Postpartum NCLEX

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 (Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the baby's Rh-positive blood can enter the maternal circulation, thus causing the woman's immune system to form antibodies against the Rh-positive blood. The administration of Rho(D) immune globulin prevents the woman from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.)

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." (In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. Separation should be allowed to occur naturally, which will take place between 3 years and 5 years of age. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.)

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." (Abdominal exercises should not start following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision. )

A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates a need for further instruction?

"I need to isolate my infant for 48 hours after the starting the antibiotics." (Broad-spectrum antibiotics will be prescribed for the mother, and the mother should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.)

A nurse provides home care instructions to a postpartum client who had a cesarean delivery. Which statement by the client indicates an understanding of the instructions?

"If I develop a fever, I will call my doctor." (The client should not lift anything heavier than the baby for 2 weeks. When getting out of bed, the client should turn on the side and push up with the arms. The client should call the doctor if a fever develops. Abdominal exercises should not be started following abdominal surgery until 3 to 4 weeks postoperatively to allow for healing of the incision.)

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." (Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage.)

A nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement would provide the best encouragement?

"Tell me about the delivery of your baby." (It is important for the mother to think of the procedure as the birth of the baby. The mother may become disappointed because she was unable to deliver vaginally, complicating the postpartum phase. Option 2 brings the surgery to focus and can inhibit the mother from bonding with the neonate. Options 3 and 4 place the focus on the future, and the mother needs to focus on the birth of the baby.)

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Choose the instructions that would be included on the list. Select all that apply.

1. Wear a supportive non-underwire bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breast-feed if the breasts are not too sore. (Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.)

A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which of the following interventions should be included in the plan of care? Select all that apply.

1. Maintaining bed rest 2. Elevating the affected extremity 5. Applying warm compresses to the affected area as prescribed (Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may be recommended. Warm packs may be applied to the affected area to promote healing. Anticoagulants or anti-inflammatory agents are not needed unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate.)

A nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience?

A positive nurse-client relationship (Because hospital stays are short, all contacts with the mother become teachable moments. A positive nurse-client relationship is a growth-fostering experience that will enhance the teaching and learning experience. Separation of the infant and mother decreases the chance of correct latch and suck in the immediate postpartum period. The infant should be placed at the breast immediately after delivery. The mother, not the health care provider, makes the decision regarding the method of feeding. Although previous breast-feeding experience is helpful, the most significant factor is the nurse-client relationship.)

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 (Symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104° F. This intrauterine infection may lead to further maternal complications such as infections of the fallopian tubes, ovaries, and blood (sepsis). Options 1, 2, and 4 represent normal maternal physiological responses in the immediate postpartum period. These changes represent the normal adaptation of reproductive organs (involution) and maternal physiological responses because of the decreased hormonal levels and fluid losses that occur during labor.)

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 (Fever is the first indication of an infection. An absence of fever would indicate that the goal stated in the question has been met. Chills, abdominal tenderness, and loss of appetite indicate the presence of an infection.)

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 purpose of anticoagulant therapy is to prevent the clot from moving to another area.)

A nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which of the following would the nurse anticipate to be prescribed by the health care provider?

Administration of a subcutaneous rubella virus vaccine (A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A postpartum woman with a titer of 1:8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II). This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.)

A client had a cesarean delivery with a low transverse uterine incision. The nurse explains the benefits of this type of incision to the client, knowing that this type of incision:

Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy (A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.)

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. (Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis.)

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 (Endometritis is an acute infection of the mucous lining of the uterus that occurs immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. Options 1, 2, and 3 do not describe the client "at risk" to develop endometritis following delivery.)

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'. (To further assess and plan for the newborn's care, the newborn's blood type and direct Coombs' must be known. If the newborn's blood type is Rh negative, or if the newborn's blood type is Rh positive with a negative direct Coombs' test, then there is no concern for Rh incompatibility. If the newborn's blood type is Rh positive and the direct Coombs' is positive, then Rh incompatibility exists. Options 1 and 2 are inappropriate at this time because additional data are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease in the newborn.)

A delivery room nurse performs an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that it is positioned:

At the level of the umbilicus (Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is more than 1 cc above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.)

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 (After delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. By about 10 days postpartum, the uterus will be in the symphysis pubis area.)

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 (It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks)

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. (The nurse would instruct the mother to begin feeding on the less sore nipple. The infant sucks with greater force at the beginning of feeding. Rotating breast-feeding positions, breaking suction with the little finger, nursing frequently, not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness. Options 1, 2, and 3 are incorrect measures.)

A nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding may indicate:

Bladder distention (Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus upward and to the side. Options 2, 3, and 4 are complications not usually indicated by a firm and displaced uterus.)

A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would most likely indicate a hematoma?

Changes in vital signs (Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 3 and 4 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma.)

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 potential complication following delivery is hemorrhage. The most significant source of bleeding is the site where the placenta is implanted. It is critical that the uterus remain contracted, and vaginal blood flow is monitored every 15 minutes for the first 1 to 2 hours. )

A nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?

Checks the calf areas for redness or swelling (Redness, swelling, and pain in the calf area are signs of thrombophlebitis, a potential complication in the postpartum period. Options 1 and 4 do not determine the presence of thrombophlebitis. Although the client with thrombophlebitis may experience pain when ambulating, option 3 is not the best intervention from those provided in the options.)

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. (As a result of anesthesia, anxiety, and the experience of a sudden catastrophic event, the client may well have experienced a decreased ability to take in and process information. The nurse should first identify the client's perception of the event before deciding how to intervene. Having time to interact with the infant may be helpful but not as a first step. The remaining options are not helpful because they are not therapeutic or deal with subjects the client may not be ready to face.)

A nurse is caring for a woman who is being treated with antibiotics for mastitis. The nurse reinforces instructions and tells the woman to:

Complete the entire antibiotic regimen. (If antibiotics are prescribed, the client must complete the regimen even though symptoms will be reduced in 24 to 48 hours. Options 1, 3, and 4 are inappropriate treatment measures for mastitis. The client should breast-feed, wear a supportive bra, and take analgesics as prescribed.)

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 (In the postpartum period, a woman may commonly experience a shaking and uncontrollable chill immediately after birth. The exact cause of this occurrence is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The best nursing action is to provide a warm blanket to the client and a warm drink if this is not contraindicated. It is not necessary to contact the health care provider. Massaging the fundus and placing the client in the Trendelenburg's position have no effect on the client's condition.)

A postpartum nurse is collecting data from a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia would the nurse expect to note at this time?

Dark red lochia (In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red. Options 1, 2, and 3 are not the expected characteristics of lochia at this time.)

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 (The normal amount of lochia may vary with the individual but should never exceed eight pads a day. The average number of pads used daily is six.)

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 (Options 1, 2, and 4 identify interventions to reverse uterine atony. When uterine atony cannot be reversed, surgery is required.)

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. (Holding the infant close and allowing the infant to feel the warmth initiates a positive experience for the mother and consoles the infant. The use of a high-pitched voice and participating in infant care are additional methods of promoting parent-infant attachment. Infants should not be allowed to sleep in the parental bed. The parents require time alone as a couple. Additionally, the danger of suffocation of the infant exists if the infant is allowed to sleep between the parents.)

A postpartum nurse obtains the vital signs on a mother who delivered a healthy newborn infant 2 hours ago. The mother's temperature is 100° F (38° C). The initial nursing action would be to:

Encourage oral fluid intake. (During the first 24 hours following delivery, the mother's temperature may rise to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore the initial nursing action is to encourage fluid intake. The nurse would document the temperature, but this is not the initial action. Options 2 and 3 are not necessary at this time)

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 (Keeping the client comfortable by appropriately using prescribed analgesics will facilitate her interest in caring for the infant. Nursing responsibilities for the care of a client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), promoting bedrest in Fowler's position to facilitate drainage and lessen congestion. The correct option is the only nursing intervention that demonstrates the nurse's understanding of both the physiological and psychosocial needs of the postpartum client experiencing endometritis.)

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 (The birth of a baby is an emotionally charged moment for new parents. Crying can be a normal expression of emotions surrounding birth. Holding, eye contact, and touch are signs of healthy maternal-newborn attachment.)

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 (The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish brown, and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum.)

A nurse is reviewing the procedure for vitamin K injection in a newborn. Which information is included in the procedure?

Inject into skin that has been cleansed and allowed to have alcohol dry on the puncture site for 1 minute. (Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ⅝-inch needle. It is injected into skin that has been cleansed or allowed to alcohol dry for 1 minute to remove organisms and prevent infection. It is given at a 90-degree angle. The site is massaged after removing the needle to increase absorption.)

A nurse is collecting data on a client who is 6 hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate?

Instruct the mother to request help when getting out of bed. (Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness and dizziness are signs that caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times getting out of bed. Option 1 requires a health care provider's prescription. Option 3 is not a helpful action. Option 4 is unnecessary.)

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 (Respiratory distress is common in premature neonates and may be due to lung immaturity as a result of surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route)

A nurse is checking lochia discharge in a woman in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. The nurse determines that this finding:

Is normal (Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time the lochial flow should steadily decrease and the color of the discharge should change to a pinkish red or reddish brown.)

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. (Keeping the client and her family informed about her condition will help minimize fear and apprehension. )

A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down. (Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding.)

A nurse is caring for a newborn with respiratory distress syndrome (RDS). Which of the following data obtained by the nurse indicate potential complications associated with this disorder?

No audible breath sounds in left lung; heart sounds louder in right side of chest (Pneumothorax is a complication associated with RDS. Clinical signs of pneumothorax include a sudden rapid deterioration in condition, tachypnea, grunting, pallor, cyanosis, decreased breath sounds in the affected lung, shifting of the cardiac apex away from the affected lung, bradycardia, and hypertension. Options 1, 2, and 3 are normal findings.)

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 registered nurse, who will then contact the health care provider (HCP). (During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2° F above normal, this may indicate infection, and the HCP will need to be notified. Applying cool packs to the abdomen is an inappropriate action and additionally, this action requires a prescription. The remaining options may be a component of care but are not the most appropriate based on the data in the question.)

A nurse is caring for a newborn whose mother had an elevated temperature during a prolonged labor. Which intervention(s) would be important to include in the newborn's plan of care?

Observe vital signs and central nervous system status frequently during the first 2 days. (Clinical signs of sepsis in the newborn include temperature instability, tachycardia, respiratory changes, and central nervous symptoms such as lethargy or irritability. If sepsis is a risk, the nurse would monitor vital signs and central nervous system status frequently. Promoting early maternal-newborn interaction is always important but is unrelated to this question. Delaying a feeding is not appropriate.)

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 (Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the health care provider. Options 1, 3, and 4 are normal changes that occur in the postpartum period.)

Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a nurse contacts the health care provider who prescribed the medication if which of the following conditions is documented in the client's medical history?

Peripheral vascular disease (Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia, because these conditions are worsened by the vasoconstrictive effects of the ergot alkaloids)

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. (Severe nipple soreness most often occurs as a result of poor positioning, incorrect latch-on, improper suck, or monilial infection. Comfort measures for nipple soreness include positioning the newborn 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 (Because the placenta is implanted in the lower uterine segment that does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage.)

A nurse is caring for the postpartum client who is diagnosed with a low-lying placenta. The nurse monitors the client carefully for which complication?

Postpartum hemorrhage (The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to bleeding. The client is not at greater risk for postpartum infection, coagulopathy, or chronic hypertension with this disorder.)

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. (The application of ice will reduce the swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 will not reduce swelling.)

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. (The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding)

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client states that it will:

Promote healing of the perineum. (Warm, moist heat provided by a sitz bath is used 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. Ice is used in the first 24 hours to reduce edema and numb the tissue in the perineal area. Promoting a bowel movement is best achieved by ambulation. Thrombophlebitis prevention is not related to a sitz bath.)

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. (Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn to grasp the nipple. True inverted nipples will retract if the areola is pressed between the thumb and forefinger, making option 2 incorrect. Option 3 is appropriate advice for mothers experiencing inverted nipples. Option 4 will only make the mother cold, and has no effect on inverted nipples.)

A nurse receives a report at the beginning of the shift regarding a client with an intrauterine fetal demise. Which of the following would the nurse expect to note when collecting data on the client?

Regression of pregnancy symptoms and absence of fetal heart tones (Symptoms of an intrauterine fetal demise include decrease in fetal movement, no change or a decrease in fundal height, and absent fetal heart tones. Many symptoms of pregnancy may diminish, such as uterine size, and breast size and tenderness. Option 2 identifies signs of preeclampsia. Option 3 can be a result of twins. Option 4 is associated with hyperemesis gravidarum.)

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. A nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents:

Request to hold the infant following delivery (The nurse should explain to the parents the expected events following delivery of the fetus and should tell the parents that they can hold their infant following delivery. Viewing and holding the dead infant can alleviate any negative images the mother or her partner may have. Providing a picture or other mementos will help preserve the memory of the infant. If the parents refuse a picture, most hospitals will keep a picture and copy of the footprints on file for parents to access later. Parents should be encouraged to verbalize their feelings, ask questions about the process, and make their own decisions about care as much as possible.)

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because she is:

Required to stay on bedrest (Clients with thrombophlebitis are placed on bedrest with elevation of the affected extremity. Bedrest restricts normal newborn care, feeding, and parenting and will require interventions that promote attachment. )

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 (There is a period shortly after birth that is uniquely important to attachment and mother-infant bonding. Option 2 identifies the problem that could exist if the client is unable to have the newborn infant present in the room. Options 1, 3, and 4 do not relate to the information provided in the question.)

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. (Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.)

Oxytocin (Pitocin) is prescribed to be administered intravenously to a client after a cesarean delivery. The nurse understands that the action of the medication is to:

Stimulate the uterus to contract, thus reducing possible blood loss. (The action of oxytocin is to stimulate the uterus to contract, to control uterine atony, and therefore reduce hemorrhage. Options 2, 3, and 4 are not actions of this medication.)

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that:

The bright red bleeding is abnormal and should be reported. (Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations.)

Which of the following if noted in the new mother indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness and fatigue. (Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.)

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. (Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.)

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 fourth stage of labor is the period of time from 1 to 4 hours after delivery, when the woman's body begins to readjust and relax)

Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for an effective response from the medication by monitoring for:

Uterine contractions (Oxytocin stimulates uterine contractions and is administered to reduce the incidence of hemorrhage after expulsion of the placenta. It does not directly affect urinary output or milk production. The subsequent contraction of the uterus may cause an increase in the afterbirth pains. )

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 (Hematoma is suspected when the client reports pain or pressure in the vulvar area. Massive hemorrhage can occur into the tissues, resulting in hypovolemia and shock; therefore the client's complaints must be checked so that interventions may begin immediately. The client's complaints are not related to options 1, 2, or 4.)

A nurse provides instructions to a breast-feeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?

"I will massage the breasts before feeding to stimulate let-down." (Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive well-fitting bra at all times, taking a warm shower just before feeding or applying warm compresses, and alternating the breasts during feeding. Options 1, 2, and 4 are incorrect measures.)

A postpartum client asks a nurse when she can resume sexual activity. The appropriate nursing response is which of the following?

"Sexual activity can be resumed in about 3 weeks once the episiotomy has healed and the lochia has stopped." (It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Options 1, 2, and 4 are inaccurate.)

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to hold your baby?" (Nurses should explore measures that assist the family to create memories of an infant so that the existence of the child is confirmed and the parents can complete the grieving process.)

A nurse suspects her client has a pulmonary embolism when the client exhibits which of these signs and symptoms?

Dyspnea, tachypnea, and tachycardia (Pulmonary embolism is the passage of a thrombus into the lungs. The usual signs and symptoms are dyspnea, tachypnea, tachycardia, a congested cough (not a dry cough), hemoptysis (not hematemesis), pleuritic chest pain, and a feeling of impending doom. Back pain, edema, skin tenderness, hematemesis and increased skin temperature are not associated with pulmonary embolism.)

A nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, the nurse determines that the appropriate nursing action would be to:

Have the mother place the infant in the bassinet and assist the mother in dressing the baby. (The infant needs to be placed in the bassinet for safety. The mother needs to be reassured that she can safely care for her infant, and the nurse should assist the mother in dressing the baby. Option 1 is incorrect because the infant needs to be placed in the bassinet for safety. Options 2 and 3 are incorrect because these actions do not address the mother's needs. Option 4 is the only option that focuses on the mother's feelings and needs and the safety of the infant.)

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 (Clinical manifestations of an imperforate anus include failure to pass meconium stool within 24 hours following birth, absence or stenosis of the anorectal canal, an anal membrane, and an external fistula to the perineum. During neonatal assessment, the defect should be identified easily on sight. However, a rectal thermometer may be necessary to determine patency if meconium stool is not passed. The presence of stool in the urine, the vagina, or a skin dimple should be reported immediately as an indication of abnormal anorectal development. Option 4 is a clinical manifestation of intussusception.)

A postpartum client with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse tells the client:

To breast-feed from the left breast and gently pump the right breast

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 (Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict handwashing before contact with the newborn will assist in prevention of the transmission of infection. Options 1 and 2 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B. Option 4 will not affect disease transmission.)

A nurse is assigned to care for a client in the immediate postpartum period who received methylergonovine maleate (Methergine). The nurse determines the medication is effective when the client says:

"My afterpains are really strong." (Methylergonovine maleate is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used postpartally to stimulate the uterus to contract and control excessive blood loss. The client statements in options 1, 2, and 4 are not related to this medication.)

A postpartum client is getting ready for discharge. The nurse suspects that the client is in need of further teaching related to breast-feeding when she states:

"I don't need birth control since I will be breast-feeding." (Amenorrhea may occur during breast-feeding, but the client can still ovulate without menstruating. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples. The caloric intake should be increased by 200 to 500 cal/day (per health care provider's prescription), and the diet should include additional fluids and prenatal vitamins, as prescribed.)

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 (The treatment for thrombophlebitis is anticoagulant therapy. Adverse effects of anticoagulants include bleeding and would be recognized by the presence of hematuria, ecchymosis, and epistaxis. )

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 (The nurse-client relationship is most significant. Option 1 is the opposite of what needs to happen. Brief separation decreases the chance of correct latch and suck in the immediate postpartum period. Infants should be placed at the breast immediately after delivery. Previous breast-feeding experience and a health care provider who encourages clients to breast-feed are not the significant factors.)

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 (Mastitis is an infection frequently associated with a break in the skin surface of the nipple. The measures described in the question are personal hygiene measures to help prevent mastitis.)

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 (Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately one fingerbreadth or 1 cm per day.)

The new breast-feeding mother has been seen in the clinic for the treatment of mastitis. The nurse knows that the mother needs further teaching when the mother states:

"My left breast is sore, so I will offer only my right breast frequently for breast-feeding." (Failure to nurse equally on both sides will decrease the flow of milk through the breast, causing engorgement of the breast that has been offered less frequently)

After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further discharge instructions if the new mother states:

"The only medications that I will take are prenatal vitamins and stool softeners." (After surgical evacuation and repair of a vaginal hematoma, the client will need an antibiotic because she is at increased risk for infection because of the break in skin integrity and collection of blood at the hematoma site. The client statements in options 1, 2, and 3 indicate that the client understands the necessary home care measures.)

Methylergonovine (Methergine) is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the priority nursing action is to check the:

Blood pressure (Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority before the administration of the medication is to check the blood pressure. The health care provider should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum data collection procedures, option 2 is related specifically to the administration of this medication. )

In formulating the plan of care, which problem is most important to address for a postpartum client who has expressed concerns about not knowing how to care for her newborn?

Lack of knowledge regarding ability to care for the newborn (Lack of knowledge regarding ability to care for the newborn implies a lack of information or psychomotor skills concerning a condition or treatment. This problem best describes the situation presented in the question. Lack of ability to cope implies that the person is unable to manage stressors adequately. Lack of self-esteem with regard to caring for the newborn represents temporary negative feelings about self in response to an event. Grieving in a dysfunctional way implies prolonged unresolved grief leading to detrimental activities.)

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. (Vitamin K is given in the middle third of the vastus lateralis muscle using a 25-gauge, ⅝-inch needle. It is injected into skin that has been cleansed with alcohol and allowed to dry for 1 minute; this removes organisms and prevents infection. It is administered at a 90-degree angle. The site is massaged after removing the needle to increase absorption of the medication.)

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

Less pain (Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater and the repair is more difficult and painful with the mediolateral episiotomy than the midline episiotomy.)

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 (Midline episiotomies are effective, easily repaired, and generally result in less pain. The blood loss is greater and the repair is more difficult and painful with the mediolateral than the midline episiotomy.)

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." (Although HBV is transmitted in breast milk, once the first dose of hepatitis B vaccine and the serum immune globulin have been administered to the newborn, the woman may breast-feed without risk to the newborn. Options 2, 3, and 4 are incorrect responses.)

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further instructions?

"Foods and fluids that will increase urine alkalinity should be consumed." (The woman with a urinary tract infection must be encouraged to take the medication for the entire time it is prescribed. The woman also should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.)

A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further instructions?

"I need to isolate my infant for 48 hours after starting the antibiotics." (Broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take them as prescribed. Analgesics often are necessary, and warm compresses or sitz baths may be used to provide comfort. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.)

A nurse is providing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further instructions?

"I should avoid wearing a bra at this time." (Wearing a bra or applying a breast binder applies pressure, which reduces congestion and discomfort. Ice packs reduce circulation and thus congestion and also provide an anesthetic effect. Analgesics help relieve the pain.)

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

2. Adhere to standard precautions during delivery and in the nursery. 4. Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5. Fingerprint the mother and footprint the infant on the identification card prior to removing the infant from the delivery room.

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 (If the mother is breast-feeding, her calorie needs increase by approximately 500 calories per day. The mother should also be instructed regarding the need for increased fluids and the need for prenatal vitamins and iron supplements.)

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. (Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When fundal assessment is performed, the woman is asked to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, in which case it should be massaged gently until firm.)

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. (Temperatures up to 100.4° F (38° C) in a mother during the first 24 hours after birth are often related to the dehydrating effects of labor. Increasing hydration by encouraging oral fluids will help bring the temperature to a normal reading. Options 2, 3, and 4 are unnecessary actions at this time.)

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 (During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. An elevation in temperature is not a sign of excessive blood loss. Although the respiratory rate may increase, this would not be an early sign. In addition, an increase in the respiratory rate from 18 to 22 breaths per minute is not significant.)

A nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?

Assist the client to the bathroom to void and then reassess the fundus. (A full bladder causes the uterus to be displaced above the umbilicus and well to one side of the abdominal midline. After voiding, if the fundus is boggy, it can be massaged, but this is not the first action. The woman should be assisted to the bathroom to void and then the fundus reassessed. Turning the client to her left side will not bring the fundus to midline. This is not a normal finding; the fundus should be firm at the umbilicus or 1 fingerbreadth below the umbilicus 6 hours after delivery.)

A nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage, as a result of this condition. The nurse plans care based on what information related to the condition?

Fewer muscle fibers in the lower segment of the uterus will result in poor contractions. (In placenta previa, the placenta is in the lower segment of the uterus near or over the internal cervical os. After delivery, the muscle tissue in that segment has fewer muscle fibers and the weak contractions cannot compress the open vessels at the site. Infection is a high risk because the placenta site is located near the vagina, and any vaginal organisms can easily travel to the uterus, causing infection. Options 1, 2, and 4 are incorrect.)

A nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the emotional needs of the client and her spouse is which of the following?

Gather data from the client and spouse about the perception of the event. (The most appropriate initial intervention in planning to meet the emotional needs of the client and her spouse is to gather data about the perception of the event. Although options 1, 2, and 3 are likely to be a component of the plan of care, the initial intervention is to assess the perception of the event.)

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 person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the diagnosis of grieving, deficient knowledge, or anxiety.)

A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia (Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers usually are delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks. Polycythemia, not anemia, is commonly associated with infants of diabetic women.)

When performing a postpartum assessment on a client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is appropriate?

Notify the registered nurse (RN). (Normally a few small clots may occur in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of such clots, such as uterine atony or retained placental fragments, must be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the RN. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be an appropriate action in this situation.)

A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the following?

Prepare to administer oxygen at 8 to 10 L by tight face mask. (If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L by tight face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bedrest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action would not be the initial nursing action. An IV line also will be required, but this action would follow the administration of the oxygen.)

A nurse has reinforced instructions to a new mother 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. (Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Women who maintain the perineal muscle tone may benefit in later life by the development of less stress urinary incontinence.)

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 (Following delivery of the placenta, the maternal cardiac system begins to make several normal changes, leading to slowing of the pulse rate and an elevation in blood pressure. Respirations usually remain unchanged and the client should be alert and oriented.)

After a precipitate delivery, a nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse would do which of the following first to help the woman process what has happened?

Support the mother no matter what her reaction to the newborn is. (There may be many reactions to the birth of a baby. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or may be following her cultural norms. The mother may want to process what has happened and will need time to assimilate all that occurred. The new mother requires support, and the nurse needs to provide a nurturing and accepting attitude.)

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 pulse range of 50 to 70 beats per minute is normal in a mother following delivery and may occur for the first 1 to 2 days after delivery. A weak and thready or rapid pulse is abnormal and may be a sign of hemorrhage or shock. Particular attention should be paid to the pulse rate when there has been a blood loss of 500 mL or greater during or after delivery. Options 1, 3, and 4 are incorrect interpretations.)

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 (Inflammation and engorgement are symptoms of mastitis that may alter the new breast-feeding mother's body image. The client's statement does not relate to a problem with newborn nutrition, or inadequacy. Although mastitis is the result of a break in the skin at the nipple resulting in infection and leading to the need for antibiotics, the question is psychosocial and not physiological.)

A postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Based on this information, the nurse determines that:

The bright red bleeding is abnormal and should be reported. (Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and presents as a continuous trickle of bleeding even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Options 1, 2, and 4 are incorrect interpretations of the assessment data.)

A client experiences subinvolution during the puerperium. The nurse recalls that which of the following are the most common causes for this occurrence?

Retained placental fragments and infections (Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting.)

A postpartum client who delivered at 32 weeks of gestation would like to breast-feed her preterm infant. At this time, the infant is receiving tube feedings only. What is the nurse's best response to the mother?

"You can begin pumping as soon as possible after delivery with an electric breast pump." (Prematurity usually causes a delay before the baby can be fed at the breast. Mothers must initiate and maintain their milk supply with an electric breast pump. Milk expression by electric pump needs to begin as soon as possible after delivery and be done eight or more times each 24 hours. Hand expression is not as effective as using an electric pump.)

Choose the safety measures that should be implemented when working in the newborn nursery. Select all that apply.

1. Adhere to standard precautions. 5. The parents should be instructed to not release their infant to anyone wearing improper identification. 6. The mother should be fingerprinted and the infant should be footprinted on the identification card before removing the infant from the delivery room. (Newborn safety, infection prevention, and abduction prevention are a major responsibility for nurses working in the newborn nursery. Standard precaution guidelines need to be followed to prevent transmission of bacteria and other illnesses to newborns. Following safety precautions to prevent newborn abduction includes footprinting the newborn along with fingerprinting of the mother on the identification card. This also includes placing bracelet identification on the mother and infant prior to removing the newborn from the delivery room. Educating parents to release their newborn only to those wearing proper identification is key in preventing newborn abductions in the inpatient situation. Bassinets are to be 3 feet apart. Nurses who are ill should not be working in the nursery.)

A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How will the nurse be most therapeutic in this situation?

Provide support to the mother regardless of her reaction to the newborn. (After a precipitate delivery, the woman may need help to process what has happened and time to assimilate what has happened. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or simply following cultural norms. Providing support to the mother is the most therapeutic action by the nurse. Culturally, competent care is correct but is not the best option because it does not take into account the other factors that could contribute to the mother's reactions after birth. Documentation does not enhance the therapeutic relationship. Breast-feeding is an appropriate nursing intervention, but the question does not indicate whether the mother is going to be breast-feeding.)

A nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates:

The presence of infection (Lochia, the discharge present after birth, is red the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor of menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids and ambulate are not accurate interpretations related to the assessment finding.)

A nurse is providing instructions to a client who had an episiotomy during the birthing process. Which statement by the client would indicate a need for further instructions?

"I should take sitz baths three or four times a day and test the water temperature to be sure that it is at 115° F." (Following episiotomy, the client should be instructed in measures to decrease discomfort and perineal swelling. Gluteal muscle tightening reduces direct pressure on the perineum, so discomfort is minimized. Ice decreases circulation, promotes vasoconstriction, reduces edema, and promotes a local anesthetic effect. Local anesthetic sprays reduce discomfort. Heat from sitz baths increases circulation to the perineum, thereby promoting oxygenation and healing, which reduces discomfort. However, the water temperature should not be any greater than 100° F to 105° F.)

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." (Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineum area to prevent infection. The mother also should be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina. Warm water should be used to rinse the perineum after elimination. The mother also should be instructed that the perineal pad should be changed after each elimination and may be changed in between.)

A nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. What action should the nurse take first?

Check the blood glucose level. (This infant has classic symptoms of hypoglycemia. The nurse should plan to check the infant's blood glucose to determine the extent of hypoglycemia, if any, and then to take action by calling the health care provider and feeding the infant as per agency policy. Allowing the infant to sleep may cause the hypoglycemia to remain untreated and result in neurological damage)

A nurse is planning for a nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?

Heelstick blood glucose (After birth, the most common problem in the LGA infant is hypoglycemia, especially if the mother has diabetes mellitus. At delivery when the umbilical cord is clamped and cut, the maternal blood glucose supply is lost. The newborn continues to produce large amounts of insulin, which depletes the infant's blood glucose within the first hours after birth. If immediate identification and treatment of hypoglycemia are not performed, the newborn may suffer central nervous system damage because of inadequate circulation of glucose to the brain. Indirect and direct bilirubin levels are usually prescribed after the first 24 hours because jaundice is usually seen at 48 to 72 hours after birth. There is no rationale for prescribing an Rh and ABO blood type unless the maternal blood type is O or Rh negative. Serum insulin levels are not helpful because there is no intervention to decrease these levels in order to prevent hypoglycemia.)

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.

The term, "involution," is used to describe the rapid reduction in size and the return of the uterus to a normal condition similar to its pre-pregnant state. Immediately following the delivery of the placenta, the uterus contracts to the size of a large grapefruit. The fundus is situated in the midline between the symphysis pubis and the umbilicus. Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus. The top of the fundus remains at the level of the umbilicus for about a day and then descends into the pelvis approximately one fingerbreadth on each succeeding day.

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity is a part of the method to accurately determine the amount of flow for documentation purposes?

Weighing the perineal pad before and after use (The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time between pad changes is a factor that must also be incorporated into the analysis. The remaining options are incorrect.)

Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs?

Naloxone (Narcan) (Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid that is administered to enhance fetal lung maturity.)

The pregnant client who is anemic tells the nurse that she is concerned about her baby's condition following delivery. The nurse makes which statement that will best address the client's concern?

"The effects of anemia on your baby are difficult to predict, but let's review your plan of care to ensure you are providing the best nutrition and growth potential." (The effects of maternal iron deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores. Options 1 and 3 provide false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client's plan of care to clarify information and reassure the mother.)

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." (The client is at risk for developing gestational diabetes with each pregnancy. She also has an increased risk of developing overt diabetes and needs to comply with follow-up appointments. She needs to be taught techniques to lower her risk for developing diabetes, such as weight control. The diagnosis of gestational diabetes indicates that this client has an increased risk for developing overt diabetes; however, with proper care it may not develop.)

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. (By definition, a postpartum infection is present when the temperature is greater than 100.4° F or more on 2 successive days, not counting the first 24 hours after birth. Temperatures of this magnitude must be considered a sign of a postpartum infection unless proven otherwise. Therefore a temperature of 99° F does not warrant notification of the health care provider. The woman needs to contact the health care provider if the temperature rises above 100.4° F. The other signs listed should be reported as stated.)

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." (Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. It is more common in mothers nursing for the first time and usually affects at least one breast. Constriction of the breasts from a bra that is too tight may interfere with emptying of all the ducts and may lead to infection.)

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.

1. Tremors 3. Irritability 4. Hypertension 6. Exaggerated startle reflex (Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea.)

A nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs:

Every 15 minutes for the first 2 hours (During the immediate postpartum period, vital signs are taken every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. )

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 (Prolactin stimulates the secretion of milk. Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Oxytocin is also responsible for the "let-down" reflex associated with lactation, but it is not responsible for secretion of the milk. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation.)