough to trickle or run from the vagina. The information provided states the fundus is firm, midline, and at the umbilicus, which are the expected outcomes at this point postpartum. These findings would indicate to the nurse that the bleeding is not coming from the uterus or from uterine atony. The bladder is not palpable, which indicates that the bleeding is not related to a full bladder, which is further validated by the fundus being at the umbilicus. The most likely etiology is cervical or vaginal lacerations or tears. The nurse is unable to do anything to stop this type of bleeding and must notify the health care provider. Increasing the IV rate will not decrease the amount or type of vaginal bleeding. Rechecking the hematocrit and hemoglobin will only provide background information for the nurse and identify the beginning levels for this mother, rather than where she is now. It will do nothing to stop the bleeding. The bleeding level and color is not normal and documenting such findings as normal is incorrect.

18. The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following? 1. Tomatoes. 2. Potatoes. 3. Corn products. 4. Meat products.

4. Meat products. Because the diet of immigrants from Mexico and Central America commonly includes beans, corn products, tomatoes, chili peppers, potatoes, milk, cheeses, and eggs, the nurse needs to encourage an intake of meats, dark green leafy vegetables, and other high protein products that are rich in iron. Doing so helps to compensate for the significant blood loss and subsequent iron loss that occurs during the postpartum period. Additionally, fresh fruits, meats, and green leafy vegetables may be scarce, possibly resulting in deficiencies of vitamin A, vitamin D, and iron. Tomatoes are high in vitamin C, potatoes are good sources of carbohydrates and vitamin C, and corn products are high in thiamine, but these are not rich sources of iron.

30. On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for: 1. Puerperal infection. 2. Vaginal lacerations. 3. History of drug abuse. 4. Perineal hematoma.

4. Perineal hematoma. If the client continues to have perineal pain after an analgesic medication has been given, the nurse should inspect the client's perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the first 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when implemented after the first 24 hours. Typically hematomas resolve themselves within 6 weeks. A puerperal infection would be indicated if the client's temperature were 100.4°F (41°C) or higher. Also, lochia most likely would be foul smelling. A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is presented to suggest a history of drug abuse.

39. While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should: 1. Continue to monitor the client's vital signs. 2. Assess the client's lochia for large clots. 3. Notify the client's physician about the findings. 4. Offer the mother an ice pack for her forehead.

1. Continue to monitor the client's vital signs. The nurse needs to continue to monitor the client's vital signs. During the first 24 hours postpartum it is normal for the mother to have a slight temperature elevation because of dehydration. A temperature of 100.4°F (38°C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and her fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The physician does not need to be notified at this time. An ice pack is not necessary because the client's temperature is within normal limits.

6. A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority? 1. By discharge, the family will bond with the neonate. 2. The client will demonstrate self-care and infant care by the end of the shift. 3. The client will state instructions for discharge during the first postpartum day. 4. By the end of the shift, the client will describe a safe home environment.

2. The client will demonstrate self-care and infant care by the end of the shift. Educating the client about caring for herself and her infant are the two highest priority goals. Following childbirth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously

17. While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following? 1. Effects of the anesthetic during labor. 2. Hemorrhage during the birth process. 3. Effects of analgesics used during labor. 4. Decreased blood volume in the vascular system.

4. Decreased blood volume in the vascular system. The client's dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after birth. The client is experiencing dizziness because not enough blood volume is available to perfuse the brain. The nurse should first allow the client to "dangle" on the side of the bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours postpartum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss during birth should not exceed 500 mL.

3. The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is 1 day postpartum following a vaginal birth. Which of the following indicates a need for further assessment? 1. Hemoglobin 12.1 g/dL (121 g/L). 2. WBC count of 15,000 (15 × 109/L). 3. Pulse of 60. 4. Temperature of 100.8°F (38.2°C).

4. Temperature of 100.8°F (38.2°C). 4. Within the first 24 hours postpartum, maternal temperature may increase to 100.4°F (38.2°C), a normal postpartum finding attributed to dehydration. A temperature above 100.4°F (38.2°C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal range. WBC count is normally elevated as a response to the inflammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure from the uterus on vessels, blood flow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.

34. While assessing the fundus of a multiparous client 36 hours after birth of a term neonate, the nurse notes a separation of the abdominal muscles. The nurse should tell the client: 1. She will have a surgical repair at 6 weeks postpartum. 2. To remain on bed rest until resolution occurs. 3. The separation will resolve on its own with the right posture and diet. 4. To perform exercises involving head and shoulder raising in a lying position.

4. To perform exercises involving head and shoulder raising in a lying position. The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third postpartum day. An exercise involving raising the head and shoulders about 8 inches (20.3 cm) with the client lying on her back with knees bent and hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles together and the client gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side, because further separation may occur. The condition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles.

4. The nurse is providing follow-up care with clients 1 week after the birth of their neonate. The nurse would anticipate what outcomes from this new mother? Select all that apply. 1. The client feels tired but is able to care for herself and her new infant. 2. The family has adequate support from one another and others. 3. Lochia is changing from red to pink and is smaller in amount. 4. The client feeds the baby every 6 to 8 hours without difficulty. 5. The client has positive comments about her new infant.

1. The client feels tired but is able to care for herself and her new infant. 2. The family has adequate support from one another and others. 3. Lochia is changing from red to pink and is smaller in amount. 5. The client has positive comments about her new infant. Outcome evaluation for a family about 10 days after childbirth would include a mother who is tired but is able to care for herself and her baby. Having adequate support systems enables the mother to care better for herself and family members, as they can provide the backup for situations that may arise and a resource for new families. The normal progression for lochia is to change from red to pink to off-white while decreasing in amount. This is within the usual time periods for a postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected that a 10-day-old infant feeds every 3 to 4 hours if bottle-feeding and every 1½ to 3 hours if breast-feeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first checkup? It is expected that the mother has positive comments about the infant, but the nurse will evaluate to determine if there is at least one positive comment.

7. In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? 1. Taking in. 2. Taking on. 3. Taking hold. 4. Letting go.

3. Taking hold. The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.

24. Four hours after giving spontaneous vaginal birth under epidural anesthesia to a viable neonate, the client states she needs to urinate. The nurse should next: 1. Catheterize the client to obtain an accurate measurement. 2. Palpate the bladder to determine distention. 3. Assess the fundus to see if it is at the midline. 4. Measure the first two voidings and record the amount.

4. Measure the first two voidings and record the amount. After birth, the nurse should plan to measure the client's first two voidings and record the amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL suggest that the client is experiencing urinary retention. In addition, if urinary retention is occurring, the bladder may be palpable and the fundus may be displaced from midline. The client does not need to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before voiding is unnecessary. However, if the client has difficulty voiding or exhibits signs of urinary retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and should be assessed after the client voids.

31. The nurse assigns an unlicensed assistive personnel to care for a client who is 1 day postpartum. Which of the following would be appropriate to delegate to this person? Select all that apply. 1. Changing the perineal pad and reporting the drainage. 2. Assisting the mother to latch the infant onto the breast 3. Checking the location of the fundus prior to ambulating the client. 4. Reinforcing good hygiene while assisting the client with washing the perineum. 5. Discussing postpartum depression with the client who is found crying. 6. Assisting the client with ambulation shortly after birth.

1. Changing the perineal pad and reporting the drainage. 4. Reinforcing good hygiene while assisting the client with washing the perineum. 6. Assisting the client with ambulation shortly after birth. Delegating care to unlicensed assistive personnel requires that the nurse knows which tasks are within their capability. Changing the perineal pad and reporting drainage, reinforcing hygiene with perineal care, and assisting with ambulation are within the individual's capacity. Unlicensed assistive personnel should never be asked to complete any assessments, such as checking fundal location or performing skilled procedures on a client. In addition, it would be beyond the scope of the job of unlicensed assistive personnel to assist the mother with latching on and discussing postpartum depression with the client. State Boards of nursing list the procedures and tasks that unlicensed assistive personnel can complete when directed.

45. A nurse is discussing discharge instructions with a client. Which of the following statements indicate that the client understands the resources and information available if needed after discharge? Select all that apply. 1. "I know to wait 2 weeks before I start my birth control pills." 2. "I have the hospital phone number if I have any questions." 3. "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." 4. "My mother is coming to help for a month so I will be fine." 5. "I know if I get fever or chills or change in lochia to call the physician." 6. "I will continue my prenatal vitamins until my postpartum checkup or longer."

2. "I have the hospital phone number if I have any questions." 3."If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." 5. "I know if I get fever or chills or change in lochia to call the physician." 6. "I will continue my prenatal vitamins until my postpartum checkup or longer." The nurse is responsible for providing discharge instructions that include signs and symptoms that need to be reported to the physician as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. The use of birth control pills needs to be discussed with the physician. A progesterone-only pill is used if the client is breast-feeding. Oral contraceptives should be initiated according to the physician's advice. Although the client's mother may be helpful, the client's statement that she will be fine because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources.

11. When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which of the following? 1. Chorioretinitis from cytomegalovirus. 2. Blindness secondary to gonorrhea. 3. Cataracts from beta-hemolytic streptococcus. 4. Strabismus resulting from neonatal maturation.

2. Blindness secondary to gonorrhea. The instillation of erythromycin into the neonate's eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate's eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.

23. A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation? 1. Her bleeding needs to be reported to the physician immediately. 2. The increased lochia occurs from lochia pooling in the vaginal vault. 3. The increase in lochia may be an early sign of postpartum hemorrhage. 4. This increase in lochia usually indicates retained placental fragments.

2. The increased lochia occurs from lochia pooling in the vaginal vault. Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.

15. Two hours after the vaginal birth of a viable male neonate under epidural anesthesia, a client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following? 1. Prolonged first stage of labor. 2. Urinary tract infection. 3. Pressure of the uterus on the bladder. 4. Edema in the lower urinary tract area.

4. Edema in the lower urinary tract area. Urinary retention soon after childbirth is usually caused by edema and trauma of the lower urinary tract; this commonly results in difficulty with initiating voiding. Hyperemia of the bladder mucosa also commonly occurs. The combination of hyperemia and edema predisposes to decreased sensation to void, overdistention of the bladder, and incomplete bladder emptying. A prolonged first stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a urinary tract infection, she would exhibit symptoms such as dysuria and a burning sensation. After birth, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on the bladder occurs during labor.

32. While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that woman doing who lost her baby from prematurity? We were in labor together." Which of the following responses by the nurse would be most appropriate? 1. Ignore the client's question and continue with morning care. 2. Tell the client "I'm not sure how the other woman is doing today." 3. Tell the client "I need to ask the woman's permission before discussing her well-being." 4. Explain to the client that "Nurses are not allowed to discuss other clients on the unit."

4. Explain to the client that "Nurses are not allowed to discuss other clients on the unit." Legal regulations and ethical decision making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse isn't sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other woman's permission to discuss her with another client is inappropriate because confidentiality must be maintained at all times.