PostPartum PrepU

A client is 24 hours postpartum. The nurse anticipates that the client's body is returning to homeostasis. Which assessment finding requires immediate intervention?

Positive Homans' sign

A client takes a hormonal contraceptive to prevent pregnancy. The nurse should instruct her to use an alternative contraceptive method when receiving which drug concomitantly?

Primidone

Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?

progestin

A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair with the baby. Which of the following instructions would be most appropriate?

"Squeeze your buttock muscles together before sitting down."

Four hours after cesarean birth of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which of the following?

VBAC may be possible if the client has not had a classic uterine incision

While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following?

Decreased blood volume in the vascular system.

The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the postpartum dietary plan of care for the client, the nurse would encourage the client's intake of which of the following?

meat products

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul-smelling and she has had chills. During palpation of the uterus, the client indicates that she is very sore. The nurse should further assess the client for:

Puerperal infection

A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which of the following responses by the nurse would be most appropriate?

"It will probably be 6 to 10 weeks before it starts again."

A woman who is Rh-negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) Immune Globulin (RhoGAM). The nurse determines that the client understands the purpose of RhoGAM when she states:

"RhoGAM will prevent antibody formation in my blood."

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:

3 full days of elevated basal body temperature and clear, thin cervical mucus.

Staff nurses on the postpartum floor are concerned that discharge teaching is consuming a large portion of their time. How can the nurses teach their clients in a more efficient manner?

Conduct a class for clients who require the same discharge teaching

A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?

The condition typically is treated with I.V. antibiotic therapy.

A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0-to-10-point scale. The priority of care should be for the nurse to:

administer any ordered pain medication

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in her teaching?

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which of the following responses would be most appropriate?

"They usually fade to a silvery-white color over a period of time."

A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift?

Bottle- or breastfeeding preference

A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve?

Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for her clients during a fire alarm?

Close all of the doors on the unit.

The nurse has assisted a multigravida with a precipitous birth of a viable neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication?

Encourage the mother to breast-feed the infant.

A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with:

Passive immunity from maternal antibodies

After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least which of the following time spans?

12 months.

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which of the following?

Fainting

Express a small amount of breast milk

Close all of the doors on the unit

The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which of the following?

Praise and encouragement.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage?

Placenta previa

During a home visit to a primiparous client who gave vaginal birth 14 days ago, the client says, "I've been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don't have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. Which of the following would be the nurse's best response?

"It's not unusual for some mothers to feel depressed after the birth of a baby. I think I should contact your doctor."

A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate?

"Leave the diaphragm in place for at least 6 hours after intercourse."

A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which of the following?

The mother can bring the daughter any foods that she desires

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline and her breasts are soft. She has scant lochia and a negative Homans' sign. The client reports pain in her lower back. Which of the following should the nurse do next?

Administer an ordered mild analgesic.

When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the nurse instructs the client not to "prop" the bottle while feeding the neonate because this can lead to which of the following?

Aspiration of the formula.

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

Fundus two fingerbreadths above the umbilicus

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

Gloves are required for standard precautions."

A woman who is breast-feeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" The nurse should instruct the client about which of the following?

Gradual decrease in milk supply as the baby nurses less.

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

One fingerbreadth below the umbilicus

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which of the following?

Overdistention of the uterus from hydramnios.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

Removing the initial dressing for incision inspection

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other childbirths were like this." The nurse's response to the client is based on the understanding of which of the following?

The client's feeling of grief is a normal reaction

Which statement summarizes the underlying principle for the development of a parent-child relationship?

The relationship is based on the need for early and frequent parent-infant contact

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area

On the first postpartum day after a cesarean birth, the client is ordered a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which of the following?

bowel sounds

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother:

pushes only the tip of the nipple into the neonate's mouth.

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, observation of which of the following should alert the nurse to the development of a possible side effect?

Dizziness.

Which of the following measures would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis?

Emptying the bladder every 2 to 4 hours while awake.

A client whose blood type is A− gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important?

Ensuring that the client understands the procedure and signs a consent for the vaccination

In the maternal attachment process, which statement best describes the anticipated actions in the taking-hold phase?

Kissing, embracing, and caring for the neonate

Which of the following forms the basis for the teaching plan about avoiding medication use unless prescribed for a primiparous client who is breastfeeding?

Medications may be excreted in breast milk to the nursing neonate

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation?

Tachycardia

In response to the nurse's question about how a postpartum client is feeling, the client replies that she is tired, sore, and hungry. She then begins to relate her birth experience. Based on these data, the nurse determines that the client is in which phase of postpartal psychological adaptation?

Taking in.

A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?

Taking-in phase

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which of the following interpretations by the nurse is most appropriate?

The client needs application of an ice pack

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift

The nurse brings the infant to the new mother after obtaining assessment data and performing newborn interventions. Which of the following behaviors exhibited by the mother demonstrates that effective bonding is beginning to take place?

The mother looks at the newborn with direct eye contact

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a post-term neonate after oxytocin induction. When developing the client's plan of care, which of the following should the nurse expect to assess for frequently?

Uterine atony

Normal lochial findings in the first 24 hours after birth include:

bright red blood.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?

Document these expected behaviors of the taking-in period.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. Which of the following should the nurse do next?

Document this observation as a normal finding.

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response?

Medroxyprogesterone needs to be administered every 12 weeks

On the first postpartum day, the nurse instructs a primipara who has given birth to a term neonate about the neonate's senses. Which of the following statements by the mother indicates successful teaching?

My baby has very good peripheral vision and can see shapes."

A primiparous client who is bottle-feeding her neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?

6 months.

A nurse is teaching a postpartum client how to perform Kegel exercises. Which client statement indicates an understanding of the purpose of these exercises?

"These exercises help to strengthen the perineal muscles."

The nurse is reviewing discharge instructions with a postpartum breastfeeding client who is going home. She has chosen medroxyprogesterone as birth control. Which statement by the client identifies that she needs further instruction concerning birth control?

"You will give me my first medroxyprogesterone shot before I leave today."

During a home visit to a breastfeeding primiparous client at 1 week postpartum, the client tells the nurse that her nipples have become sore and cracked from the feedings. Which of the following should the nurse instruct the client to do?

Position the baby with the entire areola in the baby's mouth.

A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when she states:

"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."

A diabetic postpartum client plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when she states:

"Breastfeeding will assist in lowering maternal blood glucose."

A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following childbirth. The nurse determines the client understands principles of infection control to follow when the client says:

"I must practice frequent hand washing."

After a vaginal birth, a postpartum client complains of perineal discomfort when sitting. A nurse provides teaching on how to promote comfort. Which statement by the client indicates an understanding of how to promote comfort?

"I should contract my buttocks before sitting or rising."

A client tells a nurse that she's going to breast-feed her neonate, but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy."

During a postpartum examination, the mother of a 2-week-old infant tearfully tells the nurse she feels very tired and thinks she is not a good mother to her baby. Which statement by the nurse would be best?

"I'm concerned about what you are experiencing. Tell me more about what you are thinking and feeling.

The nurse has provided health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding her neonate. Which of the following client statements indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

A client who is 1-day postpartum following birth of a viable neonate asks the nurse about resuming sexual activity. After giving instructions, the nurse determines that the client understands the instructions when she says:

"Sexual intercourse may be resumed about 3 to 4 weeks postpartum."

A primiparous client planning to breast-feed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth breasts begin to fill with milk within which of the following periods?

2 to 4 days

The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breastfeeding mother who would like medication to decrease the pain in her uterus. Which of the medications listed on the orders sheet would be the most appropriate for this client?

Acetaminophen and hydrocodone 10 mg 1 tab P.O. q 4 to 6 hr p.r.n.

A 25-year-old primiparous client who gave bith 2 hours ago has decided to breastfeed her neonate. Which of the following instructions should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

Placing as much of the areola as possible into the baby's mouth

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn?

Increased amounts of vernix

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth

On a client's first postpartum day, the nurse assesses the client's vaginal discharge as dark red and containing shreds of decidua and mucus. What term should the nurse use in her nurse's notes to describe the discharge?

Lochia rubra

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which of the following responses would be most appropriate?

Sometimes baby girls have this from hormones received from the mother."

The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours ago. The nurse should encourage the mother and husband to:

Relate to each twin individually to enhance the attachment process

A woman who has given birth to a healthy baby is being discharged. As a part of the discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the healthcare provider about?

Saturating a pad in an hour

A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which of the following?

Slow pulse.

During a home visit on the fifth postpartum day, the client begins to cry and says that she is worried about her ability to care for her baby adequately. She tells the nurse, "I wish I could just get organized---I need 8 hours of sleep!" The nurse determines that she is experiencing which of the following?

Taking-hold phase of childbearing; she is feeling inadequate about neonatal care.

The nurse is beginning a shift caring for a group of postpartum clients. Which of the following clients would be a priority for the nurse to see first?

Client who states she has pain in the left calf

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother

pushes only the tip of the nipple into the neonate's mouth

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which of the following conditions should the nurse assess further?

Perineal lacerations.

A client and her boyfriend of 5 months are celebrating the birth of a healthy baby boy when the client's estranged partner arrives to visit the baby he believes is his son. The nurse caring for the client knows that the estranged partner has the right to:

hold the neonate after the mother gives permission.

A nurse is providing teaching to a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day?

500

A primipara has given birth to her baby, with labor, birth, recovery, and the postpartum period in the same hospital room. The client had a midline episiotomy and epidural anesthesia. While assessing the client's pulse 30 minutes after the birth, the nurse determines that the pulse rate is 60 bpm. The nurse should:

Do nothing because this pulse rate is considered a normal finding.

At which of the following times should the nurse anticipate assisting a client to breast-feed her neonate?

During the neonate's first period of reactivity.

A multiparous client at 24 hours postpartum demonstrates a positive Homan's sign with discomfort. The nurse should:

Notify the client's physician immediately

When assessing an 18-year-old primipara who gave birth to a viable neonate under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assesses for:

urinary retention

During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse?

One whose parent died recently

A primiparous client, who has just given birth to a healthy term neonate after 12 hours of labor, holds and looks at her neonate and begins to cry. The nurse interprets this behavior as a sign of which of the following?

A normal response to the birth

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which of the following clients should the nurse assess first?

A primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby, the client should do which of the following?

Express a small amount of breast milk

A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100°F (37.8°C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should:

Contact the primary care provider

While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8° F (37.2° C), the pulse is 66 bpm, and the respirations are 18 breaths/minute. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:

Continue to monitor the client's vital signs

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which of the following?

Orange juice.

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the neonate's father seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which interpretation of his behavior is most appropriate?

The father has depression because of grieving

A primiparous client has just given birth to a healthy male infant. The client and her husband are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse interprets the father's actions as indicative of which of the following?

Singing to his son from the Koran in praise of Allah

Which factor is the most important in nursing care in the postpartum period?

Supporting the mother's ability to successfully feed and care for her neonate

Puerperium is defined as

the 6 weeks following birth.

The nurse is caring for a client in the newborn nursery. Which of the following are appropriate actions for the nurse to take that will help to prevent neonatal infection? Select all that apply.

• Good hand washing technique • Isolation of infected infants with communicable disease • Hand sanitizer with points of contact

A nurse is assisting a grieving client and his/her spouse to deal with their loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.

• Provide an early opportunity for the couple to see their child if they desire. • Offer to stay with the grieving parents. • Answer the parents' questions accurately

The nurse assesses for complications in a newborn infant born with assistance of forceps. Which of the following findings would indicate a need for further assessment? Select all that apply.

• Reduction of movement in one of the infant's arms • Lifting causes the infant to cry • Loss of sensation in one the infant's arms

While instructing the client about breast-feeding, which instructions should the nurse include to help the mother prevent mastitis? Select all that apply.

• Wash your hands before handling your breast and breast-feeding. • Expose your nipples to air part of the day. • Change the breast pads frequently. • Release the baby's grasp on the nipple before removing him or her from the breast

A postpartum client is ready for discharge. Which client statement reflects an understanding of the teaching session?

"I will call my physician if I notice redness, warmth, and pain in my breasts."

After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching?

"I should use a soft toothbrush to brush my teeth."

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which of the following information?

Pregnancy should be avoided for 3 months after the immunization.

A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. Which of the following would be most appropriate to include in the nurse's instructions?

Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which of the following would be most appropriate for the nurse to suggest?

Football hold.

Which of the following should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate?

Gradually eliminate one feeding at a time.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

Administer pain medication per order.

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a vaginal birth. The nurse should next:

Apply an ice pack to the perineal area.

The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care?

Assess the client's bleeding flow and color.

A registered nurse is staff-shared to the maternal-neonatal unit where she has never worked before. How can this nurse be best employed?

Assign her a client care assignment in the postpartum unit

The nurse is preparing to administer a rubella vaccine to a postpartum client before discharge. Which of the following should the nurse caution the client to avoid?

Becoming pregnant for at least 1 month

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 ml. The nurse palpates the fundus 2 fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?

Catheterize the client.

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?

Discuss the unit's policy with the charge nurse.

While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the client's physician immediately if the client exhibited which of the following?

Dyspnea

A client gives birth to a stillborn neonate at 36 weeks' gestation. When caring for this client, which strategy by the nurse would be most helpful?

Encourage the client to see, touch, and hold the dead neonate.

The physician orders an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which of the following?

Hemorrhage

A nurse demonstrates infant bathing to a primiparous client. Which statement by the client indicates a need for additional teaching?

I have all kinds of pretty, scented soaps and lotions to bathe the baby with."

A 15-year-old unmarried primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the following responses would be most appropriate?

I'll bring the baby to you for feeding."

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

Massaging the uterus gently

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?

Notify the physician

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma

A client recently gave birth to a boy. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?

To stimulate lactation

A client who gave birth to her first child 6 weeks ago seems overwhelmed by her new role as a mother. She tells the nurse, "I can't keep up with my housework any more because I spend so much time caring for the baby." The nurse should:

help the client break down large tasks into smaller ones.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" The nurse should tell the client:

"You can continue to breastfeed as long as you want to do so."

The nurse assigns an unlicensed assistive personnel to care for a client who is one day postpartum. Which of the following would be appropriate to delegate to this person? Select all that apply.

• Changing the perineal pad and reporting the drainage. • Reinforcing good hygiene while assisting the client with washing the perineum. • Assisting the client with ambulation shortly after delivery.

The nurse palpates a client's fundus, and notes it is 1 in. (3 cm) above the umbilicus and displaced to the right. Which of the following would be priority nursing actions? Select all that apply.

• Have the client void and reassess the fundus. • Ask the client how many pads she is soaking per hour.

A nurse brings a new mother her neonate for the first time approximately 1 hour after the neonate's birth. After checking the identification, the nurse hands the neonate to the mother. Within a few minutes, the mother begins to undress her baby. What should the nurse do?

Anticipate and support the behavior as a normal part of bonding.

A 30-year-old woman, G 4, P 4, has given cesarean birth to a healthy term female neonate following an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's Foley catheter and observes that the client's urine is slightly red tinged. Which of the following should the nurse do next?

Contact the client's physician for further orders.

While observing a new mother interact with her first baby, the nurse observes that the client appears hesitant to care for the neonate. Which of the following actions would be most important for the nurse to do?

Continue to provide praise and support to the client

Which of the following would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate?

Maintain eye contact while talking to the baby.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to do which of the following?

Observe individuals in the area for large bags or oversized coats.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red lochia seemed heavier. Which of the following would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

Which of the following client statements indicates effective teaching about burping a breastfed neonate?

"When I switch to the other breast, I'll burp the baby."

A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?

Identify strategies to prevent difficulties in parenting

Which finding requires further intervention in a mother who's breast-feeding?

The neonate's lips smack.

A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to:

discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?

hemorrhage