postpartum

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breast-feed the baby as planned after delivery. The nurse makes which response to the client?

"Breast-feeding is allowed once the baby has been vaccinated."

The parents of a male neonate who is not circumcised request information on how to clean the newborn's penis. Which of the following is the correct response for the nurse to make to the parents?

"Avoid retracting the foreskin to cleanse the glans because this may cause adhesions."

A nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for more information?

"I can start doing abdominal exercises as soon as I get home."

A nurse is providing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further instructions?

"I will change the perineum pads three times a day."

A nurse provides explanation to a client prescribed methylergonovine maleate (Methergine) in the immediate postpartum period regarding this medication. Which of the following statements made by the client demonstrates understanding of rationale for administration?

"It will help to prevent and control bleeding if it occurs."

A new mother is seen in the health care clinic 2 weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu and complains of fatigue and aching muscles. On further data collection the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse how the condition occurs. The appropriate nursing response is which of the following?

"The infection can occur at anytime during breast-feeding."

A postpartum client with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse makes which response to the client?

"You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."

A nurse is assisting in developing a plan of care for a client preparing to breast-feed. In planning care, which factor is significant in teaching a client to breast-feed?

A positive nurse-client relationship

It has been 12 hours since a client's delivery of a newborn. The nurse assesses the mother for the process of involution and documents that it is progressing normally when palpation of the client's fundus is noted at which level? Refer to figure.

1

A nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse instructs the mother that her calorie intake needs to increase by approximately:

500 calories per day

A nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery may support this diagnosis?

Abdominal tenderness and chills

A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which of the following data would support that the goal has been met?

Absence of fever

Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.

Adhere to standard precautions during delivery and in the nursery. Instruct the parents to not release their newborn infant to anyone wearing improper identification. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room.

The goal for the postpartum client with thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should:

Administer anticoagulants as prescribed.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to take which priority action?

Ambulate frequently.

A nurse in a postpartum unit identifies which client as being at risk for developing endometritis following delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress

After delivery, the nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted:

At the level of the umbilicus

A postpartum client asks the nurse when she may resume sexual activity. The nurse tells the client that sexual activity may:

Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped

A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the soreness, the nurse suggests that the client:

Begin feeding on the less sore nipple.

A nurse is caring for a client during the immediate recovery phase or fourth stage of labor. The nurse's important action at this time is to:

Check the uterine fundus and lochia

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse takes which approach as the best first step to support the client psychologically?

Collect data regarding how the client perceived the event.

A client arrives to the postpartum unit following the delivery of her newborn premature infant. On data collection, the nurse notes that the client is shaking uncontrollably. Which of the following nursing actions is appropriate?

Covering her with a warm blanket

A nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed:

Eight pads a day

A postpartum client has lost 700 mL of blood. The vital signs indicate hypovolemia and the uterus remains atonic in spite of treatment. The nurse assisting in caring for the client understands the treatment that is necessary in this situation and prepares the client for:

Emergency surgery

A nurse is adding to a plan of care for a postpartum client. Which intervention will promote parent-infant bonding?

Encourage her to hold the infant even when the infant is crying.

A nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. What intervention would best facilitate the client's participation in infant care?

Encouraging the client to take pain medication as prescribed

While a client is holding and talking to her newborn immediately following delivery, she begins to cry. The nurse interprets this behavior as indicating the client is:

Experiencing a normal response to birth

A nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for:

Hematuria, ecchymosis, and epistaxis

When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her health care provider?

Her temperature is 99° F.

A nurse is reviewing the procedure for vitamin K injection in the newborn with a nursing student. Which information would the nurse provide to the student?

Inject into skin that has been cleansed with alcohol.

A client has had a midline episiotomy. In relation to a mediolateral episiotomy, the nurse anticipates that this client will generally experience:

Less pain

A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience:

Less pain

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). The appropriate nursing action would be to:

Notify the RN

A postpartum nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the health care provider?

Pain, redness, or swelling in the breasts

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. On the basis of this diagnosis, the nurse would plan to:

Prepare the client for surgery.

A nurse is conducting a prenatal session with a group of expectant parents. The nurse tells the parents that the primary hormone that stimulates the secretion of milk is

Prolactin

A new mother is attempting to breast-feed for the first time. The nurse notices that the client has inverted nipples. What nursing action can the nurse take to assist the client in breast-feeding the newborn?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn to grasp.

A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which of the following is the highest priority problem at this time?

Risk of ineffective bonding between the mother and newborn

As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she states that:

She should alternately contract and relax the muscles of the perineal area.

A nurse observes the client following delivery for normal maternal physiological changes that are anticipated. The nurse would document which expected changes?

Slowed pulse rate and elevated blood pressure

A nurse is monitoring a new mother for signs of postpartum depression. Which of the following, if noted in the new mother, would indicate the need for further data collection related to this form of depression?

The mother constantly complains of tiredness and fatigue.

A nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented finding is unassociated with this disorder?

The passage of bloody mucus stool

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. The nurse responds to the client, knowing that involution is:

The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

A nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding would indicate which of the following to the nurse?

This may be a sign of hemorrhage or shock.

A nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse expect to note in the neonate? Select all that apply.

Tremors Irritability Hypertension Exaggerated startle reflex

A nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which of the following problems is most likely to occur during this stage?

Urinary retention caused by the loss of sensation to void and rapid bladder filling

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse would:

keep the client and her family members informed of her progress

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. The nurse expects the lochia to be:

red

A nurse has instructed a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?

Washes and dries her hands before feeding

A nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action would be appropriate?

Encourage oral fluids

A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse specifically checks the client's:

Vulva for a hematoma

A nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which of the following appropriately describes the situation?

Hopelessness related to loss of the baby and illness of the spouse

A nurse is assisting in caring for a newborn whose mother is Rh negative. In planning the newborn's care, it would be important for the nurse to:

Ask about the newborn's blood type and direct Coombs'.

A nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that the initial nursing action when performing this assessment is which of the following?

Ask the client to urinate and empty her bladder.

Breast-feeding instructions for the postpartum mother should include avoidance of soaps on the nipples, frequent changing of breast pads, intermittent exposure of nipples to air, and handwashing before handling the breast and before breast-feeding. The nurse understands that these measures are specific to the prevention of:

Mastitis

A nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would indicate an early sign of excessive blood loss and shock?

A increase in the pulse rate from 88 to 102 beats per minute

Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a newborn infant, and the nurse provides information to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the woman states that it will protect her next baby from which of the following?

Being affected by Rh incompatibility

A new mother attempting breast-feeding for the first time has developed mastitis. She states, "My breasts look terrible and I think that I will stop breast-feeding." The nurse plans care, knowing that the client's statement relates to:

Body image

A nurse is assisting in administering beractant (Survanta) to a premature infant who has respiratory distress syndrome. The nurse understands that the medication will be administered by which of the following routes?

Intratracheal

A mother is breast-feeding her newborn infant. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which of the following suggestions to the client?

Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.

A nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. The nurse monitors the client frequently, knowing that the client is at risk for:

Postpartum hemorrhage

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should:

Prepare an ice pack for application to the area.