PrepU Ch. 17 After Labor

atony

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

frequent scant voidings

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?

dehydration

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

to facilitate maternal-infant bonding

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason?

Assess for uterine contractions

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next?

acutely decreased

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Ensure ice pack is changed frequently

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure

prolonged labor uterine infection hydramnios

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

Contact the Social Services department

The nurse is concerned that a new mother is ambivalent about the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at this time?

To check for postpartum hemorrhage

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?

promoting uninterrupted infant bonding

What nursing intervention by the maternity nurse is the most important in providing family-centered care?

Multiple gestation

Which condition should the nurse look for in the client's history that may explain an increase in the severity of afterpains?

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

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?

Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

estrogen

A woman who gave birth to a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence?

moderate lochia serosa

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding?

dentify common features between themselves and the newborn make direct eye contact with the newborn

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment their newborn when they demonstrate which behavior? Select all that apply.

Educate the client on how to perform Kegel exercises.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

taking-in phase

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

breastfeeding early ambulation

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.

Assess for calf redness and edema

A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery?

Administer acetaminophen with codeine

A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours?

Perform urinary catheterization

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next?

postpartum diuresis

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

oxytocin

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

possible experience of fluctuations in sexual interest use of a water-based lubricant to ease vaginal discomfort possibility of increased breast sensitivity during sexual activity

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply.

bleeding

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

increased heart rate

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning

instructing her to apply ice packs to both breasts every other hour

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

Assess the woman's fundus

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

pad count

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?

Bladder distention

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation

Wear a tight, supportive bra

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?

1 cm below the umbilicus

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?

Height of fundus

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What data should she monitor during the immediate postpartum period (first 2 hours) of this client?

difficult to separate clots

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

Involution

The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

decreased intra-abdominal pressure

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?

Ask the client when she last changed her perineal pad

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

diuresis

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

Health-seeking behaviors related to care of newborn

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?