Ch 17: Postpartum Adaptations & Nursing Care

The new mother comments that the newborn "has his father's eyes." The nurse recognizes this as: A. Part of the bonding process termed claiming. B. The mother trying to find signs of the baby's paternity. C. The mother trying to include the father in the bonding process. D. Part of the letting-go phase of maternal adaptation.

A. Part of the bonding process termed claiming. Rationale: Claiming or binding-in begins when the mother begins to identify specific features of the newborn. She then begins to relate features to family members.

The postpartum woman has a blood pressure of 150/90 mm Hg, pulse of 72 bpm, and respirations of 14 breaths/min. She continues to bleed heavily. The order states she may have methylergonovine, 0.2 mg IM, or oxytocin, 10 units IM for heavy bleeding. The nurse should administer which medication? A. Methylergonovine B. Oxytocin

B. Oxytocin Rationale: Methylergonovine is contraindicated if the woman has an elevated blood pressure.

The new mother is complaining of pain at the episiotomy site; however, because she is breastfeeding, she does not want any medication. What other alternatives can the nurse offer this mother to help relieve the pain? A. Ambulation B. Topical anesthetics C. Hot fluids to drink D. Stool softeners

B. Topical anesthetics Rationale: Topical anesthetics can be applied directly to the site to numb the area. This will not cause systemic effects like pain medications.

The development of a strong emotional tie of a parent to a newborn is called _____________.

Bonding

A woman was admitted to the ED with her newborn baby. The baby was born 4 days ago at home. The woman had no prenatal care. The nurse is assessing the lab work and sees that the mother has an O-negative blood type, the baby is O-positive, and the Coombs test shows that the mother is not sensitized to the positive blood. The nurse's next action should be: A. Order Rho (D) immune globulin to be given to the mother. B. Order Rho (D) immune globulin to be given to the baby. C. Record the findings of the lab work and not plan on any further action at this time.

C. Record the findings of the lab work and not plan on any further action at this time. Rationale: The mother is a candidate for Rho (D) immune globulin; however, it should be given within 72 hours after childbirth to prevent the development of maternal antibodies. Because she gave birth 4 days ago, that time period as passed and she is not sensitized to the positive blood.

During the second postpartum day, a woman asks the nurse, "Why are my after pains so much worse this time than after the birth of my other child?" The best answer by the nurse would be: A. "Most women forget how strong the after pains can be." B. "They should not be strong with you because you are breastfeeding." C. You should not be feeling the pains now; I will notify the physician for you." D. "After pains are more severe for women who have already given birth."

D. "After pains are more severe for women who have already given birth." Rationale: After pains are more acute for multiparas because repeated stretching of muscle fibers leads to low muscle tone, which results in repeated contraction and relaxation of the uterus. Breastfeeding increases the severity of after pains. The pains are self-limiting and will decrease rapidly after 48 hours

Immediately after birth, the nurse can anticipate the fundus to be located: A. At the umbilicus B. 2 cm above the umbilicus C. 1 cm below the umbilicus D. Midway between the symphysis pubis and umbilicus

D. Midway between the symphysis pubis and umbilicus Rationale: Immediately after birth, the uterus is about the size of a large grapefruit and the fundus can be palpated midway between the symphysis pubis and umbilicus. Within 12 hours the fundus rises to the level of the umbilicus. By the second day, the fundus starts to descend by approximately 1 cm/day

On the first day postpartum a client's white blood cell count is 25,000/mm3. The nurse's next action should be to: A. Notify the physician for an antibiotic order B. Assess the client's temperature and blood pressure C. Request the count be repeated D. Note the results in the chart

D. Note the results in the chart Rationale: Marked leukocytosis occurs during the postpartum period. WBC count increases to as high as 30,000/mm3. The WBC count should fall to normal values by day 7. Neutrophils, which increase in response to inflammation, pain, and stress to protect against invading organisms, account for the major increase in WBCs. Because this is a normal reading, noting the results in the chart is the appropriate action.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A. Tell the woman she can rest after she feeds her baby. B. Recognize this as a behavior of the taking-hold stage. C. Record the behavior as ineffective maternal-newborn attachment. D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. Rationale: The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being to care for their baby effectively.

Ice causes vasoconstriction and is most effective if applied soon after the birth to the perineal area to prevent ______________.

Edema

When the father develops a bond with the new infant and has an intense interest in how the infant looks and responds, this is called ________________.

Engrossment

The placental site heals by a process of _______________.

Exfoliation

The maternal adaptation phase in which the mother relinquishes her previous role as being childless and her old lifestyle is called the _______________ phase.

Letting-go

Which patient is more likely to have less stress adjusting to her role as a mother? a. A 26-year-old woman who is returning to work in 10 weeks b. A 35-year-old anxious mother who has had no contact with babies or children c. A 16-year-old teenager who lives with her parents and has a strained relationship with her mother d. A 25-year-old woman who knew at 16 weeks of gestation that she was pregnant with twins, who were delivered by cesarean birth

a. A 26-year-old woman who is returning to work in 10 weeks

The nurse is teaching a non-breastfeeding patient measure to suppress lactation. Which information should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended. d. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

a. Avoid massaging the breasts. d. Ice packs or cabbage leaves can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

Which vaccinations are indicated for the postpartum patient if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM e. Varicella

a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) e. Varicella

When reading the postpartum chart the nurse notices that the client's fundus is recorded as "u+1." The nurse understands that this means the fundus is: A. 1 cm above the umbilicus. B. 1 cm below the umbilicus. C. 1 inch above the umbilicus. D. 1 inch below the umbilicus.

A. 1 cm above the umbilicus Rationale: Descent of the fundus is documented in relation to the umbilicus and is measured in cm. Numbers with a plus sign mean the fundus is above the umbilicus; numbers with a minus sign mean the fundus is below the umbilicus.

Nursing measures to promote bonding and attachment include which of the following? (Select all that apply). A. Assist the parents in unwrapping the baby to inspect. B. Point out that the infant grasping the mother's or father's finger is a natural reflex. C. Explain the physical changes in the newborn, such as molding, as being normal. D. Encourage the mother to let the infant stay in the nursery as much as possible so the mother can rest. E. Position the infant in a face to face position with the mother.

A. Assist the parents in unwrapping the baby to inspect. E. Position the infant in a face to face position with the mother.

To promote bonding during the first hour after birth, the nurse can do which of the following? (Select all that apply). A. Delay procedures if appropriate. B. Allow the father to hold the newborn. C. Demonstrate proper bottle feeding techniques. D. Allow as much contact with the newborn as possible. E. Use the time to do parent teaching on newborn characteristics.

A. Delay procedures if appropriate. B. Allow the father to hold the newborn. D. Allow as much contact with the newborn as possible.

Constipation is a common problem during the postpartum period. Select all the reasons for constipation during this period. (Select all that apply). A. Diminished bowel tone B. Over hydration during labor C. Episiotomy that causes the fear of pain with elimination D. Iron supplementation E. Some pain medications

A. Diminished bowel tone C. Episiotomy that causes the fear of pain with elimination D. Iron supplementation E. Some pain medications

The nurse is assessing the client's vaginal discharge. It is red and has about a 2-inch stain on the peri-pad. The nurse will record this finding as a: A. Light amount of lochia rubra B. Scant amount of lochia alba C. Moderate amount of lochia rubra D. Heavy amount of lochia alba

A. Light amount of lochia rubra Rationale: Lochia rubra is red in color and occurs the first 3-4 days after birth. A light amount of discharge is classified as a 1-4 inch stain on the peri-pad.

A newborn is rooming-in with his teenage mother, who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to: A. Pick the baby up and point out his alert behaviors to the mother. B. Tell the mother to pick up her baby and talk with him while he is awake. C. Focus care on the mother, rather than the infant so she can recuperate. D. Encourage the mother to feed the infant before he begins crying.

A. Pick the baby up and point out his alert behaviors to the mother. Rationale: Modeling behavior by the nurse is an excellent way to teach infant care. The inexperienced teenage mother can observe the proper skills and then the nurse can encourage her to try those skills.

During the early post-cesarean section phase, it is important for the woman to turn, cough, and deep-breathe. The rationale for this is to prevent: A. Pooling of secretions in the airway. B. Thrombus formation in the lower legs. C. Gas formation in the intestinal tract. D. Urinary retention.

A. Pooling of secretions in the airway. Rationale: The post-cesarean section woman is usually on bed rest for the first 8 to 12 hours. She is at risk for pooling of secretions in the airway. By assisting her to turn, cough, and expand her lungs by breathing deeply at least every 2 hours, the pooling of secretions will be decreased.

When assessing the perineum, episiotomy site, or surgical site, the nurse should assess for specific signs. Select all the signs that are appropriate when assessing a surgical site. (Select all that apply). A. Redness B. Edema C. Ecchymosis D. Discharge E. Asymmetry

A. Redness B. Edema C. Ecchymosis D. Discharge

The first time a woman ambulates after the birth of the newborn, she has a nursing diagnosis of Risk for injury because of the: A. Risk for developing orthostatic hypotension. B. Development of bradycardia. C. Increase in cardiac output. D. Increase in circulatory volume.

A. Risk for developing orthostatic hypotension. Rationale: After birth a rapid decrease in intra-abdominal pressure results in dilation of the blood vessels supplying the viscera. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in blood pressure when the woman moves from a recumbent to a sitting position. The mother feels dizzy or lightheaded and may faint when she stands. Bradycardia is a normal change during the postpartum period. The cardiac output increases during the postpartum period, but does not produce orthostatic hypotension.

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be: A. Soft, non-tender; colostrum is present. B. Leakage of milk at let-down. C. Swollen, warm, and tender on palpation. D. A few blisters and a bruise on each areola.

A. Soft, non-tender; colostrum is present. Rationale: Breasts are essentially unchanged for the first 2 or 3 days after birth. Colostrum is present and may leak from the nipples. On day 3 or 4 lactation begins and engorgement can occur, resulting in the findings of B and C. Response D indicates problems with the breastfeeding techniques used.

The new parents express concern that their 4-year-old son is jealous of the new baby. They are planning on going home tomorrow and are not sure how the preschooler will react when they bring the baby home. Which of the following suggestions by the nurse will be most helpful? A. Be aware that the child may regress to an earlier stage. B. Have the mother go into the house alone and spend time with the child before the father brings the baby in. C. Have the child stay with a grandparent until the parents adjust to the new baby. D. Tell the child that he is a "big boy" now and doesn't need his crib so the new baby will be using it for a while.

B. Have the mother go into the house alone and spend time with the child before the father brings the baby in. Rationale: The child needs to have the mother's love reaffirmed. By giving the child some private time with the mother, he will get the extra attention and reassurance he needs at this point.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing women's needs during this stage, should: A. Foster an active role in the baby's care. B. Provide time for the mother to reflect on the events of the childbirth. C. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

B. Provide time for the mother to reflect on the events of the childbirth. Rationale: The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of the newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions and using written materials to reinforce the content presented are a more effective approach.

The home care nurse is visiting a new mother who delivered 1 week ago. The mother complains about not being able to sleep and that she is tired and cries easily. The best response by the nurse would be: A. "Having a baby is difficult; it will be a long time before you get a good night's sleep." B. "Maybe your mother can come in and help you out." C. "It is normal for this to happen and should go away in 2 weeks. It must be very difficult for you to feel this way with a new baby." D. "The hospital nurses must not have taught you enough information about the changes you will experience during these first 6 weeks."

C. "It is normal for this to happen and should go away in 2 weeks. It must be very difficult for you to feel this way with a new baby." Rationale: Postpartum blues begins in the first week and usually last no longer than 2 weeks. The mother needs to be supported during this time and given accurate information about the process. Responses A and B belittle the mother and may make her feel inadequate. Response D places blame on someone else and does not deal with the problem.

When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth. B. Exhibit a reduced attention span, limiting readiness to learn. C. Attempt to meet the needs of the infant and is eager to learn about infant care. D. Have reestablished her role as a spouse and partner.

C. Attempt to meet the needs of the infant and is eager to learn about infant care. Rationale: One week after birth the woman should exhibit behaviors characteristic of the taking-hold phase. This stage lasts for as long as 4 to 5 weeks after birth. Responses A and B are characteristic of the taking-in stage, which lasts for the first few days after birth. Response D reflects the letting-go stage, which indicates that psychosocial recovery is complete.

While doing client teaching, the woman tells the nurse, "I don't have to worry about contraception because I am breastfeeding." The nurse should base her answer on the fact that: A. Breastfeeding can be considered a reliable system of birth control. B. Breastfeeding can be used as a contraceptive method if strict guidelines are followed through. C. Breastfeeding is not a reliable contraceptive method.

C. Breastfeeding is not a reliable contraceptive method. Rationale: Menses in a breastfeeding mother may resume between 12 weeks and 18 months. Normally the first few cycles of menses are without ovulation; however, ovulation may occur before the first menses. Therefore, other contraceptive measures are important considerations for this mother.

A mother that is 3 days postpartum calls the clinic and complains of "night sweats." She is afraid that she is going into early menopause. The nurse should base her answer on the fact that: A. Birth may put some women into early menopause; an appointment is needed to have this checked out. B. Night sweats may be an indication of many other problems; an appointment is needed to assess the problem. C. Diaphoresis is normal during the postpartum period, and comfort measures can be suggested to the mother. D. Diaphoresis is normal only if the mother is breastfeeding.

C. Diaphoresis is normal during the postpartum period, and comfort measures can be suggested to the mother. Rationale: Diaphoresis and diuresis rid the body of excess fluids that accumulated during the pregnancy. Diaphoresis is not clinically significant, but can be unsettling for the mother who is not prepared for it. Explanations of the cause and provision of comfort measures, such as showers and dry clothing, are generally sufficient.

One nursing measure that can help prevent postpartum hemorrhage and urinary tract infections is: A. Forcing fluids. B. Perineal care. C. Encouraging voiding every 2 to 3 hours. D. Encouraging the use of stool softeners.

C. Encouraging voiding every 2 to 3 hours. Rationale: Urinary retention and over distention of the bladder may cause UTI and postpartum hemorrhage. Encouraging the mother to empty her bladder frequently will help prevent retention and over distention. Forcing fluids and perineal care may assist with preventing UTIs. Stool softeners assist with return of normal bowel elimination.

The day after giving birth, the woman complains that she did not lose all the weight she had gained during the pregnancy. The nurse can best respond to the mother with the knowledge that: A. She has lost the most of the weight and the rest will be gone within 1 week. B. She has lost some of the weight and the rest will slowly disappear within 6 weeks. C. It will take about 6 to 12 months for all the weight gained with the pregnancy to disappear. D. Most women do not lose all the weight gained with each pregnancy.

C. It will take about 6 to 12 months for all the weight gained with the pregnancy to disappear. Rationale: Women are very concerned about regaining their normal figure. Nurses must emphasize that weight loss should be gradual and that about 6 to 12 months is usually required to lose most weight gained during pregnancy.

A new father of 1 day expresses concern to the nurse that his wife, who is normally very independent, is asking him to make all the decisions. The nurse can best explain this as a(n): A. Normal occurrence because the mother is in pain. B. Abnormal occurrence that needs to be assessed further. C. Normal occurrence because the mother is in the taking-in phase. D. Normal occurrence because the mother is frustrated with the care of the newborn.

C. Normal occurrence because the mother is in the taking-in phase. Rationale: During the taking-in phase, the mother is focused primarily on her own need for fluid, food, and sleep. She may be passive and dependent. This is normal and lasts about 2 days.

When assessing a woman who gave birth 2 hours ago, the nurse notices a constant trickle of lochia. The uterus is well contracted. The next nursing action should be to: A. Massage the fundus. B. Continue to monitor. C. Notify the physician. D. Assess the blood pressure and pulse for changes.

C. Notify the physician. Rationale: Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. The uterus is well contracted, so further massage is not necessary.

Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

a. Distended bladder Rationale: The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the patient should not alter uterine position. The problem is a full bladder displacing the uterus.

During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Formal b. Informal c. Personal d. Anticipatory

a. Formal

Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Patient who is bottle feeding her first child d. Patient who is breastfeeding her second child

a. Gravida 5, para 5 Rationale: The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems that will cause her discomfort. The patient who is nursing her second child will have more afterpains than her first pregnancy; however, they will not be as severe as the grand multiparous patient.

The nurse observes a patient on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which action is most appropriate for the nurse to take at this time? a. Hand the baby to the woman. b. Explain "taking-in" to the woman. c. Offer to hand the baby to the woman. d. No action, because this situation is perfectly acceptable.

a. Hand the baby to the woman.

Which anticipatory guidance action by the nurse makes role transition to parenthood easier? a. Helps the new parents identify resources. b. Recommends employing babysitters frequently. c. Tells the parents about the realities of parenthood. d. Offers a home phone number and tells parents to call if they have a question.

a. Helps the new parents identify resources.

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting-go b. Taking-in c. Taking-on d. Taking-hold

a. Letting-go

The postpartum patient who continually repeats the story of her labor, birth, and recovery experiences is performing which of the following tasks? a. Making the birth experience "real" b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. Taking hold of the events leading to her labor and birth

a. Making the birth experience "real"

Which situation would require the administration of Rho(D) immune globulin? a. Mother Rh-negative, baby Rh-positive b. Mother Rh-negative, baby Rh-negative c. Mother Rh-positive, baby Rh-positive d. Mother Rh-positive, baby Rh-negative

a. Mother Rh-negative, baby Rh-positive An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold. c. Patient reports she took two sitz baths in 12 hours. d. Edges of the perineal laceration are well approximated.

a. No swelling or edema to the perineal area

Which of the following are nursing measures that can promote parent-infant bonding and attachment? (Select all that apply.) a. Provide comfort and ample time for rest. b. Keep the baby wrapped to avoid cold stress. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way. e. Limit the amount of modeling so the mother doesn't feel insecure.

a. Provide comfort and ample time for rest. c. Position the infant face to face with the mother. d. Point out the characteristics of the infant in a positive way.

A new father calls the nurse's station stating that his wife, who delivered last week, is happy one minute and crying the next. He states, "She was never like this before the baby was born." How should the nurse best respond? a. Reassure him that this behavior is normal. b. Advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away. d. Instruct him in the signs, symptoms, and duration of postpartum blues.

a. Reassure him that this behavior is normal.

The nurse is planning comfort measures to implement for a patient after a vaginal birth. Which measures should the nurse plan to include in the patient's care plan? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Relax the perineal and buttock areas when sitting

a. Sitz baths four times a day c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours

The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture? a. Special foods brought from home. b. Preference for fresh fruits. c. Preference for "cold" foods. d. Request for ice water instead of hot water.

a. Special foods brought from home.

The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary? a. "I may not have a bowel movement until the 2nd postpartum day." b. "If I breastfeed and supplement with formula, I won't need any birth control." c. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." d. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

b. "If I breastfeed and supplement with formula, I won't need any birth control."

The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 10 to 15 cm (4- to 6-inch) stain on the peripad c. 2.5 to 10 cm (1- to 4-inch) stain on the peripad d. Less than a 1-inch stain on the peripad

b. 10 to 15 cm (4- to 6-inch) stain on the peripad

The nurse is conducting discharge teaching for a patient going home after a cesarean birth. Which signs and symptoms should the patient be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

b. Feeling of pelvic fullness d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

Which description best explains the term reciprocal attachment behavior? a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback that the infant exhibits toward parents during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents

b. Positive feedback that the infant exhibits toward parents during the attachment process

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

b. The fundus is palpable two fingerbreadths above the umbilicus. Rationale: The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

An example of bonding in during the postpartum period is a: a. new mother telling her friends all about her labor and birth experience. b. father looking at his newborn and stating that he "looks like I did when I was a baby." c. mother reporting increasing anxiety during the postpartum period because she feels like she is without support. d. mother wanting some time alone so that she can catch up on needed sleep.

b. father looking at his newborn and stating that he "looks like I did when I was a baby."

A postpartum patient asks, "Will these stretch marks ever go away?" Which is the nurse's best response? a. "No, never." b. "Yes, eventually." c. "They will fade to silvery lines but won't disappear completely." d. "They will continue to fade and should be gone by your 6-week checkup."

c. "They will fade to silvery lines but won't disappear completely." Rationale: Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.

The nurse is developing a plan of care for the patient's fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process? a. Encourage the patient to call the baby by his or her first name. b. Stimulate the grasp reflex by placing the patient's finger in the infant's palm. c. Ask the patient if she wants her baby placed on her chest immediately after birth. d. Assess for familial characteristics and remark on the resemblance to the patient or the father.

c. Ask the patient if she wants her baby placed on her chest immediately after birth.

The nurse is providing care to a patient 2 hours after a cesarean birth. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

c. Contact the health care provider.

Which measure is optimal in order to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing

c. Early and frequent ambulation Rationale: Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention. Abdominal strengthening will not prevent distention.

The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38°C (100.4°F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

c. Firm fundus, but excessive lochia

A family is concerned about how their 2-year-old son is going to react to the new baby. Which intervention would help facilitate sibling attachment? a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. Make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role. d. Observe the son's reaction to the baby and let him decide when he wants to be introduced to his new sibling.

c. Include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role.

Which of the following behaviors would be applicable to a nursing diagnosis of Risk for Impaired Parenting? a. En face behavior is observed between father and infant. b. Mother relates that she feels exhilarated postbirth. c. Mother states that she feels excessive fatigue as a result of the childbirth experience. d. Father displays finger tipping behavior toward infant.

c. Mother states that she feels excessive fatigue as a result of the childbirth experience.

The postpartum nurse is observing a patient holding the baby she delivered less than 24 hours ago. The partner is watching his wife and asking questions about newborn care. The 4-year-old big brother is punching his mother on the back. What should the nurse do next? a. Report the incident to the social services department. b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. Report to oncoming staff that the mother is probably not a good disciplinarian.

c. No action; this is a normal family adjusting to family change.

Which action should the nurse take in order to provide support and encouragement to the new postpartum patient? a. Recount how she solved her own problems. b. Correct the new mother at every opportunity. c. Praise the mother's early attempts at infant care. d. Explain to the new mother that everything will be fine.

c. Praise the mother's early attempts at infant care.

When assessing the A of the acronym REEDA, the nurse should evaluate the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge.

c. edges of the episiotomy.

A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nurse's most appropriate response at this time? a. "When did these symptoms begin?" b. "Sounds like normal postpartum depression." c. "Are you having trouble getting enough sleep?" d. "Are you able to get out of bed and provide care for your baby?"

d. "Are you able to get out of bed and provide care for your baby?"

Which should the nurse do to provide support to a patient who must return to full-time employment 6 weeks after a vaginal birth? a. Discuss child care arrangements with her. b. Allow her to solve the problem on her own. c. Reassure her that she'll get used to leaving her baby. d. Allow her to express her positive and negative feelings freely.

d. Allow her to express her positive and negative feelings freely.

To promote bonding and attachment immediately after birth, which action should the nurse take? a. Assist the mother in feeding her baby. b. Allow the mother quiet time with her infant. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newborn.

d. Assist the mother in assuming an en face position with her newborn.

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart.

d. Document the finding in the patient's chart.

If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

d. Explanation of the risks of becoming pregnant within 28 days following injection Rationale: Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.

To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries.

d. Gently palpate, applying the same technique used for vaginal deliveries. Rationale: Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

d. Lochial color changes from rubra to alba Rationale: For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

d. Postpartum hemorrhage and urinary tract infection Rationale: Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care? a. Have the patient drink carbonated beverages to promote urinary excretion. b. Tell the patient that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence

d. Teach the patient to perform pelvic floor exercises to combat potential stress incontinence

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

d. Uterine fundus 2 cm above the umbilicus

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to a. increased estrogen. b. increased progesterone. c. decreased human placental lactogen. d. decreased melanocyte-stimulating hormone.

d. decreased melanocyte-stimulating hormone. Rationale: Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.