O'Meara Prep U Ch: 17

A client is Rh-negative and has given birth to her newborn. What should the nurse do next

Determine the newborn's blood type and rhesus.

A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding

The client states, "He has my eyes and nose."

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as mother by going through a series of four developmental stages. What is one of them

Achieving a maternal identity

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation

Bladder distention

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next

Document the lochia as scant.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next

Educate the client on how to perform Kegel exercises.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus

One fingerbreadth below the umbilicus

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize

Place an ice pack.

The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from

developing Rh sensitivity.

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains

oxytocin

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement

Feed the baby at least every two or three hours.

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply

Possible experience of fluctuations in sexual interest Use of a water-based lubricant to ease vaginal discomfort Possibility of increased breast sensitivity during sexual activity

A 26-year-old new mother says to her nurse, "I am so disappointed. I gained 25 pounds with my baby. Just what the doctor said I should gain. But after I had my baby I only lost 12 pounds." What is the best response by the nurse

"It is normal to lose between 12 and 14 pounds after the baby delivers. You should be back to your pre-pregnancy weight by the time your baby is about 6 months old."

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate

"It might take up to a week for your bowels return to their normal pattern."

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize

Palpate her fundus.

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia

delayed hemorrhage

A woman who gave birth to a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence

estrogen

The LVN/LPN will be assessing a postpartum client for danger signs of infection after a vaginal birth. What assessment finding would the nurse assess as a possible sign of infection for this client

fever more than 100.4° F (38° C)

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention

frequent scant voidings

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as

moderate.

When palpating for fundal height on a postpartum woman, which technique is preferable

placing one hand at the base of the uterus, one on the fundus

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency

postpartum diuresis

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production

prolactin

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing

taking- hold phase

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved

vasodilation

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate

"You might try using a water-soluble lubricant to ease the discomfort."

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate

"Your body is undergoing many changes that cause your bladder to fill quickly."

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize

100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure

Apply an ice pack to the site.

A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery

Assess for calf redness and edema.

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first

Assess the fundus.

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment with their newborn when they demonstrate which behavior? Select all that apply

B) Identify common features between themselves and the newborn, D) Make direct eye contact with the newborn

A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply

Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago

Gently massage the fundus until it tones up

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What data should she monitor during the immediate postpartum period (first 2 hours) of this client

Height of fundus

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client

Her bladder for distension

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth

Resume intercourse if bright red bleeding stops.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase

Showing increased confidence when caring for the newborn

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting

Sims position

A postpartum client delivered her infant 1 day ago and the nurse is monitoring her blood pressure. What position would the nurse place the client in to get the most accurate reading

Sitting on the side of the bed for 2 to 3 minutes

A client with vaginitis reports itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms

Take sitz baths frequently.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding

The urinary output is normal.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding

Two fingerbreadths below the umbilicus

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal

a moderate amount of lochia rubra

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply

a. Breasts are hard. b. Breasts are tender.

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn

bringing the newborn into the room