Ch 15

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know." "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "My episiotomy should begin to heal and feel better over the next few weeks" "I need to let the doctor know if my lochia begins to have a foul smell."

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? "I can't wait for these stretch marks to disappear after I give birth." "I might lose some hair, but it will grow back." "This line on my belly will go away over time." "My nipples won't be so dark after I give birth."

"I can't wait for these stretch marks to disappear after I give birth."

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Let me show you how to calm him down. I've been doing this for many years." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?"

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? "You should notice a change in your respiratory status within the next 24 hours." "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." "Everyone is different, so it is difficult to say when your respirations will be back to normal." "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally."

"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? "You might try using a water-soluble lubricant to ease the discomfort." "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort."

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem? Elevated white blood cell count Acute decrease in hematocrit Increased levels of clotting factors Pulse rate of 60 beats/minute

Acute decrease in hematocrit

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following would the nurse expect to occur first? Reestablishing relationships with others Demonstrating increasing confidence in care of the newborn Assuming a passive role in meeting her own needs Becoming preoccupied with the present

Assuming a passive role in meeting her own needs

group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following? Puerperium Lactation Attachment Engrossment

Attachment

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? shaking chills with a fever of 99° F (37.2° C) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. heart rate 70 bpm and excessive, soaking diaphoresis blood loss of 250 mL and WBC 25,000 cells/mL

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min.

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? Uterine atony Full bowel Bladder distention Poor bladder tone

Bladder distention

A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the clients cervix, the nurse would expect the external cervical os to appear: Shapeless Circular Triangular Slit-like

Slit-like

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the clients fundus, expecting it to be at which location? Two finger-breadths above the umbilicus At the level of the umbilicus Two finger-breadths below the umbilicus Four finger-breadths below the umbilicus

Two finger-breadths below the umbilicus

After teaching a group of nursing students about the process of involution, the instructor determines that additional teaching is needed when the students identify which of the following as being involved? Catabolism Muscle fiber contraction Epithelial regeneration Vasodilation

Vasodilation

When caring for a mother who has had a cesarean birth, the nurse would expect the clients lochia to be: Greater than after a vaginal delivery About the same as after a vaginal delivery Less than after a vaginal delivery Saturated with clots and mucus

Less than after a vaginal delivery

The partner of a woman who has given birth to a healthy newborn says to the nurse, I want to be involved, but I'm not sure that I'm able to care for such a little baby. The nurse interprets this as indicating which of the following stages? Expectations Reality Transition to mastery Taking-hold

Reality

A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? The patient may be drinking too much fluid. Body secreting the excess fluids from pregnancy Change in pregnancy hormone The body is trying to get rid of the extra blood made during pregnancy.

Body secreting the excess fluids from pregnancy

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the clients fundus? Cannot be palpated 2 cm below the umbilicus 6 cm below the umbilicus 10 cm below the umbilicus

Cannot be palpated

The nurse interprets which of the following as evidence that a client is in the taking-in phase? Client states, He has my eyes and nose. Client shows interest in caring for the newborn. Client performs self-care independently. Client confidently cares for the newborn.

Client states, He has my eyes and nose.

A woman who delivered 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? Estrogen hCG hPL Progesterone

Estrogen

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? Youll notice that this will fade to silvery lines. Exercise will help to improve the muscles. Expect the color to lighten somewhat. Youll notice that your shoe size will increase.

Exercise will help to improve the muscles.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Provide the infant oral nystatin. Dry the nipples following feedings.

Feed the baby at least every two or three hours.

A group of nursing students are reviewing respiratory system adaptations that occur during the postpartum period. The students demonstrate understanding of the information when they identify which of the following as a postpartum adaptation? Continued shortness of breath Relief of rib aching Diaphragmatic elevation Decrease in respiratory rate

Relief of rib aching

A postpartum mother calls the nurse in and tells her that her right calf hurts whenever she walks around the room or in the hall. What other data needs to be collected in assessing this client for a DVT? Select all that apply. Feel the right calf for increased warmth. Note any reddened areas on the right calf. Note capillary refill of the toes. Measure the diameter of both calves. Have the mother actively flex both legs for equal movement.

Feel the right calf for increased warmth. Note any reddened areas on the right calf. Measure the diameter of both calves.

A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.) Use of an opioid anesthetic during labor Generalized swelling of the perineum Decreased bladder tone from regional anesthesia Use of oxytocin to augment labor Need for an episiotomy

Generalized swelling of the perineum Decreased bladder tone from regional anesthesia Use of oxytocin to augment labor

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? Changing the infant's diapers for the mother Demonstrating how to do cord care on the newborn Correcting the mother when she holds the newborn incorrectly. Telling the mother to feed the baby when it cries.

Demonstrating how to do cord care on the newborn

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? Correcting the mother when she holds the newborn incorrectly. Changing the infant's diapers for the mother Telling the mother to feed the baby when it cries. Demonstrating how to do cord care on the newborn

Demonstrating how to do cord care on the newborn

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? Early ambulation Prolonged labor Large fetus Use of anesthetics

Early ambulation

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Notify the primary care provider, and document the findings. Have the client void, and then massage the fundus until it is firm. Assess a full set of vital signs. Check and inspect the lochia, and document all findings.

Have the client void, and then massage the fundus until it is firm.

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? Involution Engorgement Mastitis Engrossment

Engorgement

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? Deep red, fleshy-smelling lochia Voiding of 350 cc Heart rate of 120 beats/minute Profuse sweating

Heart rate of 120 beats/minute

A postpartum client who is bottle feeding her newborn asks, When should my period return? Which response by the nurse would be most appropriate? Its difficult to say, but it will probably return in about 2 to 3 weeks. It varies, but you can estimate it returning in about 7 to 9 weeks. You won't have to worry about it returning for at least 3 months. You don't have to worry about that now. It'll be quite a while.

It varies, but you can estimate it returning in about 7 to 9 weeks

The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed? Harm to self Lack of a social network Withdrawal from others Poor nutrition

Harm to self

Which of the following would the nurse interpret as being least indicative of paternal engrossment? Demonstrating pleasure when touching or holding the newborn Identifying imperfections in the newborns appearance Being able to distinguish his newborn from others in the nursery Showing feelings of pride with the birth of the newborn

Identifying imperfections in the newborns appearance

.The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for which reason? Reduce lochia Promote uterine involution Improve pelvic floor tone Alleviate perineal pain

Improve pelvic floor tone

A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be least likely to include as a factor increasing her risk? Increased clotting factors Vessel damage Immobility Increased red blood cell production

Increased red blood cell production

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? Encouraging the woman to manually express milk Suggesting that she take frequent warm showers to soothe her breasts Telling her to limit the amount of fluids that she drinks Instructing her to apply ice packs to both breasts every other hour

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

The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? Express doubt in ability to care for newborn. Neglects to engage or provide care or show interest in infant. Hesitates to hold newborn, expressing disappointment with baby's appearance. Tearful for several days, difficulty eating and sleeping.

Neglects to engage or provide care or show interest in infant.

A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? Prolactin Estrogen Progesterone Oxytocin

Oxytocin

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? Insert a 20 gauge IV. Administer oxytocin IV. Notify the health care provider. Perform urinary catheterization.

Perform urinary catheterization.

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find? Bright red discharge Pinkish brown discharge Deep red mucus-like discharge Creamy white discharge

Pinkish brown discharge

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Notify a health care provider. Apply a warm washcloth. Place an ice pack. Put on a witch hazel pad.

Place an ice pack.

A client who is breast-feeding her newborn tells the nurse, I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now? Which response by the nurse would be most appropriate? Your uterus is still shrinking in size; thats why youre feeling this pain. Let me check your vaginal discharge just to make sure everything is fine. Your body is responding to the events of labor, just like after a tough workout. The babys sucking releases a hormone that causes the uterus to contract.

The babys sucking releases a hormone that causes the uterus to contract.

The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The mother states that she has her father's eyes. The father holds the newborn en face and talks to her. The mother is reluctant to touch the newborn for fear of hurting her. The parents explore the newborn's extremities, counting fingers and toes.

The mother is reluctant to touch the newborn for fear of hurting her.

A father of a newborn tells the nurse, I may not know everything about being a dad, but I'm going to do the best I can for my son. The nurse interprets this as indicating the father is in which stage of adaptation? Expectations Transition to mastery Reality Taking-in

Transition to mastery

A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Apply warm compresses. Wear a well-fitting bra. Express milk frequently. Apply hydrogel dressing.

Wear a well-fitting bra.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct? You should be able to resume normal activities after 2 weeks. You should not lift anything heavier than your infant in its carrier. You need to hire a maid for the first month after delivery to help out around the house. Only clean half of the house per day to allow yourself more rest.

You should not lift anything heavier than your infant in its carrier.

A woman who gave birth 24 hours ago tells the nurse, Ive been urinating so much over the past several hours. Which response by the nurse would be most appropriate? You must have an infection, so let me get a urine specimen. Your body is undergoing many changes that cause your bladder to fill quickly. Your uterus is not contracting as quickly as it should. The anesthesia that you received is wearing off and your bladder is working again.

Your body is undergoing many changes that cause your bladder to fill quickly.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a moderate amount of lochia alba a scant amount of lochia serosa a moderate amount of lochia rubra a scant amount of lochia alba

a moderate amount of lochia rubra

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: slightly decreased. slightly increased. acutely decreased. acutely increased.

acutely decreased.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine

applying ice

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? lactation blood loss diuresis nausea

diuresis

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. early ambulation breastfeeding uterine infection hydramnios prolonged labor

early ambulation breastfeeding

The nurse is providing care to a postpartum woman who has given birth vaginally to a healthy term neonate about 4 hours ago. While assessing the client, the client tells the nurse, "I've really been urinating a lot in the past hour." The nurse interprets this finding as suggestive of a decrease in which hormone? prolactin estrogen progesterone hCG

estrogen

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? blood type folic acid level hemoglobin and hematocrit iron level

hemoglobin and hematocrit

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? hemorrhoids thromboembolism hemorrhage cervical laceration

hemorrhage

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? hyperglycemia hypertension hypovolemia hypothyroidism

hypovolemia

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? cracking of the nipple improper positioning of infant inadequate secretion of prolactin inability of infant to empty breasts

inability of infant to empty breasts

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? uterus 5 cm below umbilicus lochia rubra edematous vagina diaphoresis

lochia rubra

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately? moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? postpartum baby blues postpartum anxiety postpartum reaction postpartum depression

postpartum baby blues

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum psychosis postpartum depression postpartum blues anxiety disorders

postpartum depression

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? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles

postpartum diuresis

In preparing for a birth education class for a group of pregnant women and their partners, the nurse will be describing the uterine involution changes that occur after the pregnancy. Which information will be included in the class? Select all that apply. regeneration of the uterine epithelium catabolism of the individual myometrial cells the importance of Kegel exercises to prevent involution contraction of muscular fibers return to its prepregnancy size approximately 1 week after birth

regeneration of the uterine epithelium catabolism of the individual myometrial cells contraction of muscular fibers

A nurse is making a postpartum home visit to a woman who gave birth vaginally about 12 days ago. The woman's partner is present during the visit. When assessing the woman and the family, which finding related to the partner would lead the nurse to suspect that the partner may be experiencing postpartum depression? Select all that apply. reports of feeling highly stressed use of encouraging statements about the infant reports of frequent headaches statements that the woman is getting all the attention feelings of being unprepared for the role

reports of feeling highly stressed reports of frequent headaches statements that the woman is getting all the attention

Which factor might result in a decreased supply of breast milk in a postpartum client? maternal diet high in vitamin C supplemental feedings with formula an alcoholic drink frequent feedings

supplemental feedings with formula

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment? letting-go taking-hold taking-in acquaintance/attachment

taking-in

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? taking-in phase taking-hold phase letting-go phase rooming-in phase

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? taking-in phase taking-hold phase letting-go phase attachment phase

taking-in phase

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the letting-go phase the binding-in phase the taking-hold phase the taking-in phase

the taking-hold phase

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? uterine atony hemorrhoid diuresis iron deficiency

uterine atony