Postpartum Management
The nurse is preparing to administer 2 mg hydromorphone hydrochloride to the client who is 28 hours post-cesarean section. The medication available is in a concentration of 4 mg/mL. How many milliliters should the nurse administer? _________ mL (record your answer in tenths)
0.5 mL 4 mg:1 mL :: 2 mg : x mL; 4 X =2; 2 / 4 = 0.5 mL
The postpartum client tells the nurse that she has pain when she breastfeeds. The nurse identifies that the infant has poor latch during breastfeeding. Which breast appearance shows that the client is experiencing symptoms associated with poor latch?
4) this graphic shows breasts that have reddened nipples, one of which is cracked. if proper latch is not obtained during breastfeeding, the newborn's sucking may cause nipple cracking, blistering and bleeding
The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client's parity? __________ Parity (record your answer as a whole number)
1 Parity refers to the number of births after 20 weeks' gestation
The client, who had preeclampsia and delivered vaginally 4 hours ago, is still receiving magnesium sulfate IV. When assessing the client's deep tendon reflexes (DTRs). the nurse finds that they are 3+. What should be the nurse's plan? (Select all that apply) 1. Notify the client's HCP about the reduced DTRs 2. Prepare to increase the magnesium sulfate dose 3. Prepare to administer calcium gluconate IV 4. Assess the level of consciousness and vital signs 5. Ask the HCP about drawing a serum calcium level
1. Notify the client's HCP about the reduced DTRs 3. Prepare to administer calcium gluconate IV 4. Assess the level of consciousness and vital signs The HCP should be notified about the decreased DTRs because weakening of these may indicate magnesium sulfate toxicity Any time the client is receiving a magnesium sulfate infusion, the nurse should be prepared for the possibility of needing the antidote, calcium gluconate The nurse should assess the client's vital signs and level of consciousness, as decreased level of consciousness and respiratory effort are serious side effects of magnesium sulfate
The client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now? 1. Call the HCP to report the pain 2. Closely reinspect the perineum 3. Help her out of bed to ambulate 4. Administer a stool softener
2. Closely reinspect the perineum A forceps-assisted delivery can increase the risk of hematoma development. Rectal pressure and perineal pain can indicate a hematoma in the posterior vaginal wall. The nurse should closely examine the perineum and the vaginal introitus for ecchymosis and a bulging mass
The client, who is 12 days postpartum, telephones the clinic and tells the nurse that she is concerned that she may have an infection because her vaginal discharge has been creamy white for 2 days now. Which response by the nurse is correct? 1) you need to come to the clinic as soon as possible 2) you'll need an antibiotic; which pharmacy do you use? 3) take your temperature and let me know if it is elevated 4) a creamy, white discharge 10 days postpartum is normal
4) a creamy, white discharge 10 days postpartum is normal creamy white discharge 10-21 days postpartum is normal. her lochia changed color on her 10th postpartum day
The nurse receives report for four postpartum clients. In which order should the nurse assess the clients? Prioritize the clients in order from first to last. 1. The client who had a normal, spontaneous vaginal delivery 30 minutes ago 2. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant 3. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding 4. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control
1, 4, 3, 2 1. The client who had a normal, spontaneous vaginal delivery 30 minutes ago 4. The client who delivered her newborn via scheduled C-section 8 hours ago and has a PCA pump with morphine for pain control 3. The client who had a vaginal delivery 32 hours ago and is having difficulty breastfeeding 2. The client who had a cesarean section 48 hours ago and is bottle feeding her newborn infant
The client is diagnosed with moderate postpartum depression (PPD) after vaginal delivery of a 10-lb baby. One week following the delivery, the nurse completes a home visit. Which finding is the priority? 1. Lochia has a foul-smelling odor 2. Small but tender hemorrhoids 3. Yells at her baby to stop crying 4. Client cries throughout the visit
3. Yells at her baby to stop crying It is inappropriate for the client to yell at her baby to stop crying. Verbal abuse can escalate to physical abuse. The safety of the infant should be the nurse's priority
The client has a vaginal delivery of a full-term newborn. immediately after delivery, the nurse assesses that the client's perineum and labia are edematous, but she does not have an episiotomy or a perineal laceration. Which intervention should the nurse implement? 1) give her an ice pack to apply to the perineum 2) teach her to relax her buttocks before sitting 3) apply warm packs to the affected areas 4) provide a plastic donut cushion for sitting
1) give her an ice pack to apply to the perineum if perineal edema is present, ice packs should be applied for the first 24 hours. ice reduces edema and vulvar irritation
immediately after delivery of the client's placenta, the nurse palpates the client's uterine fundus. The fundus is firm and located halfway between the umbilicus and symphysis pubis. Which action should the nurse take based on the assessment findings? 1) immediately begin to massage the uterus 2) document the findings of the fundus 3) assess the client for bladder distention 4) monitor for increased vaginal bleeding
2) document the findings of the fundus immediately after birth, the uterus should contract, and the fundus should be located one-half to two-thirds of the way between the symphysis pubis and umbilicus. Thus the only action required is to document the assessment findings.
twenty-four hours after the birth of her first child, the 25 y/o single client tells the nurse that she has several different male sex partners and asks the nurse to recommend an appropriate birth control method for her. Considering her lifestyle, which method of birth control should nurse suggest? 1) an intrauterine device (IUD) 2) depot-medroxyprogesterone acetate injection 3) a female condom with nonoxynol-9 4) a diaphragm
3) a female condom with nonoxynol-9 a female condom does provide protection against some of the pathogens that cause STIs, and it would be readily available over the counter
The nurse observes the postpartum multiparous client rubbing her abdomen. When asked if she is having pain, the client says, "It feels like menstrual cramps." Which intervention should the nurse implement? 1. Offer a warm blanket for her to place on her abdomen 2. Encourage her to lie on her stomach until the cramps stop 3. Instruct the client to avoid ambulation while having pain 4. Check her lochia flow; pain sometimes precedes hemorrhage
2. Encourage her to lie on her stomach until the cramps stop Multiparous women frequently experience intermittent uterine contractions called afterpains. Lying in a prone position applies pressure to the uterus, stimulating continuous uterine contraction. When the uterus maintains a state of contraction, the afterpains will cease
The RN and the student nurse are caring for a postpartum client who is 16 hours post-delivery. The RN evaluates that the student needs more education about uterine assessment when the student is observed doing which activity? 1) elevating the clients head 30 degrees before doing the assessment 2) supporting the lower uterine segment during the assessment 3) gently palpating the uterine fundus for firmness and location 4) observing the abdomen before beginning palpation
1) elevating the clients head 30 degrees before doing the assessment For the uterine assessment, the client should be positioned in a supine position so the height of the uterus is not influenced by an elevated position
The nurse is caring for the client who is 28 hours postpartum. Which assessment findings should prompt the nurse to notify the HCP of possible puerperal infection? select all that apply 1) oral temp of 102.2 F 2) telangiectasis on the neck and chest 3) mild abdominal tenderness with palpation 4) lochial discharge that is foul smelling 5) white blood cells count of 16,500 cells/mm3
1) oral temp of 102.2 F 4) lochial discharge that is foul smelling a temp of 100.4 F or higher after 24 hours postpartum is associated with a puerperal infection malodorous lochia is a common sign of a puerperal infection
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client's leg. Which action by the nurse in response to the client's bleeding is correct? 1. Explain that extra bleeding can occur with initial standing 2. Immediately assist the client back into bed 3. Push the emergency call light in the room 4. Call the HCP to report this increased bleeding
1. Explain that extra bleeding can occur with initial standing Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required
while assessing the breastfeeding mother 24 hours postdelivery, the nurse notes that the client's breasts are hard and painful. Which intervention should be implemented by the nurse? select all that apply 1) tell her to feed a small amount from both breasts at each feeding 2) apply ice packs to the breasts at intervals between feedings 3) give supplemental formula at least once in a 24-hour period 4) administer an anti-inflammatory medication prescribed prn 5) apply warm, moist packs to the breasts between feedings 6) pump the breasts as needed to ensure complete emptying
2) apply ice packs to the breasts at intervals between feedings 4) administering anti-inflammatory medication prescribed prn 6) pump the breasts as needed to ensure complete emptying because engorgement is caused, in part, by swelling of the breast tissue surrounding the milk gland ducts, applying ice at intervals between feedings will help to decrease this swelling. administering anti-inflammatory medication will decrease breast pain and inflammation pumping the breasts may be necessary if the infant is unable to completely empty both breasts at each feeding. pumping at this time will not cause a problematic increase in breast milk production
The client, who had a vaginal delivery 18 hours ago, asks the nurse how she should take care of her perineal laceration. Which statements by the nurse are appropriate? select all that apply 1) you should change your peri pad at least twice each day 2) once home, use a warm sitz bath to sooth your perineum 3) keep your perineum warm and dry until stitches are removed 4) use your peri bottle to apply water to the perineum after each void 5) wash your perineum with mild soap at least once each 24 hours 6) check your perineum for foul odor or increased redness, heat, or pain
2) once home, use a warm sitz bath to sooth your perineum 4) use your peri bottle to apply water to the perineum after each void 5) wash your perineum with mild soap at least once each 24 hours 6) check your perineum for foul odor or increased redness, heat, or pain a warm sitz bath is used after the first 24 hours to provide comfort, increase circulation to the area, and reduce incidence of infection cleansing the perineum after each void with the peri-bottle of water provides comfort and helps reduce the chance of infection washing with mild soap and rinsing with water each 24 hours reduces the risk for infection teaching the client to each for S/S of infection is important and allows the client to be an active participant in her care
In the process of preparing the client for discharge after a c section, the nurse addresses all of the following during discharge education. Which should be the priority advice for the client? 1) how to manage her incision 2) planning for assistance at home 3) infant care procedures 4) increased need for rest
2) planning for assistance at home Because the client has had a surgical procedure, the priority consideration is for the mother to plan additional assistance at home. Without this assistance, it is difficult for the mother to get the rest she needs for healing, pain control, and appropriate infant care.
when looking in the mirror at her abdomen, the postpartum client says to the nurse, "my stomach still looks like im pregnant" the nurse explains that the abdominal muscles, which separate during pregnancy, will undergo which change? 1) regain tone within the first week after birth 2) regain pregnancy tone with exercise 3) remain separated, giving the abdomen a slight bulge 4) regain tone as the weight gained during pregnancy is lost
2) regain pregnancy tone with exercise The "still pregnant" appearance is caused by relaxation of the abdominal wall muscles. With exercise, most women can regain prepregnacy abdominal muscles tone within about 6 weeks.
While assessing the postpartum client who is 10 hours post-vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first? 1. "How often are you having uterine cramping?" 2. "When was the last time you changed your pad?" 3. "Do you have any bladder urgency or frequency?" 4. "Did you pass clots that required a pad change?"
2. "When was the last time you changed your pad?" The amount of lochia on a perineal pad is influenced by the individual client's pad changing practices. Thus the nurse should ask about the length of time the current pad has been in place before making a judgment about whether the amount is concerning
The postpartum client suffered a fourth-degree perineal laceration during her vaginal birth. Which interventions should the nurse add to the client's plan of care? select all that apply 1) limit ambulation to bathroom privileges only 2) decrease fluid intake to 1000 mL every 24 hours 3) instruct the client on a high-fiber diet 4) monitor the uterus for firmness ever 2 hours 5) give prn prescribed stool softeners in the a.m. and at h.s.
3) instruct the client on a high-fiber diet 5) give prn prescribed stool softeners in the am and at hs the client with a fourth-degree perineal laceration should be instructed to increase dietary fiber to help maintain bowel continence and decrease perineal trauma from constipation
The postpartum client's blood type is A negative, and her newborn infant's blood type is AB negative. The client received RhoGAM in her second trimester, after a minor car accident. The client is preparing for discharge and asks the nurse when she will receive her RhoGAM injection. The nurse correctly responds with which statement? 1) you already recieved two doses of RhoGAM and do not need an additional dose 2) i will give your last dose of RhoGAM today, before you are discharged home 3) you and your baby have negative blood types; a dose of RhoGAM is not needed 4) RhoGAM would have been already given while you were in the delivery room
3) you and your baby have negative blood types; a dose of RhoGAM is not needed Rh immune globulin is administered to women with Rh negative blood types at approx 28 weeks of gestation and again after any trauma, such as a car accident or fall. After delivery, RhoGAM is only indicated if the newborn has a positive blood type; both the client and the newborn are Rh negative
The postpartum client, who is 24-hours post-cesarean section, tells the nurse that she has much less lochial discharge after this birth than with her vaginal birth 2 years ago. The client asks if this is normal after a cesarean birth. Which statement should be the basis for the nurse's response? 1. A decrease in her lochia is not expected; further assessment is needed 2. Women usually have increased lochial discharge after cesarean births 3. Women normally have less lochial discharge after a cesarean birth 4. The lochia amount depends on whether surgery was emergent or planned
3. Women normally have less lochial discharge after a cesarean birth The client's lochial discharge is usually decreased after cesarean birth because the uterus is cleaned during surgery
the postpartum client delivered a full-term infant 2 days previously. The client states to the nurse, :my breasts seem to be growing, and my bra no longer fits." Which statement should be the basis for the nurse's response to the client's concern? 1) rapid enlargement of breasts usually is a symptoms of infection 2) increasing breast tissue may be a sign of postpartum fluid retention 3) thrombi may form in veins of the breast and cause increased breast size 4) breast tissue increases in the early postpartum period as milk forms
4) breast tissue increases in the early postpartum period as milk forms breast tissue increases as breast milk forms, so a bra that was adequate during pregnancy may no longer be adequate by the second or third postpartum day
The student nurse reports to an experienced nurse finding a warm, red, tender area on the left calf of the client who is 48 hours post-vaginal delivery. The nurse assesses the client and explains that postpartum clients are at increased risk for thrombophlebitis due to which factors? select all that apply 1) the fibrinogen levels in the blood of postpartum clients are elevated 2) fluids normally shift from the interstitial to the intravascular space 3) postpartum hormonal shifts irritate vascular basement membranes 4) pressure is placed on the legs when elevated in stirrups during delivery 5) dilation of veins in the lower extremities occurs during pregnancy 6) compression of the common iliac vein occurs during pregnancy
1) the fibrinogen levels in the blood of postpartum clients are elevated 4) pressure is placed on the legs when elevated in stirrups during delivery 5) dilation of veins in the lower extremities occurs during pregnancy 6) compression of the common iliac vein occurs during pregnancy during pregnancy, fibrinogen levels increase, and this increase continues to be present in the postpartum period. The increased levels can contribute to clot formation elevation of the legs in stirrups during delivery leads to pooling of blood and vascular stasis dilation of the veins in the lower extremities occurs during pregnancy and increased the risk of venous stasis compression of the common iliac vein occurs during pregnancy due to an enlarging fetus and increases the risk for venous stasis
The nurse is evaluating a breastfeeding session. the nurse determines that the infant has appropriately latched on to the mother's breast when which observations are made? select all that apply 1) the mother reports a firm tugging feeling on her nipple 2) a smacking sound is heard each time the baby sucks 3) the infant's mouth covers only the mother's nipple 4) the baby's nose, mouth, chin, are touching the breast 5) the infant's cheek are rounded when sucking 6) the infant's swallowing can be heard after sucking
1) the mother reports a firm tugging feeling on her nipple 4) the baby's nose, mouth and chin, are touching the breast 5) the infant's cheek are rounded when sucking 6) the infant's swallowing can be heard after sucking if the latch is correct, the mother should feel only a firm tugging and not pain or pinching when the infant sucks when an infant is correctly latched to the breast, 2 to 3 cm of areola should be covered by the infant's mouth. if this occurs, it will result in the infant's nose, mouth, and chin touching breasts when the infant is latched correctly, the cheeks will be rounded rather than dimpled. when the infant is latched correctly, the swallowing will be audible
The client with mastitis asks the nurse if she should stop breastfeeding because she has developed a breast infection. Which response by the nurse is best? 1. "Continuing to breastfeed will decrease the duration of your symptoms" 2. "Breastfeeding should only be continued if your symptoms decrease." 3. "Stop feeding for 24 hours until antibiotic therapy begins to take effect." 4. "It is best to stop breastfeeding because the infant may become infected."
1. "Continuing to breastfeed will decrease the duration of your symptoms" Continuing to breastfeed is recommended when the client has mastitis. If the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased
The home care nurse is visiting the mother and her 6-day-old son. The nurse observes that the infant is sleeping in a crib on his back and has a blanket draped over his body. The mother had been sleeping in a nearby room. Which statements are appropriate for the nurse to make in response to this situation? (Select all that apply) 1. "I'm glad to see that you are sleeping while your baby sleeps." 2. "Having your baby sleep on his back reduces the risk of SIDS." 3. "It is best for you to sleep in the same room as your newborn." 4. "Position your baby on his tummy and side when he is awake." 5. "When using a blanket, always tuck its sides under the mattress."
1. "I'm glad to see that you are sleeping while your baby sleeps." 2. "Having your baby sleep on his back reduces the risk of SIDS." 4. "Position your baby on his tummy and side when he is awake." This is an appropriate statement. Sleeping while the infant sleeps will help the mother get the rest she needs This is an appropriate statement. The American Academy of Pediatricians recommends the supine position for infant sleeping to decrease the risk of SIDS This is an appropriate statement. While awake, the infant should be positioned prone and side-lying to help build neck muscles and decrease the chance of deformation plagiocephaly. Deformation plagiocephaly is a malformation of the skull caused by consistently lying on the back
The nurse educates the breastfeeding client diagnosed with mastitis. The nurse evaluates that the client has an adequate understanding of how to prevent mastitis in the future when the client makes which statements? (Select all that apply) 1. "Incorrect latch of my baby can lead to mastitis." 2. "I should perform hand hygiene before I breastfeed." 3. "I should rinse my baby's mouth before I let her latch." 4. "A tight underwire bra has support that prevents mastitis." 5. "I should allow my nipples to air-dry after breastfeeding."
1. "Incorrect latch of my baby can lead to mastitis." 2. "I should perform hand hygiene before I breastfeed." 5. "I should allow my nipples to air-dry after breastfeeding." Incorrect latch can cause nipple tissue to blister, crack, and bleed. These breaks in the tissue may serve as an entry point for pathogens Hand hygiene prior to breastfeeding reduces the number of pathogens available for invasion Allowing breasts to air-dry helps to reduce skin breakdown that might be caused by a moist, wet environment
The primiparous client, who is bottle feeding her infant, asks the nurse when she can expect to start having her menstrual cycle again. Which response by the nurse is most accurate? 1. "Most women who bottle feed can expect their period within 6 to 10 weeks after birth." 2. "Your period should return a few days after your lochial discharge stops." 3. "Your lochia will change from pink to white; when white, your period should return." 4. "Bottle feeding delays the return of a normal menstrual cycle until 6 months postbirth."
1. "Most women who bottle feed can expect their period within 6 to 10 weeks after birth." In nonlactating women, the average time to first ovulation is 45 days, and the return of menstruation usually happens within 6 to 10 weeks postbirth
The nurse asks the 12-hour postpartum client, who is breastfeeding her baby now, why she has not yet received a dinner tray. The client states that her mother is bringing curry and that she won't be eating the hospital food tonight. Which response by the nurse is best? 1. "Please let me know if you change your mind. I can order food for you later." 2. "Because you are breastfeeding, you should avoid eating highly spiced food." 3. "I will ask the dietitian to meet with you so you can discuss your nutritional needs." 4. "You should not be eating highly spiced food 12 hours after delivery."
1. "Please let me know if you change your mind. I can order food for you later." Offering to order food later if the client changes her mind is the best response. Many clients have culturally based beliefs about food and beverages that should be consumed in the postpartum period. Unless contraindicated, nurses should support and encourage women to incorporate food preferences with cultural significance into their postpartum diet
The postpartum client, who is 24-hours post-vaginal birth and breastfeeding, asks the nurse when she can begin exercising to regain her pregnancy body shape. Which response by the nurse is correct? 1. "Simple abdominal and pelvic exercises can begin right now." 2. "You will need to wait until after your 6-week postpartum checkup." 3. "Once your lochia has stopped, you can begin exercising." 4. "You should not exercise while you are breastfeeding."
1. "Simple abdominal and pelvic exercises can begin right now." On the first postpartum day, the client should be taught to start abdominal breathing and pelvic rocking. Kegel exercises, which should have been taught during pregnancy, should be continued. Simple exercises should be added daily until, by 2 to 3 weeks postpartum, the mother should be able to do sit-ups and leg raises
Twenty-four hours post-vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse? 1. Document the data in the client's medical record 2. Notify the HCP immediately 3. Administer a laxative that was prescribed prn 4. Assess the client's abdomen and bowel sounds
1. Document the data in the client's medical record A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus documentation of the lack of a BM is the only action required
The clinic nurse reviews the laboratory results illustrated from the postpartum client who is 3 days post delivery. What should the nurse do in response to these results? Hct - 35% Hgb - 11 g/dL WBCs - 20,000/mm3 1. Document the laboratory report findings 2. Assess the client for increased lochia 3. Assess the client's temperature orally 4. Notify the HCP immediately
1. Document the laboratory report findings The only action required is to document the findings; all values are within expected parameters. Nonpathological leukocytosis often occurs during labor and in the immediate postpartum period because labor produces a mild pro-inflammatory state. WBCs should return to normal by the end of the first postpartum week. Hct and Hgb will begin to decrease on postpartum day 3 or 4 from hemodilution
The nurse is caring for the postpartum primiparous client who is 13 hours post-vaginal delivery. The nurse observes that the client is passive and hesitant about making decisions about her own and her newborn's care. In response to this observation, which interventions should be implemented by the nurse? (Select all that apply) 1. Question her closely about the presence of pain 2. Ask if she would like to talk about her birth experience 3. Encourage her to nap when her infant is napping 4. Encourage attendance in teaching sessions about infant care 5. Suggest that she begin to write her birth announcements
1. Question her closely about the presence of pain 2. Ask if she would like to talk about her birth experience 3. Encourage her to nap when her infant is napping Many women hesitate to ask for medication, as they believe their pain is expected. Thus the nurse should ask the client about pain and assure her that there are methods to decrease her pain During the initial postpartum "taking-in" phase, the client may have a great need to talk about her birthing experience and to ask questions for clarification as necessary. By encouraging this verbalization, the nurse helps the client to accept the experience and enables her to move to the next maternal phase Physical discomfort can be intense initially postpartum and can interfere with rest. Sleep is a major need and should be encouraged
The postpartum client is being admitted for mastitis. The nurse should prepare the client for which interventions? select all that apply? 1) walking at least four times in 24 hours 2) receiving a prescribed oral antibiotic 3) applying warm packs to the breasts 4) getting a prescribed anti-inflammatory drug 5) limited oral fluid intake to 1000 mL per day 6) emptying the milk from her breast frequently
2) receiving a prescribed oral antibiotic 3) apply warm packs to the breasts 4) getting a prescribed anti-inflammatory drug 6) emptying the milk from her breast frequently treatment for mastitis includes administration of antibiotics to treat the infection application of warm packs decrease pain and promotes milk flow and breast emptying. treatment for mastitis includes anti-inflammatory medication to treat fever and decrease breast inflammation if the breasts continue to be emptied by either breastfeeding or pumping, the duration of symptoms and the incidence of a breast abscess are decreased
The nurse is caring for the postpartum family. the nurse determines that paternal engrossment is occurring when which observation is made of the newborn's father? 1) talks to his newborn from across the room 2) shows similarities b/w his and baby's ears 3) expresses feeling frustrated when the infant cries 4) seems to be hesitant to touch his newborn
2) shows similarities between his and baby's ears engrossment is demonstrated by the father touching the infant, making eye contact with the infant, and verbalizing awareness of features in the newborn that are similar to his and that validate his clam to that newborn
Before hospitalization, an adolescent client had decided to give up her newborn for adoption. The client had an uncomplicated vaginal delivery and is still committed to her decision. Which intervention should the nurse exclude? 1) offer the client a transfer to different unit within the hospital 2) talk to the client about having possible feelings of ambivalence. 3) initiate a case management or social. work consult for the client 4) notify her family to ensure that support is available upon her discharge
4) notify her family to ensure that support is available upon her discharge the adolescent may not have disclosed the pregnancy to family. although it would be appropriate for the nurse to explore the client's support system with the client, the nurse should not contact the client's family
A LPN asks an RN to assist in locating the fundus of the client who is 8 hours post-vaginal delivery. Place an X at the location on the client's abdomen where the RN should direct the LPN to begin to palpate the fundus
the top one 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus due to blood and clots that remain within the uterus and changes in ligament support. thus the RN should direct the LPN to locate the client's fundus at the level of the umbilicus
The client, whose parity is 1, had a vaginal delivery 6 days ago and arrived home yesterday after treatment for endometritis. The home health nurse visits the client and plans teaching after seeing which most concerning item in the client's bathroom? 1) a box of tampons on the floor outside of the shower stall 2) loofa bath sponge sitting on the seat of the shower stall 3) damp towel bunched on the towel bar and near the floor 4) can of bathroom cleaner on the floor of the shower stall
1) a box of tampons on the floor outside of the shower stall the nurse should plan teaching about the use of tampons during postpartum. The tampon may irritate or dry the vagina, holds lochia in the body, and increases the risk of infection. The client should be instructed to wear a peri-pad.
After delivering the full-term infant, the breastfeeding mother asks the nurse if there is any contraceptive method that she should avoid while she is breastfeeding. Which contraceptive should the nurse advise the client to avoid? 1. A diaphragm 2. An intrauterine device (IUD) 3. The combined oral contraceptive (COC) pill 4. The progesterone-only mini pill
3. The combined oral contraceptive (COC) pill Birth control pills containing progesterone and estrogen (COC) can cause a decrease in milk volume and may affect the quality of the breast milk
the caucasian postpartum client asks the nurse if the stretch marks on her abdomen will ever go away. Which response by the nurse is most accurate? 1) your stretch marks should totally disappear over the next month 2) your stretch marks will appear raised and reddened 3) your stretch marks will lighten in color with good skin hydration 4) your stretch marks will fade to pale white over the next 3 to 6 months
4) your stretch marks will fade to pale white over the next 3-6 months in caucasian women, stretch marks will fade to a pale white over 3 to 6 months
The postpartum client delivered a healthy newborn 36 hours previously. The nurse finds the client crying and asks what is wrong. The client replies, "Nothing, really. I'm not in pain or anything, but I just seem to cry a lot for no reason." What should be the nurse's first intervention? 1. Call the client's support person to come and sit with her 2. Remind her that she has a healthy baby and that she shouldn't be crying 3. Contact the HCP to have the counselor come see the client 4. Ask the client to discuss her birth experience
4. Ask the client to discuss her birth experience A key feature of postpartum blues is episodic tearfulness without an identifiable reason. Interventions for postpartum blues include allowing the client to relive her birth experience
The client delivered a healthy newborn 4 hours ago after being induced with oxytocin. While being assisted to the bathroom to void for the first time after delivery, the client tells the nurse that she doesn't feel a need to urinate. Which explanation should the nurse provide when the client expresses surprise after voiding 900 mL of urine? 1) a decreased sensation of bladder filling is normal after childbirth 2) the oxytocin you received in labor makes it difficult to feel voiding 3) you probably didn't empty completely. I will need to scan your bladder. 4) your bladder capacity is large; you likely wont void again for 6 to 8 hours
1) a decreased sensation of bladder filling is normal after childbirth The nurse should explain about the decreased sensation of bladder filling after childbirth. it is not uncommon for the postpartum client to have increased bladder capacity, decreased sensitivity to fluid pressure, and a decreased sensation of bladder filling.
The husband of the postpartum client diagnosed with moderate postpartum depression asks the nurse about the treatments his wife will require. The nurse's response should be based on knowing that which treatment's are included in the initial collaborative plan of care? select all that apply. 1) antidepressant medication 2) individual or group psychotherapy 3) removal of the infant from the home 4) sedative-hypnotic agents 5) electroconvulsive therapy (ECT)
1) antidepressant medication 2) individual or group psychotherapy SSRIs are first-line agents for treating moderate PPD individual or group psychotherapy is a treatment for moderate PPD
The nurse is caring for four postpartum clients. Which client should be the nurse's priority for monitoring for uterine atony? 1) the client who is 2 hours post c section birth for a breech baby 2) the client who delivered a macrocosmic baby after a 12-hour labor 3) the client who has a firm fundus after a vaginal delivery 4 hours ago 4) the client receiving oxytocin IV for past 2 hours
2) the client who delivered a macrocosmic baby after a 12-hour labor this client is the nurse's priority for monitoring for uterine atony. a macrocosmic baby stretched the client's uterus, and thus the muscle fibers of the myometrium, beyond the usual pregnancy size. After delivery the muscles are unable to contract effectively.
The nurse is caring for the client who just gave birth. Which observation should lead the nurse to be concerned about the client's attachment to her male infant? 1. Asking the caregiver about how to change his diaper 2. Comparing her newborn's nose to her brother's nose 3. Calling the baby "Kelly," which was the name selected 4. Repeatedly telling her husband that she wants a girl
4. Repeatedly telling her husband that she wants a girl Attachment is demonstrated by expressing satisfaction with a baby's appearance and sex. Frequent expressions of dissatisfaction with the sex of the infant should be concerning and followed up
The nurse is assessing the postpartum client, who is 5 hours postdelivery. Initially, the nurse is unable to palpate the client's uterine fundus. Prioritize the nurse's actions to locate the client's fundus by placing each step in the correct sequence. 1. Place the side of one hand just above the client's symphysis pubis 2. Press deeply into the abdomen 3. Place the other had at the level of the umbilicus 4. Massage the abdomen in a circular motion 5. Position the client in the supine position 6. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage
5, 1, 3, 2, 4, 6 5. Position the client in the supine position 1. Place the side of one hand just above the client's symphysis pubis 3. Place the other had at the level of the umbilicus 2. Press deeply into the abdomen 4. Massage the abdomen in a circular motion 6. If the fundus is not felt, move the upper hand lower on the abdomen and repeat the massage
The client delivered vaginally six hours ago, and is upset about bleeding too much. She shows the nurse the peri-pad that was just removed. What should the nurse do first? 1) ask her how long she has been wearing this pad 2) notify the HCP of this increased amount of lochia 3) prepare to give oxytocin to decrease bleeding 4) document the finding; this amount is normal
1) ask her how long she has been wearing this pad while a constant trickle or oozing of lochia would indicate excessive bleeding, the nurse would need to first know how long the client had been wearing the peri-pad to evaluate whether the amount was excessive. The client should not be saturating a large peri-pad every hour. If the client had been wearing the same pad for 3 or 4 hours, it may indicate an expected amount of lochia
The client, who is 20 days postpartum, telephones the perinatal clinic to tell the nurse that she is having heavy, bright red bleeding since hospital discharge 18 days ago. Which instruction to the client is correct? 1. "You need to come to the clinic immediately." 2. "Limit physical activity until the bleeding stops." 3. "There is no need for concern; this is expected." 4. "Call next week if the bleeding has not stopped."
1. "You need to come to the clinic immediately." Lochia rubra that persists for longer than 2 weeks is suggestive of subinvolution of the uterus, which is the most common cause of delayed postpartum hemorrhage. The client should be seen in the clinic immediately to determine what is causing her abnormal lochial discharge
The nurse is teaching the client, who is breastfeeding, about returning to sexual activity after vaginal delivery. Which statement should the nurse include? 1. "Orgasm may decrease the amount of breast milk you produce." 2. "You may need to use lubrication when resuming sexual intercourse." 3. "You should not have sexual intercourse until two months postpartum." 4. "Your HCP will let you know when you can resume sexual activity."
2. "You may need to use lubrication when resuming sexual intercourse." The nurse should inform the client that she may need lubrication with sexual intercourse because the low estrogen levels in the early postpartum period causes vaginal dryness
The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client's fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next? 1. Continue to monitor the client's bleeding and weigh the peri-pads 2. Call the client's HCP and request an additional visual examination 3. Prepare to give oxytocin to stimulate uterine muscle contraction 4. Document the findings as normal with no interventions needed at that time
2. Call the client's HCP and request an additional visual examination The nurse should consider the possibility of a vaginal wall or cervical laceration, which could produce heavy, bright red bleeding. The HCP should be notified and asked to perform a visual exam of the vagina to assess for possible lacerations in need of repair
Two hours after delivery, the mother tells the nurse that she will be bottle feeding. She asks what she can do to prevent the terrible pain experienced when her milk came in with her last baby. Which response by the nurse is most appropriate? 1. "Once you have recovered from the birth, I will help you bind your breasts." 2. "Engorgement is familial. If you had it with your last baby, it is inevitable." 3. "I can help you put you on a supportive bra; wear one constantly for 1 to 2 weeks." 4. "Engorgement occurs right after birth; if you don't have it yet, it won't occur."
3. "I can help you put you on a supportive bra; wear one constantly for 1 to 2 weeks." Wearing a supportive, well-fitting bra within 6 hours after birth can suppress lactation. The bra should be worn continuously, except for showering, until lactation is suppressed (usually 7 to 14 days)
The postpartum client is being discharged to home with a streptococcal puerperal infection. The client is taking antibiotics but asks the nurse what precautions she should take at home to prevent spreading the infection to her husband, newborn, and toddler. Which is the best response by the nurse? 1. "No precautions are necessary because you are taking antibiotics." 2. "You should always wear a mask when caring for your newborn and toddler." 3. "Wash your hands before caring for your children and after toileting and perineal care." 4. "Your husband should provide all cares for both children until your infection is gone."
3. "Wash your hands before caring for your children and after toileting and perineal care." Other than hand hygiene, no additional precautions need to be taken by the client in her home
two hours after the client's vaginal delivery, she reports feeling "several large, warm gushes of fluid" and finds a large pool of blood on the client's bed. Which nursing action is priority? 1) encourage the client to ambulate to the bathroom to empty her bladder 2) place two hands on the uterine fundus and prepare to vigourisly massage the uterus 3) reassure the client that heavy bleeding is expected in the first few hours postpartum 4) support the lower uterine segment with one hand and assess the fundus with the other
4) support the lower uterine segment with one hand and assess the fundus with the other the nurse's first action should be support the lower uterine segment and to assess the fundus. increased bleeding will occur if soft or boggy. failing to support the lower uterine segment may result in inversion of the uterus
