Post partum

When diagnostic testing reveals a bone fracture, what type of pain is the client experiencing? acute somatic pain chronic visceral pain visceral pain neuropathic pain

acute somatic pain Sprains and other traumatic injuries are examples of acute somatic pain. Somatic pain results from stimulation of nociceptors in the skin, bone, muscle, and soft tissue. Visceral pain, which is diffuse and not well localized, results when nociceptors are stimulated in abdominal or thoracic organs and their surrounding tissues either from acute or chronic injuries. Neuropathic pain is caused by lesions or physiologic changes that injure peripheral pain receptors, nerves, or the central nervous system.

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." "We will be discussing birth control with our primary care provider to find the best method for us." "We're going to use a barrier for the first few months and then decide what we want to do." "I'm going back on the pill as soon as the doctor okays it."

"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months."

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels to return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your health care provider about this problem."

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

The mother of a child who just had abdominal surgery holds his hand and smooths his hair. When the nurse appears to administer a scheduled analgesic, the mother says she believes the child has been in pain the last hour or more. The nurse's best response is: "Please tell me and all of the nurses when you believe he is in pain." "This is the medication he gets every 4 to 6 hours. It will control his pain for that period of time." "We will check every 4 hours to see if he needs the pain medicine." "He looks comfortable to me and was sleeping each time I checked. The medication given earlier seems adequate." "His vital signs are stable, telling me he must be comfortable."

"Please tell me and all of the nurses when you believe he is in pain."

A woman who is at 31 weeks' gestation comes to the clinic in labor. The health care provider decides to use terbutaline therapy before transferring the woman to the hospital. The client is upset and confused and asks the nurse why she can't just have the baby, that it's only 5 weeks early. An appropriate response by the nurse should be: "This drug will make your delivery in a few days less painful." "The drug that you are being given will prevent and control postpartum bleeding." "The drug provides sufficient time for other medications to be given to improve your baby's outcome." "This drug helps induce uterine contractions and milk ejection for breast-feeding."

"The drug provides sufficient time for other medications to be given to improve your baby's outcome."

Which of the following assessment tools will be most effective when assessing for pain in a four-year-old client? A numeric scale A word scale A linear scale A FACES scale

A FACES scale

A nurse has an 80-year-old female client who states she is tired and ready to sleep at 7:00 PM each night and is ready to rise at 4:00 AM each morning. Which symptom is the client exhibiting? Irregular sleep-wake rhythm Delayed sleep phase syndrome Advanced sleep phase syndrome Free-running sleep disorder

Advanced sleep phase syndrome

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Check the lochia. Assess the temperature. Monitor the pain level. Assess the fundal height.

Check the lochia.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? Vigorously massage the fundus. Immediately call the primary care provider. Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad.

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Demonstrate how to self-administer IV infusions. Demonstrate how to apply and remove elastic support stockings. Assess for the sites of bleeding. Assess for skin integrity.

Demonstrate how to apply and remove elastic support stockings.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Determine the newborn's blood type and rhesus. Determine if this is the client's first baby. Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy.

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. Instruct the client to empty her bladder before the examination. Wear sterile gloves when assessing the pad and perineum. Perform the examination as quickly as possible.

Instruct the client to empty her bladder before the examination.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: inspect the perineum for lacerations. increase the flow of an IV. assess and massage the fundus. call the primary care provider or the nurse-midwife.

assess and massage the fundus.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? infection dehydration change in the temperature from the birth room fluid volume overload

dehydration

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? increasing oral fluid intake increasing intravenous fluids screening for bacteriuria in the urine encouraging the woman to empty her bladder completely every 2 to 4 hours

encouraging the woman to empty her bladder completely every 2 to 4 hours

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? first 30 to 60 minutes first 3 to 5 days first month first 6 months

first 30 to 60 minutes

A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include fresh orange slices. ground beef patties. steamed broccoli. ice cream.

ground beef patties.

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? hematocrit level the size of her infant her bladder for distention her episiotomy

her bladder for distention

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? breast yeast mastitis plugged milk duct engorgement

mastitis

A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply. moderate glycosuria mild ketonuria Occasional RBCs trace WBCs gross proteinuria

moderate glycosuria mild ketonuria Occasional RBCs trace WBCs

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? oxytocin agent magnesium sulfate indomethacin nifedipine

oxytocin agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? showing increased confidence when caring for the newborn talking about her labor experience to others around her pointing out specific features in the newborn having feelings of grief or guilt

showing increased confidence when caring for the newborn

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? letting-go taking-hold taking-in acquaintance/attachment

taking-in

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? taking-in phase taking-hold phase letting-go phase attachment phase

taking-in phase

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? 500 additional calories per day 1,000 additional calories per day 250 additional calories per day 750 additional calories per day

500 additional calories per day The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? an ice pack applied to the perineum opioid pain medication a heating pad applied to the perineum a sitz bath

an ice pack applied to the perineum

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? Assign a female nurse to care for her. Ensure that the newborn's daily bath is performed by the nurses. Allow time for the numerous visitors who come to see the woman and newborn. Provide time for prayers to be performed at the bedside.

Assign a female nurse to care for her.

A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? Change in pregnancy hormone Body secreting the excess fluids from pregnancy The patient may be drinking too much fluid. The body is trying to get rid of the extra blood made during pregnancy.

Body secreting the excess fluids from pregnancy

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Mastitis Blocked milk duct Engorgement Excessive oxytocin

Engorgement

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do? Assist the client to the bathroom. Have the client sit dangling her legs off the side of the bed for 5 minutes. Ask the client to lie back down and get her a bedpan. Suggest catheterizing her this time to prevent the possibility of fainting.

Have the client sit dangling her legs off the side of the bed for 5 minutes.

The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider? Tearful during appointment Talkative and asking questions Restless and agitated, concerned with self and not the infant States being tired and happy at same time

Restless and agitated, concerned with self and not the infant

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. abdominal pain active bowel sounds tender abdomen passing gas nondistended abdomen

active bowel sounds passing gas nondistended abdomen

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. inability to concentrate loss of confidence manifestations of mania decreased interest in life bizarre behavior

inability to concentrate loss of confidence decreased interest in life

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? uterus 5 cm below umbilicus lochia rubra edematous vagina diaphoresis

lochia rubra

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client's temperature remains below 100.4°F (38.8°C) orally. Fundus remains firm and midline with progressive descent. Client maintains a urinary output greater than 30 ml per hour. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.

Client's temperature remains below 100.4°F (38.8°C) orally.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Provide breastfeeding newborns with pacifiers. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter

intermittent urethral catheter

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition? diabetes long-term obesity feelings of increased self-esteem increased sex drive

long-term obesity

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "If my lochia increases, I need to call my health care provider." "I should brush my teeth vigorously to stimulate the gums." "I need to avoid using any aspirin-containing products." "If I get a cut, I need to apply direct pressure for about 5 minutes or more."

"I should brush my teeth vigorously to stimulate the gums."

Pitocin is given to prevent what condition? Letdown Postpartum bleeding Postpartum hypotension Eclampsia

Postpartum bleeding After delivery, Pitocin is the drug of choice for prevention or control of postpartum uterine bleeding. The drug reduces uterine bleeding by contracting uterine muscle. It also plays a role in letdown of breast milk to the nipples during lactation.

A 78-year-old man has been experiencing nocturnal chest pain over the last several months, and his family physician has diagnosed him with variant angina. Which of the following teaching points should the physician include in his explanation of the man's new diagnosis? "I'll be able to help track the course of your angina through regular blood work that we will schedule at a lab in the community." "With some simple lifestyle modifications and taking your heparin regularly, we can realistically cure you of this." "I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising." "There are things you can do to reduce the chance that you will need a heart bypass, including limiting physical activity as much as possible."

"I'm going to start you on low-dose aspirin, and it will help greatly if you can lose weight and keep exercising."

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: "If you are breastfeeding, that will help make your uterus contract and get smaller." "I would recommend that you rest for a few days to allow your body to heal and get back to normal." "Eating a large amount of protein and carbohydrates will help make the uterus contract." "There is really nothing you can do to speed along the progress, so just be patient."

"If you are breastfeeding, that will help make your uterus contract and get smaller."

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) administration of platelet transfusions as prescribed avoiding administration of oxytocics continual firm massage of the uterus

administration of platelet transfusions as prescribed

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Expect to see your 2-year-old become more independent when the baby gets home." "Talk to your 2-year-old about the baby when you're driving him to day care." "Ask your 2-year-old to pick out a special toy for his sister." "Have your 2-year-old stay at home while you're here in the hospital."

"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "When did you last void?"

"How much blood was on the two pads?"

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "I need to let the doctor know if my lochia begins to have a foul smell." "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know."

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."

A nurse educates a student nurse in a long-term care facility on recommended skin care practices for older adult clients. Which statement made by the student indicates that further education is required regarding this practice? "I will check the client's skin on a weekly basis." "I will avoid using soap and water on the skin daily." "I will use skin barrier products to protect the skin from incontinence." "I will use emollients to soothe dry skin."

"I will check the client's skin on a weekly basis."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "I'll contact your health care provider." "I'll check on you in a few hours."

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

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." "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort." Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse.

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

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

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 1 week 2 weeks 3 weeks 4 weeks

2 weeks Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days.

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? Ask the client to explain why she does not want to go home. Inform the primary care provider that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client if she has any support in the home.

Ask the client to explain why she does not want to go home.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Bend her knee, and palpate her calf for pain. Ask her to raise her foot and draw a circle. Blanch a toe, and count the seconds it takes to color again. Assess for pedal edema.

Assess for pedal edema.

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. Assess the client's uterine tone. Monitor the client's vital signs. Assess the client's skin turgor. Get a pad count. Assess deep tendon reflexes.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Determine if the client is emptying her bladder. Ask the client when she last urinated. Perform an "in and out" catheter on the client. Educate the client on how to perform Kegel exercises.

Educate the client on how to perform Kegel exercises.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Apply ice packs directly to the perineal area. Apply ice packs for 40 minutes continuously. Ensure ice pack is changed frequently. Use ice packs for a week after birth.

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

In starting a new job as a nurse with a group of renal specialists, the nurse is taught that while the primary function of the urinary system is the transport of urine, the kidneys perform several functions. Which is NOT a function of the kidneys? Excreting protein Excreting nitrogen waste products Regulating blood pressure Stimulating RBC production

Excreting protein

A G4P4 mother calls the nurse's station reporting uterine pain following birth. 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? Tell her the physician will be notified of the unusual pain and subsequent action will be determined. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Recommend that the client ambulate more to help relieve the pain. Encourage the mother to breastfeed to help relax the uterus.

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

A 15-year-old adolescent shows a pattern of gaining weight, not a large amount but a little more each visit. The adolescent is not active in any sports and eats out frequently with parents. What is the best way for the nurse to assess the adolescent's eating pattern? Ask the adolescent to recall what was eaten in the last 3 days. Have the adolescent guess the calorie intake in a 24-hour period. Have the adolescent keep a food diary for 1 week. Ask the adolescent to show the nurse what a healthy portion looks like.

Have the adolescent keep a food diary for 1 week.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize? Hemoglobin 13 g/dl (130 g/L) and hematocrit 40% (0.40) in a woman who has given birth vaginally Hemoglobin 12 g/dl (120 g/L) and hematocrit 38% (0.38) in a woman who has given birth vaginally Hemoglobin 11 g/dl (110 g/L) and hematocrit 34% (0.34) in a woman who has given birth by cesarean Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean

Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client? The birth can cause perineal swelling. A neurogenic bladder results from local anesthesia. A urinary tract infection results from the birth process. Catheterization is necessary for 1 week.

The birth can cause perineal swelling.

Which situation should concern the nurse treating a postpartum client within a few days of birth? The client is nervous about taking the baby home. The client feels empty since she gave birth to the neonate. The client would like to watch the nurse give the baby her first bath. The client would like the nurse to take her baby to the nursery so she can sleep.

The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus.

A nurse is assessing an older adult with reports of constipation, for which the client often takes over-the-counter medications. What assessment should the nurse perform to address the etiology of the client's problem? Signs and symptoms of diverticula Medication regimen for drugs like anticholinergic agents or calcium History of hemorrhoids or rectal fissures History of cesarean birth or other abdominal surgery

Medication regimen for drugs like anticholinergic agents or calcium

The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? Hesitates to hold newborn, expressing disappointment with baby's appearance. Neglects to engage or provide care or show interest in infant. Tearful for several days, difficulty eating and sleeping. Express doubt in ability to care for newborn.

Neglects to engage or provide care or show interest in infant.

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? Recommend a moisturizing soap to clean the nipples. Encourage use of breast pads with plastic liners. Offer suggestions based on observation to correct positioning or latching. Fasten nursing bra flaps immediately after feeding.

Offer suggestions based on observation to correct positioning or latching.

When a peripheral nerve is irritated enough, it becomes hypersensitive to the noxious stimuli, which results in increased painfulness or hyperalgesia. Health care professionals recognize both primary and secondary forms of hyperalgesia. What is primary hyperalgesia? Pain that occurs in the tissue surrounding an injury Pain sensitivity that lasts longer than 1 week Pain sensitivity that occurs in the viscera Pain sensitivity that occurs directly in damaged tissues

Pain sensitivity that occurs directly in damaged tissues

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? Notify a health care provider. Apply a warm washcloth. Place an ice pack. Put on a witch hazel pad.

Place an ice pack.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? Avoid use of water-based gel lubricants. Resume intercourse if bright red bleeding stops. Avoid performing pelvic floor exercises. Use oral contraceptive pills (OCPs) for contraception.

Resume intercourse if bright red bleeding stops.

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? Acute pain related to afterpains or episiotomy discomfort Risk for infection related to multiple portals of entry for pathogens Risk for injury: postpartum hemorrhage related to uterine atony Risk for injury: falls related to postural hypotension and fainting

Risk for injury: postpartum hemorrhage related to uterine atony

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? Schedule home visits for high-risk families. Encourage frequent clinic visits for high-risk families. Provide phone numbers for call centers for questions. Ask family members to monitor the parents' progress.

Schedule home visits for high-risk families.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? Escherichia coli group B streptococcus (GBS) Staphylococcus aureus Streptococcus pyogenes (group A strep)

Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness.

Symptoms include fever, chills, malaise, and localized breast tenderness.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Take a mild laxative such as magnesium citrate when necessary. Take a stool softener such as docusate sodium daily. Administer a tap-water enema weekly. Administer a phospho-soda enema when necessary.

Take a stool softener such as docusate sodium daily.

A 29-year-old first-time mother has been diagnosed with postpartum psychosis after her partner reported the client was hearing voices and told the partner she "saw someone trying to steal the baby." In the planning of this client's care, which outcome should the nurse prioritize? The client will describe the causes of her fatigue. The client will demonstrate an improved ability to express herself. The client will consume at least 1,500 calories each day. The client will demonstrate the ability to differentiate between perceptual disturbances and reality.

The client will demonstrate the ability to differentiate between perceptual disturbances and reality.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The flow contains large clots. The flow is over 500 mL. Her uterus is soft to your touch. The color of the flow is red.

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

Which reason explains why women should be encouraged to perform Kegel exercises after birth? They assist with lochia removal. They promote the return of normal bowel function. They promote blood flow, enabling healing and muscle strengthening. They assist the woman in burning calories for rapid postpartum weight loss.

They promote blood flow, enabling healing and muscle strengthening.

Which is an inaccurate depiction of concrete messages? They require rephrasing of unclear statements. They elicit more accurate responses. They are easy to understand. There is no need for interpretation.

They require rephrasing of unclear statements.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Warm and flushed skin Weak and rapid pulse Elevated blood pressure Decreased respiratory rate

Weak and rapid pulse

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply. Weigh the client daily. Restrict fluids. Measure urine specific gravity. Place on a calorie-restricted diet. Monitor intake and output.

Weigh the client daily. Measure urine specific gravity. Monitor intake and output.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth a client who had an 8-hour labor a client who conceived following fertility treatments

a client who had a nonelective cesarean birth

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? an absence of lochia red-colored lochia for the first 24 hours lochia that is the color of menstrual blood lochia appearing pinkish-brown on the fourth day

an absence of lochia

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine

applying ice

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? talking about how the nurse held her own newborn while on the birthing table showing a video of parents feeding their babies allowing the mother to pick the best time to hold her newborn bringing the newborn into the room

bringing the newborn into the room

he nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? yellowish-white lochia foul-smelling lochia easy to separate clots difficult to separate clots

difficult to separate clots

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? estrogen progesterone hCG prolactin

estrogen The endocrine system rapidly undergoes several changes after birth. Levels of circulating estrogen and progesterone drop quickly with delivery of the placenta. Decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? increased white blood cell count stirrup injury during birth increased coagulation factors decreased red blood cell count

increased coagulation factors

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage infection depression pulmonary emboli

infection

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 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

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

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? positive bonding negative bonding positive attachment negative attachment

negative attachment

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? one fingerbreadth above the umbilicus one fingerbreadth below the umbilicus at the level of the umbilicus below the symphysis pubis

one fingerbreadth above the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum blues postpartum depression postpartum psychosis anxiety disorders

postpartum depression

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum psychosis postpartum blues postpartum depression postpartum panic disorder

postpartum psychosis

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? venous duplex ultrasound of the right leg transthoracic echocardiogram venogram of the right leg noninvasive arterial studies of the right leg

venous duplex ultrasound of the right leg

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women on antithyroid medications women on antineoplastic medications women using street drugs women with more than one infant women who had difficulties with breastfeeding in the past

women on antithyroid medications women on antineoplastic medications women using street drugs