Chapter 12 Postpartum Care

In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: a.Important in the production of red blood cells. b.Necessary in the production of platelets. c.Not initially synthesized because of a sterile bowel at birth. d.Responsible for the breakdown of bilirubin and prevention of jaundice.

ANS: C The bowel is initially sterile in the newborn, and vitamin K cannot be synthesized until food is introduced into the bowel. Vitamin K is necessary to activate blood clotting factors. The platelet count in term newborns is near adult levels. Vitamin K is necessary to activate prothrombin and other clotting factors.

In assisting the breastfeeding mother position the baby, nurses should keep in mind that: a.The cradle position usually is preferred by mothers who had a cesarean birth. b.Women with perineal pain and swelling prefer the modified cradle position. c.Whatever the position used, the infant is "belly to belly" with the mother. d.While supporting the head, the mother should push gently on the occiput.

ANS: C The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

The statement that indicates the parent understands the guidelines for bathing a newborn is: a."I'll use a mild soap to clean all of the body parts." b."I am going to add bath oil to the water to keep the baby's skin soft." c."I should shampoo the head after washing the rest of the body." d."I'll wash from the feet upward and change the wash cloth for the face."

ANS: C The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.

A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

ANS: C A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.

The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse? a. "There is usually something wrong with the fetus when this happens early in pregnancy." b. "Now there. You can try to conceive on your next cycle." c. "I'm here if you need to talk." d. "You are young and strong. I know you can have a healthy pregnancy."

ANS: C An effective technique when communicating with a woman experiencing pregnancy loss is to say, "I'm here if you need to talk." The nurse listens and acknowledges the woman's grief.

With regard to the nutrient needs of breastfed and formula-fed infants, nurses should be understand that: a.Breastfed infants need extra water in hot climates. b.During the first 3 months breastfed infants consume more energy than do formula-fed infants. c.Breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d.Vitamin K injections at birth are not needed for infants fed on specially enriched formula.

ANS: C Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed infants need to be given water, even in very hot climates. During the first 3 months formula-fed infants consume more energy than do breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the baby's stomach at birth.

A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse's most appropriate action? a. Contact the hospital chaplain. b. Request the couple's clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn.

ANS: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infant's forehead while saying, "I baptize you in the name of the Father, and of the Son, and of the Holy Spirit." If there is any doubt as to whether the infant is alive, the baptism is given conditionally: "If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit." The physician is attending to the patient's immediate health needs.

With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: a.Will need an extra 1000 calories a day to maintain energy and produce milk. b.Can go back to prepregnancy consumption patterns of any drinks, as long as she ingests enough calcium. c.Should avoid trying to lose large amounts of weight. d.Must avoid exercising because it is too fatiguing.

ANS: C Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother can go back to her consumption patterns of any drinks as long as she ingests enough calcium, only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother needs her rest, but moderate exercise is healthy.

In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.

ANS: C The fundus is checked gently by walking the fingers from the side of the uterus to the midline.

The nurse is caring for a 15-year-old client who gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby when assessing him. 4. A discussion on contraceptive methods is the first topic of teaching

Answer: 3 Explanation: 3. A newborn physical examination performed at the bedside gives the parent(s) immediate feedback about the newborn's health and demonstrates methods of handling an infant. This action helps the client learn about her baby as an individual and facilitates maternal-infant attachment. This is the highest priority.

The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? 1. "This condition is called parametritis." 2. "Gonorrhea is the most common organism that causes this type of infection." 3. "My Beta-strep culture's being positive might have contributed to this problem." 4. "If I had walked more yesterday, this probably wouldn't have happened."

Answer: 3 Explanation: 3. Clinical findings of metritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS).

The postpartum client is about to go home. The nurse includes which subject in the teaching plan? 1. Replacement of fluids 2. Striae 3. Diastasis of the recti muscles 4. REEDA scale

Answer: 3 Explanation: 3. Diastasis recti abdominis can be improved with exercise and abdominal muscle tone can improve significantly best taught when the mother is receptive to instruction during the postpartum assessment.

A family is visiting two surviving triplets. The third triplet died 2 days ago. What action indicates that the family has begun to grieve for the dead infant? a.Refers to the two live infants as twins b.Asks about the dead triplet's current status c.Brings in play clothes for all three infants d.Refers to the dead infant in the past tense

ANS: D Accepting that the infant is dead (in the past tense of the word) demonstrates an acceptance of the reality and that the family has begun to grieve. Parents of multiples are challenged with the task of parenting and grieving at the same time. Referring to the two live infants as twins does not acknowledge an acceptance of the existence of their third child. Bringing in play clothes for all three infants indicates that the parents are still in denial regarding the death of the third triplet. The death of the third infant has imposed a confusing and ambivalent induction into parenthood for this couple. If the two live infants are referred to as twins and/or if play clothes for all three infants are still considered, then the family is clearly still in denial regarding the death of one of the triplets.

The nurse is providing instruction to the newly delivered client regarding postbirth uterine and vaginal discharge, called lochia. Which statement is the most appropriate? a.Lochia is similar to a light menstrual period for the first 6 to 12 hours. b.It is usually greater after cesarean births. c.Lochia will usually decrease with ambulation and breastfeeding. d.It should smell like normal menstrual flow unless an infection is present.

ANS: D An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births and usually increases with ambulation and breastfeeding.

The nurse caring for a family during a loss might notice that survival guilt sometimes is felt at the death of an infant by the child's: a. Siblings. b. Mother. c. Father. d. Grandparents.

ANS: D Feedback A Survival guilt is most often felt by grandparents, not siblings, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. B Survival guilt sometimes is most often felt by grandparents, not the mother, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. C Survival guilt sometimes is most often felt by grandparents, rather than the father, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not. D Survival guilt sometimes is felt by grandparents, because they believe that the death upsets the natural order of things. They are angry that they are alive and their grandchild is not.

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance: a. PPH is easy to recognize early; after all, the woman is bleeding. b. Traditionally it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH. c. If anything, nurses and doctors tend to overestimate the amount of blood loss. d. Traditionally PPH has been classified as early or late with respect to birth.

ANS: D Feedback A Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. B Traditionally a 500-ml blood loss after a vaginal birth and a 1000-ml blood loss after a cesarean birth constitute PPH. C Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations. D Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH.

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when evaluating this client? a.Lochia rubra b.Lochia sangra c.Lochia alba d.Lochia serosa

ANS: D Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. Lochia sangra is not a real term. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.

Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch? a.She feels a firm tugging sensation on her nipples but not pinching or pain. b.The baby sucks with cheeks rounded, not dimpled. c.The baby's jaw glides smoothly with sucking. d.She hears a clicking or smacking sound.

ANS: D The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw is a good sign.

A perinatal nurse receives reports from the nurse aide on four patients who all gave birth within the last 4 hours. Which patient should the nurse assess first? A. Blood loss of 850 mL during cesarean birth B. Exhausted mother wanting only to rest after childbirth C. Pulse consistently ranges from 82 to 90 beats/minute D. Systolic blood pressure change from 132 to 110 mm Hg

ANS: D A drop in blood pressure by 15%, maternal heart rate over 110 beats/minute, or an oxygen saturation less than 95% may indicate a postpartum hemorrhage. The nurse should assess the woman whose blood pressure has changed more than 15%. Blood loss of 850 mL during cesarean birth is not considered excessive. A pulse under 100 beats/minute is normal. A mother may well be exhausted and need to rest, particularly if her birthing experience was difficult or traumatic.

A postpartum woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: a.Sleeps for 6 hours at a time between feedings. b.Has at least one breast milk stool every 24 hours. c.Gains 1 to 2 ounces per week. d.Has at least six to eight wet diapers per day.

ANS: D After day 4, when the mother's milk comes in, the infant should have six to eight wet diapers every 24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster fed. The infant should have a minimum of three bowel movements in a 24-hour period

The perinatal nurse teaches the postpartum woman about warning signs regarding the development of postpartum infection. The nurse teaches that fever and which of the following symptoms need to be assessed by a health-care provider? A. Breast engorgement B. Diarrhea C. Emotional lability D. Uterine tenderness

ANS: D During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

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

ANS: D 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 days after 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.

A nurse is caring for a patient who has excessive blood loss post-delivery from uterine atony. The perinatal nurse notifies the health-care provider while another nurse performs uterine massage. Which medication does the nurse anticipate to be given as the priority? A. Carboprost B. Ergonovine C. Methylergonovine D. Oxytocin

ANS: D If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large-bore needle and administers oxytocic drugs, starting with oxytocin. The other options are all useful in controlling postpartum hemorrhage, but oxytocin should be administered first.

A woman is being treated for endometritis after a cesarean birth. To prevent a possible complication, what action by the nurse is best? A. Encourage the woman to empty her bladder every 4 hours. B. Instruct the woman to monitor her temperature at home. C. Prepare the woman to have cultures of her lochia taken. D. Teach her to splint her abdominal incision when coughing.

ANS: D One possible complication of endometritis is dehiscence of incisions, such as from a cesarean birth or an episiotomy. Teaching the woman to firmly splint the incision when she coughs will add support and decrease the likelihood of this occurring. Taking one's temperature and collecting cultures do not prevent a complication; these are used for monitoring and diagnosing. Emptying the bladder is unrelated.

A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states: "I'm glad I have so little lochia; I'm too tired to change my pad." What action by the nurse is most appropriate? A. Assess the amount of lochia on the peri-pad. B. Cluster the nursing care given to allow uninterrupted sleep. C. Have the woman get up and attempt to void. D. Take a full set of vital signs and call the provider.

ANS: D Signs of puerperal infection include tachycardia, malaise, uterine tenderness, and subinvolution. Lochia can be heavy and foul smelling or scant and odorless, depending on the offending organism. The nurse should take a full set of vital signs, perform a complete assessment, and notify the health-care provider.

What statement made by a new mother indicates she needs additional information about breastfeeding? a. "I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast." b. "The baby needs to nurse at least 5 minutes on the breast to get the hindmilk." c. "The baby has been nursing every 2 to 3 hours." d. "If the baby gets fussy between feedings, I give her a bottle of water."

ANS: D Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.

A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. "Consider formula feeding for the first few days." b. "Pumping breast milk would be best for now." c. "Take pain medication 30 to 40 minutes prior to nursing." d. "Use the football hold when breastfeeding.

ANS: D The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding.

Which documentation in the client's chart on the 14th postpartum day indicates a normal involution process? a.Breasts firm and tender b.Episiotomy slightly red and puffy c.Moderate bright red lochial flow d.Fundus below the symphysis and not palpable

ANS: D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa.

A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: a.With his arms folded together over his chest. b.Curled up in a fetal position. c.With his head cupped in her hand. d.With his head and body in alignment.

ANS: D The infant's head and body should be in correct alignment with the mother and the breast during latch-on and feeding. Holding the infant with his arms folded together over his chest, curled up in a fetal position, or with his head cupped in her hand are not ideal positions to facilitate latch-on.

What infant response to cool environmental conditions is either not effective or not available to them? a.Constriction of peripheral blood vessels b.Metabolism of brown fat c.Increased respiratory rates d.Unflexing from the normal position

ANS: D The newborn's flexed position guards against heat loss because it reduces the amount of body surface exposed to the environment. The newborn's body is able to constrict the peripheral blood vessels to reduce heat loss. Burning brown fat generates heat. The respiratory rate may rise to stimulate muscular activity, which generates heat.

The nurse is supervising a student nurse who is working with a 14-year-old client who delivered her first child yesterday. Which statement indicates that the nursing student understands the particular needs of an adolescent client? 1. "This client will need less teaching, because she will have gotten the right information in school." 2. "Because of her age, this client will require less frequent fundal checks to assess for postpartal hemorrhage." 3. "Because of her age, this client will probably need extra teaching about the terminology for her anatomy." 4. "This client will need to have her grandmother provide day care and help raise the baby."

Answer: 3 Explanation: 3. Some adolescents may not have a working knowledge of their own anatomy and physiology or the related terminology, and they may require special assistance with postpartum hygiene and care.

The nurse is teaching a class on perinatal loss to student nurses. What would the nurse explain about the relationship between attachment and the grief response? 1. The mother has no attachment to the fetus before it is born. 2. The severity of the grieving has nothing to do with attachment to the fetus. 3. The intensity of the grief response can be assessed by determining the level of attachment to the anticipated infant. 4. The mother would feel grief only if it were a planned pregnancy.

Answer: 3 Explanation: 3. The intensity to which the grief will be experienced is best understood from the aspect of the level of attachment the grieving person had to the deceased and usually entails finding personal meaning in the loss for successful integration into the grieving person's life.

The nurse is providing education to the new family. Which question by the nurse is best? 1. "Do you know how to give the baby a bath?" 2. "You have diapers and supplies at home, right?" 3. "How have your breastfeedings been going?" 4. "How much formal education do you have?"

Answer: 3 Explanation: 3. This is an open-ended question about an important physiologic issue. A discussion that includes both partners can facilitate an open dialog between them and can provide an opportunity for questions and answers.

During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up? 1. Firm fundus 2. Fundus at the umbilical level 3. Moderate lochia rubra 4. Steady trickle of blood

Answer: 4 Explanation: 4. The continuous seepage of blood is more consistent with cervical or vaginal lacerations. Lacerations should be suspected if the uterus is firm and of expected size and if no clots can be expressed. This finding would indicate a follow-up.

The nurse is working with an adolescent parent. The adolescent tells the nurse, "I'm really scared that I won't take care of my baby correctly. My mother says I'll probably hurt the baby because I'm too young to be a mother." What is the best response by the nurse? 1. "You are very young, and parenting will be a challenge for you." 2. "Your mother was probably right. Be very careful with your baby." 3. "Mothers have instincts that kick in when they get their babies home." 4. "We can give the baby's bath together. I'll help you learn how to do it."

Answer: 4 Explanation: 4. This response is best because bathing the newborn offers an excellent opportunity for teaching and welcoming parent involvement in the care of their baby.

The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain

ANS: b Feedback a. Placing the hand over the base of the uterus does not cause uterine edema. b. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. c. Measurement is the same with or without the hand supporting the lower uterine segment. d. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient.

A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

ANS: b Feedback a. The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. b. It is important to first assess for uterine atony or displaced uterus from full bladder. c. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. d. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage

The nurse is developing a discharge teaching plan for a 21-year-old first-time mom. This was an unplanned pregnancy. She had a prolonged labor and an early postpartum hemorrhage. The woman plans to breastfeed her baby. She plans to return to work when her baby is 3 months old. Based on this information, the three primary learning needs of this woman are: a. Breastfeeding, bathing of the newborn, and infant safety b. Breastfeeding, storage of milk, and nutrition c. Breastfeeding, contraception, infant safety d. Breastfeeding, storage of milk, and rest

ANS: b Feedback a. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. b. Because this is the woman's first time breastfeeding and she plans to return to work, it is important that she feels comfortable with her understanding of breastfeeding and knows how to store her milk when she returns to work. Because she had a postpartum hemorrhage, she needs to learn what foods are high in iron. c. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage and returning to work in 3 months. d. These are important learning needs but do not reflect an understanding of learning needs based on early postpartum hemorrhage.

A multipara, 26 weeks' gestation and accompanied by her husband, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? a. Encourage the parents to pray for the baby's soul. b. Advise the parents that it is better for the baby to have died than to have had to live with a defect. c. Encourage the parents to hold the baby. d. Advise the parents to refrain from discussing the baby's death with their other children.

ANS: c Feedback a. It is inappropriate for the nurse to advise prayer. The parents must decide for themselves how they wish to express their spirituality. b. This is an inappropriate suggestion. c. This is an appropriate suggestion. Encouraging parents to spend time with their baby and hold their baby is an action that supports the parents during the grieving process. d. This is an inappropriate suggestion. It is very important for the parents to clearly communicate the baby's death with their other children.

After giving birth to a stillborn infant, the woman turns to the nurse and says, "I just finished painting the baby's room. Do you think that caused my baby to die?" The nurse's best response to this woman is: a."That's an old wives' tale; lots of women are around paint during pregnancy, and this doesn't happen to them." b."That's not likely. Paint is associated with elevated pediatric lead levels." c.Silence. d."I can understand your need to find an answer to what caused this. What else are you thinking about?"

ANS: D The statement, "I can understand your need to find an answer to what caused this. What else are you thinking about?" is very appropriate for the nurse. It demonstrates caring and compassion and allows the mother to vent her thoughts and feelings, which is therapeutic in the process of grieving. The nurse should resist the temptation to give advice or to use clichés in offering support to the bereaved. In addition, trying to give bereaved parents answers when no clear answers exist or trying to squelch their guilt feeling does not help the process of grief. Silence probably would increase the mother's feelings of guilt. One of the most important goals of the nurse is to validate the experience and feelings of the parents by encouraging them to tell their stories and listening with care. The nurse should encourage the mother to express her ideas.

Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis

ANS: a Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.

The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills

ANS: a Feedback a. An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. b. The contraceptive patch is not recommended for women over 35 or for women who smoke. c. A bilateral tubal ligation is a sterilization procedure. d. Birth control pills are not recommended for women over 35 or for women who smoke.

Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

ANS: c Feedback a. Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. b. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. c. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. d. Warfarin is an anticoagulant and will increase the risk of hemorrhage.

Four babies have just been admitted into the neonatal nursery. Which of the babies should the nurse assess first? a. The baby with respirations 52, oxygen saturation 98% b. The baby with Apgar 9/9, weight 2960 grams c. The baby with temperature 96.3°F, length 17 inches d. The baby with glucose 60 mg/dL, heart rate 132

ANS: c Feedback a. The baby's findings are within normal limits. Another baby should be seen first. b. The baby's findings are within normal limits. Another baby should be seen first. c. This baby should be assessed first. The baby's temperature is low; therefore, the baby could develop cold stress syndrome. In addition, the baby is short and, therefore, could be preterm. d. The baby's findings are within normal limits. Another baby should be seen first.

A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the client's central venous pressure. c. The nurse assesses the client's perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam.

ANS: c Feedback a. The fundal height should be measured in relation to the umbilicus. b. The central venous pressure is not monitored during postpartum assessments. c. The nurse should assess the perineum for signs of edema and ecchymoses. d. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.

The nurse is administering erythromycin (Ilotycin) ointment to a newborn. What factors are associated with administration of this medication? Select all that apply. 1. The medication should be instilled in the lower conjunctival sac of each eye. 2. The eyelids should be massaged gently to distribute the ointment. 3. The medication must be given immediately after delivery. 4. The medication does not cause any discomfort to the infant. 5. The medication can interfere with the baby's ability to focus.

Answer: 1, 2, 5 Explanation: 1. Successful eye prophylaxis requires that the medication be instilled in the lower conjunctival sac of each eye. 2. After administration, the nurse massages the eyelid gently to distribute the ointment. 5. Eye prophylaxis medication can cause chemical conjunctivitis, which gives the newborn some discomfort and can interfere with the baby's ability to focus on the parents' faces.

A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.

ANS: a Feedback a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony. b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline. c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage. d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

A healthy, full-term baby is scheduled for a circumcision. Nursing actions prior to the procedure include which of the following? (Select all that apply.) a. Obtain written consent from the mother. b. Administer acetaminophen PO 1 hour before procedure per MD order. c. Feed the neonate glucose water 30 minutes before the procedure. d. Obtain the neonate's protime.

ANS: a, b, c Feedback a. Circumcision is a surgical procedure and requires written consent signed by the parent. b. Administration of acetaminophen is a method of pain management for the newborn. c. Glucose water is a method of pain management for the newborn. d. It is not a standard protocol to obtain a protime prior to circumcision.

A G2 P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

ANS: a, b, c Feedback a. Maintaining adequate hydration can decrease a person's risk for infection. b. Lochia is a media for bacterial growth, so it is important to frequently change the peri-pads. c. Ambulation can decrease the risk of infection by promoting uterine drainage. d. Ice pack therapy is directed at decreasing edema of the perineum and promoting comfort. It has no effect on metriosis.

A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis

ANS: b Feedback a. Expected location for 6 to 12 hours postpartum. b. The firm fundus should be 2 cm below the umbilicus. c. This is an abnormal finding and may be related to subinvolution of the uterus. d. Expected location for 6 days postpartum.

During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is: a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void

ANS: b Feedback a. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. b. The first nursing action for a boggy uterus is to massage the fundus. c. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. d. You would assist the woman to the bathroom if the uterus is boggy and displaced to the side.

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? 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."

ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.

A postpartum patient is hemorrhaging despite receiving several medications and fundal massage. What action by the nurse takes priority? A. Begin weighing all used perineal pads. B. Obtain informed consent for surgery. C. Place the woman on her left side. D. Switch the IV solution to dextrose.

ANS: B If more conservative methods do not control postpartum hemorrhage, invasive surgical procedures are indicated. Procedures include the placement of uterine packing, balloon tamponade, ligation of the uterine arteries, hypogastric artery ligation, uterine suturing, embolization procedures, and hysterectomy. The nurse needs to facilitate obtaining informed consent for an emergency invasive procedure. The nurse should already be weighing pads and linens. Placing the woman on her left side will not impact the bleeding. IV solutions should be normal saline, particularly if the woman will be receiving blood transfusions.

To prevent nipple trauma, the nurse should instruct the new mother to: a.Limit the feeding time to less than 5 minutes. b.Position the infant so the nipple is far back in the mouth. c.Assess the nipples before each feeding. d.Wash the nipples daily with mild soap and water.

ANS: B If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. This will also limit access to the higher-fat "hindmilk." Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a.Notify the physician immediately. b.Place a cap on the infant's head and have the mother perform kangaroo care. c.Tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d.Change the formula because this is a sign of formula intolerance.

ANS: B Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant skin to skin should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

A nurse is teaching a postpartum patient about preventing infection after discharge. What action by the patient indicates that she needs additional teaching? A. Allows milk to dry on her nipples after nursing B. Removes her peri-pad from back to front C. Sprays water from the peri-bottle from front to back D. Washes her hands prior to using the bathroom

ANS: B Removing the peri-pad from back to front increases the likelihood of contaminating the vaginal area with organisms from the rectal area. The other actions are appropriate.

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.

ANS: B 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, but is still appropriate.

The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: a.Known as demand feeding. b.Necessary during the first 24 to 48 hours after birth. c.Used to set up the supply-meets-demand system. d.A way to control cluster feeding.

ANS: B The parents do this to make sure that the infant has at least eight feedings in 24 hours. Demand feeding is when the infant determines the frequency of feedings; this is appropriate once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk production system that occurs naturally. Cluster feeding is not a problem if the baby has eight feedings in 24 hours.

Which of the following activities allows the nurse to provide individualized parent teaching on the maternal-infant unit? Select all that apply. 1. Teach by example and role modeling when caring for the newborn in the client's room. 2. Teach at every opportunity, even during the night shift, if the occasion arises. 3. Teach using newborn care videos and group classes. 4. Teach using the 24-hour educational television channels in the client's room. 5. Teach using one-to-one instruction while in the client's room.

Answer: 1, 2, 5 Explanation: 1. The nurse can be an excellent role model for families. Teaching by example is a very effective way to teach infant care. 2. One-to-one teaching while the nurse is in the client's room is shown to be the most effective educational model. 5. One-to-one teaching while the nurse is in the client's room is the most effective educational model.

A nurse is instructing nursing students about the procedure for vitamin K administration. What information should be included? Select all that apply. 1. Gently massage the site after injection. 2. Use a 22-gauge, 1-inch needle. 3. Inject in the vastus lateralis muscle. 4. Cleanse the site with alcohol prior to injection. 5. Inject at a 45-degree angle.

Answer: 1, 3, 4 Explanation: 1. The nurse would remove the needle and massage the site with an alcohol swab. 3. Vitamin K is given intramuscularly in the vastus lateralis muscle. 4. Before injecting, the nurse must clean the newborn's skin site for the injection thoroughly with a small alcohol swab.

The client in the first trimester of pregnancy questions the nurse about the causes of fetal death. The nurse explains that factors associated with perinatal loss include which of the following? Select all that apply. 1. Maternal diabetes 2. Paternal hypertension 3. Fetal chromosomal disorders 4. Maternal infections 5. Placental abnormalities

Answer: 1, 3, 4, 5 Explanation: 1. Fetal loss can be a result of a number of physiologic maladaptations, including maternal diabetes. 3. Chromosomal abnormalities can be associated with fetal loss. 4. Infections such as human parvovirus B19, syphilis, streptococcal infection, and Listeria can lead to fetal loss. 5. Placental abnormalities such as abruptio placentae and placenta previa can result in fetal death.

The nurse is preparing to give an injection of vitamin K to a newborn. Which considerations would be appropriate? Select all that apply. 1. Administer a dose of 0.5 to 1 mg within 1 hour of birth. 2. Administer the injection subcutaneously. 3. Use a 25-gauge, 5/8-inch needle for the injection. 4. Protect the medication bottle from light. 5. Give vitamin K prior to a circumcision procedure.

Answer: 1, 3, 4, 5 Explanation: 1. 0.5 to 1 mg is the correct dosage for vitamin K. 3. 25-gauge, 5/8-inch needle is the right size needle to use. 4. Vitamin K must be kept away from light. 5. A prophylactic injection of vitamin K1 is given to prevent hemorrhage, which can occur because of low prothrombin levels in the first few days of life.

The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication? Select all that apply. 1. Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the client to void if the fundus is displaced upward or to one side.

Answer: 1, 4 Explanation: 1. Weighing the perineal pads will indicate whether the client is bleeding more than anticipated. 4. The nurse reviews hemoglobin and hematocrit levels when available, and compares them to the admission baseline.

The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Select all that apply. 1. A boggy fundus that does not respond to massage 2. Small clots and a moderate amount of lochia rubra on the pad 3. Decreased pulse and increased blood pressure 4. Hematoma formation or bulging/shiny skin in the perineal area 5. Rise in the level of the fundus of the uterus

Answer: 1, 4, 5 Explanation: 1. A boggy fundus indicates that the uterus is not contracted and will continue to bleed. 4. Shiny or bulging skin could indicate the presence of a hematoma. 5. The uterine cavity can distend with up to 1000 mL or more of blood causing the fundus to rise.

The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain? Select all that apply. 1. Offer a warm water bottle for her abdomen. 2. Call the physician to report this finding. 3. Inform her that this is not normal, and she will need an oxytocic agent. 4. Administer a mild analgesic to help with breastfeeding. 5. Administer a mild analgesic at bedtime to ensure rest.

Answer: 1, 4, 5 Explanation: 1. A warm water bottle placed against the low abdomen may reduce the discomfort of afterpains. 4. The breastfeeding mother may find it helpful to take a mild analgesic agent approximately 1 hour before feeding her infant. 5. An analgesic agent such as ibuprofen is also helpful at bedtime if the afterpains interfere with the mother's rest.

A mother and her newborn are being discharged 2 days after delivery. The general discharge instructions provided by the nurse include which of the following? Select all that apply. 1. Always place the infant in a supine position in the crib. 2. Support the infant's head when carrying for the first week or two. 3. Do not allow the baby to fall asleep in someone's arms. 4. Cover the cord stump with a bandage. 5. Use a bulb syringe to suction mucus from the infant's nostrils as necessary.

Answer: 1, 5 Explanation: 1. The newborn should be placed on his or her back (supine) for sleeping. 5. During the first few days of life, the newborn has increased mucus, and gentle suctioning with a bulb syringe may be indicated

The nurse is caring for a newborn who was recently circumcised. Which nursing intervention is appropriate following the procedure? 1. Keep the infant NPO for 4 hours following the procedure. 2. Observe for urine output. 3. Wrap dry gauze tightly around the penis. 4. Clean with cool water with each diaper change.

Answer: 2 Explanation: 2. It is important to observe for the first voiding after a circumcision to evaluate for urinary obstruction related to penile injury and/or edema

The nurse is anticipating the arrival of a couple in the labor unit. It has been determined that the 37-week fetus has died in utero from unknown causes. What should the nurse include in the plan of care for this couple? 1. Allow the couple to adjust to the labor unit in the waiting area. 2. Place the couple in a labor room at the end of the hall with an empty room next door. 3. Encourage the father to go home and rest for a few hours. 4. Contact the mother's emergency contact person and explain the situation.

Answer: 2 Explanation: 2. Upon arrival to the facility, the couple with a known or suspected fetal demise should immediately be placed in a private room. When possible, the woman should be in a room that is farthest away from other laboring women.

A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the Erythromycin ointment is to: a.Destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b.Prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c.Prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d.Prevent the infant's eyelids from sticking together and help the infant see.

ANS: B The purpose of the Erythromycin ointment is to prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

The nurse is planning an in-service presentation about perinatal loss. Which statements should the nurse include in this presentation? Select all that apply. 1. "Perinatal loss refers to third-trimester fetal death in utero." 2. "Perinatal loss occurs more frequently in assisted reproduction." 3. "Perinatal loss rates have declined in the United States over the past few years." 4. "Perinatal loss includes 25% of stillbirths occurring before the onset of labor." 5. "Perinatal loss rarely causes an emotional problem for the family."

Answer: 2, 3 Explanation: 2. Pregnancies conceived by in vitro fertilization have higher rates of pregnancy loss and pregnancy complications. 3. Perinatal loss in industrialized countries has declined in recent years as early diagnosis of congenital anomalies and advances in genetic testing techniques have increased the use of elective termination.

Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery? Select all that apply. 1. Elevated blood pressure 2. Fundus firm and midline 3. Moderate amount of lochia serosa 4. Edema and bruising of perineum 5. Inflamed hemorrhoids

Answer: 2, 4 Explanation: 2. A firm fundus that is midline indicates the normal progression of uterine involution. 4. During the early postpartum period, the soft tissue in and around the perineum may appear edematous with some bruising.

The breast-feeding mother should be taught to expect which changes to the condition of the breasts? (Select all that apply.) a.Breast tenderness is likely to persist for approximately 1 week after the start of lactation. b.As lactation is established, a mass may form that can be distinguished from cancer by its positional shift from day to day. c.In nonlactating mothers, colostrum is present for the first few days after childbirth. d.If suckling is never begun or is discontinued, then lactation ceases within a few days to a week. e.Little change occurs to the breasts in the first 48 hours.

ANS: B, C, D Breasts become fuller and heavier as colostrum transitions to milk; this fullness should last 72 to 96 hours. The movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether or not the mother breastfeeds. A mother who does not want to breastfeed should also avoid stimulating her nipples. Little change to the breasts occurs in the first 24 hours of childbirth.

The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborn's favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding.

ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.

With regard to umbilical cord care, nurses should be aware that: a.The stump can easily become infected. b.A nurse noting bleeding from the vessels of the cord should immediately call for assistance. c.The cord clamp is removed at cord separation. d.The average cord separation time is 5 to 7 days.

ANS: A The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts

ANS: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.

After delivery, the nurse's assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat.

ANS: B A poorly contracted uterus should be massaged until firm to prevent hemorrhage.

What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum.

ANS: B Cleansing from front to back prevents contamination from the rectal area.

The nurse thoroughly dries the infant immediately after birth primarily to: a.Stimulate crying and lung expansion. b.Remove maternal blood from the skin surface. c.Reduce heat loss from evaporation. d.Increase blood supply to the hands and feet.

ANS: C Infants are wet with amniotic fluid and blood at birth, and this accelerates evaporative heat loss. The primary purpose of drying the infant is to prevent heat loss. Rubbing the infant does stimulate crying; however, it is not the main reason for drying the infant. This process does not remove all the maternal blood.

Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

ANS: b Feedback a. Her nipples should be assessed, but this is not the priority assessment. b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully. c. Her lungs should be assessed bilaterally, but this is not the priority assessment. d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

The labor and delivery nurse is caring for a client whose labor is being induced due to fetal death in utero at 35 weeks' gestation. In planning intrapartum care for this client, which nursing diagnosis is most likely to be applied? 1. Powerlessness 2. Urinary Elimination, Impaired 3. Coping: Family, Readiness for Enhanced 4. Skin Integrity, Impaired

Answer: 1 Explanation: 1. Powerlessness is commonly experienced by families who face fetal loss. Powerlessness is related to lack of control in current situational crisis.

The nurse is caring for a client who has just been informed of the demise of her unborn fetus. Which common cognitive responses to loss would the nurse anticipate? Select all that apply. 1. Denial and disbelief 2. Sense of unreality 3. Poor concentration 4. Palpitations 5. Loss of appetite

Answer: 1, 2, 3 Explanation: 1. Denial and disbelief are common cognitive responses to fetal loss. 2. A sense of unreality is a common cognitive response to fetal loss. 3. Poor concentration is a common cognitive response to loss.

When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a.Obtain a syringe with a 25-gauge, 5/8-inch needle. b.Confirm that the newborn's mother has been infected with the hepatitis B virus. c.Assess the dorsogluteal muscle as the preferred site for injection. d.Confirm that the newborn is at least 24 hours old.

ANS: A The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B vaccination is recommended for all infants. If the infant is born to an infected mother who is a chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle. Hepatitis B vaccine can be given at birth

A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella.

ANS: A The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant.

Placing the baby at mother's breast facilitates early latch and promotes successful breastfeeding. When should breastfeeding be initiated? 1. 6 to 12 hours after birth 2. Within 1 hour of birth 3. 24 hours after birth 4. 48 hours after birth

Answer: 2 Explanation: 2. Breastfeeding should be initiated within the first hour of life unless medically contraindicated.

A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas: a.Increases the risk that the infant will develop allergies b.Helps the infant sleep through the night. c.Ensures that the infant is getting iron in a form that is easily absorbed. d.Requires that multivitamin supplements be given to the infant.

ANS: A Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma.

The nurse is caring for a newborn that is being breastfed. The nurse would expect the stool color to be: a.Yellow b.Brown c.Greenish brown d.Black and tarry

ANS: A The stools of a breastfed infant are bright yellow, soft, and pasty.

Which statement indicates the new mother is breastfeeding correctly? a. "I will alternate breasts when feeding the baby." b. "I keep the baby on a 4-hour feeding schedule." c. "I let the baby stay on the first breast only 5 minutes." d. "I put only the nipple in the baby's mouth when I am breastfeeding."`

ANS: A Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.

A nurse is assessing a woman who had a postpartum hemorrhage treated with fundal massage and oxytocin (Pitocin). Which assessment finding would require the nurse to intervene immediately? A. Mean arterial pressure of 58 mm Hg B. Pain of 4 on a pain scale of 1 (least amount) to 10 (most amount) 1 hour after the pain medication was administered C. Used perineal pad weight of +80 g in 2 hours D. Urinary bladder nondistended, no urge to void

ANS: A One of the first signs of hypovolemic shock is a decrease in mean arterial pressure (MAP). MAP should be at least 60 mm Hg. To determine MAP, add the systolic pressure to the doubled diastolic pressure, and divide that sum by 3. The pain level may or may not be improved after medication; the nurse needs further information to determine if the medication has been effective. A perineal pad can hold 50 to 80 mL; 1 g of weight equals 1 mL of fluid, so this pad holds 80 mL. An 80-mL blood loss in 2 hours is not alarming. A distended bladder can contribute to uterine atony (and bleeding), so a nondistended bladder and no patient urge to void does not warrant intervention.

In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs.`

ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a.Gravida 5, para 5 b.Woman who is bottle-feeding her first child c.Primipara who delivered a 7-lb boy d.Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse.

Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full" and is approximately 4 cm in diameter. The patient describes this area as "tender." What intervention does the nurse anticipate for this situation? A. Application of ice B. Exploratory surgery C. Incision and drainage D. Sitz bath every 12 hours

ANS: A This patient has a perineal hematoma. If the hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative treatments, such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 cm may require incision and drainage with the possible placement of a drain.

A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness and an inability to express milk on the left side when breastfeeding. What nonpharmacological comfort measure does the nurse teach this patient? A. Application of either warm or cold packs B. Expression of milk every 1-2 hours C. Ice and elevation of the breast when sitting D. Menthol-based lotion to draw the heat out

ANS: A This woman has the manifestations of mastitis and will be treated with antibiotics and analgesics. Comfort measures include applying either warm or cold packs to the breasts. If the woman wishes to continue breastfeeding, she should empty her breasts every 2-4 hours. Elevation and menthol-based lotions are not warranted.

As a member of the health-care team, the perinatal nurse finds it helpful following a maternal emergency, such as a postpartum hemorrhage, to engage in which of the following activities? (Select all that apply.) A. A family meeting to encourage communication and understanding B. Debriefing with the other staff members involved in the patient's care C. Health-promoting behaviors such as adequate sleep and exercise D. Review of the case to determine any fault in the care provided E. Time off to resolve any conflict with other staff members

ANS: A, B, C After the crisis has passed and immediate interventions have been completed, a debriefing of the healthcare team's response to the situation can be helpful as a learning opportunity. It is important to note the family's response to the unforeseen events and to include them, as appropriate, in the discussion. Because most families expect childbirth to be uneventful, a postpartum hemorrhage can provoke widely differing emotional responses. The prudent and compassionate clinician will take the time to let both the patient and the family express their feelings and affirm their concerns. Taking care of oneself is always helpful to decrease stress. The other actions are not helpful.

The nurse is teaching a non-breastfeeding client measures to suppress lactation. Which 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 can be applied to the breasts to relieve discomfort. e.Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production.

On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, "I don't think I did it right." What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down

ANS: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.

A newborn in the neonatal intensive care unit (NICU) is dying as a result of a massive infection. The parents speak to the neonatologist, who informs them of their son's prognosis. When the father sees his son, he says, "He looks just fine to me. I can't understand what all this is about." The most appropriate response by the nurse would be: a."Didn't the doctor tell you about your son's problems?" b."This must be a difficult time for you. Tell me how you're doing." c.To stand beside him quietly. d."You'll have to face up to the fact that he is going to die sooner or later."

ANS: B The grief phase can be very difficult, especially for fathers. Parents should be encouraged to share their feelings as the initial steps in the grieving process. This father is in a phase of acute distress and is "reaching out" to the nurse as a source of direction in his grieving process. Shifting the focus is not in the best interest of the parent. Nursing actions may help the parents actualize the loss of their infant through sharing and verbalization of feelings of grief. "You'll have to face up to the fact that he is going to die sooner or later" is a dispassionate and inappropriate statement.

What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis

ANS: B The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum

What are modes of heat loss in the newborn (Select all that apply)? a.Perspiration b.Convection c.Radiation d.Conduction e.Urination

ANS: B, C, D Convection, radiation, evaporation, and conduction are the four modes of heat loss in the newborn. Perspiration and urination are not modes of heat loss in newborns.

The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client 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

ANS: B, D, E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa).

As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a.To protect the baby from infection. b.That it is part of the Apgar protocol. c.To protect the nurse from contamination by the newborn. d.the nurse has primary responsibility for the baby during the first 2 hours.

ANS: C Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn.

A primipara tells the nurse, "My afterpains get worse when I am breastfeeding." What is the most appropriate nursing response? a. "I'll get you some aspirin to relieve the cramping that you feel." b. "Afterpains are more intense with your first baby." c. "Breastfeeding releases a hormone that causes your uterus to contract." d. "A change of position when you're breastfeeding might help."

ANS: C Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.

A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? a.Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b.Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c.Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. d.Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

ANS: C Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change are appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

What will the nurse's instructions for a new mother to care for the infant's umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off

ANS: C Diaper placement below the umbilical stump allows for drying by air circulation.

A patient is receiving methylergonovine (Methergine) after a vaginal birth. What assessment finding by the nurse warrants immediate intervention? A. Headache B. Nausea C. Palpitations D. Uterine cramping

ANS: C Methergine can cause headache, dysrhythmias, nausea and vomiting, and other side effects. Palpitations can indicate a cardiac rhythm disturbance and should be reported immediately.

After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection

ANS: C Newborns lose heat quickly after birth as fluid evaporates from their bodies.

A client is concerned that her breasts are engorged and uncomfortable. What is the nurse's explanation for this physiologic change? a.Overproduction of colostrum b.Accumulation of milk in the lactiferous ducts and glands c.Hyperplasia of mammary tissue d.Congestion of veins and lymphatic vessels

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatic vessels. An overproduction of colostrum, an accumulation of milk in the lactiferous ducts and glands, and hyperplasia of mammary tissue do not cause breast engorgement.

Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL

ANS: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.

As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? a.Prevent exposure to people with upper respiratory tract infections. b.Keep the infant away from secondhand smoke. c.Avoid loose bedding, water beds, and beanbag chairs. d.Place the infant on his or her abdomen to sleep.

ANS: D The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them. Per AAP guidelines, infants should always be placed "back to sleep" and allowed tummy time to play, to prevent plagiocephaly.

A woman gave birth to a 3200 g baby girl with an estimated gestational age of 40 weeks. The baby is 1 hour of age. In preparation of giving the baby an injection of vitamin K, the nurse will: a. Explain to the parents the action of the medication and answer their questions. b. Remove the neonate from the room so the parents will not be distressed by seeing the injection. c. Completely undress the neonate to identify the injection site. d. Replace needle with a 21 gauge 5/8 needle.

ANS: a Feedback a. It is important to always explain to parents what and why a procedure is being done on the newborn. b. It is best to give parents an option to be with their newborn when giving injections. c. It is best to keep the newborn covered as much as possible to reduce heat loss. d. A 25 gauge 5/8 needle is used for giving injections to full-term neonates.

Which of the following is an indication for the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

ANS: a Feedback a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or subinvolution. It is used when massage and oxytocin therapy have failed to contract the uterus. b. Hematoma occurs when blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptured and continues to bleed. Methylergonovine stimulates contraction of the smooth muscle of the uterus and would not have an effect on the vaginal or perineal areas. c. Heparin is usually prescribed for treatment of thrombosis. d. Methylergonovine is prescribed for treatment of uterine atony.

The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area. b. Consume an herbal galactagogue. c. Bottle feed the baby during the next day. d. Take expressed breast milk to the laboratory for analysis.

ANS: a Feedback a. The client may be developing mastitis. She should apply warm soaks to the area. b. There is no need for a galactagogue. c. It is essential that the client continue to breastfeed. If she were to stop feeding, she could develop a breast abscess. d. Unless ordered by the physician, the milk need not be cultured.

Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

ANS: a, b, c Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. The woman should not wash her breasts with soap because soap can dry the tissue and increase the woman's risk for tissue breakdown.

Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

ANS: a, b, c Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.

The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

ANS: b During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug

ANS: c Nonsensitized women who are Rh0(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.

On day four following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus

ANS: d Feedback a. Expected location for day 1 b. Expected location for day 2 c. Expected location for day 3 d. Correct. The uterus on the average descends 1 centimeter per day.

A variety of drugs are used either alone or in combination to provide relief of postpartum pain. Which of the following would be an option for pain relief? 1. Nonsteroidal anti-inflammatory agents 2. Proquad 3. Methergine 4. Intravenous oxytocin

Answer: 1 Explanation: 1. A variety of drugs are used alone or in combination to provide relief of postpartum pain. An option would include nonsteroidal anti-inflammatory agents such as ibuprofen and ketorolac.

Appropriate nursing interventions for the application of erythromycin ophthalmic ointment (Ilotycin) include which of the following? 1. Massaging eyelids gently following application 2. Irrigating eyes after instillation 3. Using a syringe to apply ointment 4. Instillation is in the upper conjunctival surface of each eye

Answer: 1 Explanation: 1. After administration, the nurse massages the eyelid gently to distribute the ointment.

The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? 1. "Cesarean birth after extended labor with ruptured membranes." 2. "Unassisted childbirth and afterbirth." 3. "External fetal monitoring used throughout labor." 4. "The client has history of pregnancy-induced hypertension."

Answer: 1 Explanation: 1. Cesarean birth is the single most significant risk of postpartum endometritis as well as prolonged premature rupture of the amniotic membranes (PPROM).

In planning care for a new family immediately after birth, which procedure would the nurse most likely withhold for 1 hour to allow time for the family to bond with the newborn? 1. Eye prophylaxis medication 2. Drying the newborn 3. Vital signs 4. Vitamin K injection

Answer: 1 Explanation: 1. Eye prophylaxis medication instillation may be delayed up to 1 hour after birth to allow eye contact during parent-newborn bonding.

The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus? 1. Methylergonovine maleate (Methergine) 2. Rh immune globulin (RhoGAM) 3. Terbutaline (Brethine) 4. Docusate (Colace)

Answer: 1 Explanation: 1. Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage.

A woman has just delivered a stillborn child at 26 weeks' gestation. Which nursing action is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the infant in a gown and swaddle it in a receiving blanket. 3. Ask the woman whether she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

Answer: 2 Explanation: 2. After bathing, the infant should be placed in a suitable-sized gown and then wrapped in a blanket.

On the 3rd day postpartum, a client who is not breastfeeding experiences engorgement. To relieve her discomfort, the nurse should encourage the client to do which of the following? 1. Remove her bra 2. Apply heat to the breasts 3. Apply cold packs to the breasts 4. Use a breast pump to release the milk

Answer: 3 Explanation: 3. Applying cold packs to the breasts relieves discomfort and helps suppress lactation.

The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? 1. The client who was overdue and delivered vaginally 2. The client who delivered by scheduled cesarean delivery 3. The client who had oxytocin augmentation of labor 4. The client who delivered vaginally at 36 weeks

Answer: 3 Explanation: 3. Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor.

A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? 1. The client can douche every other day. 2. Sexual intercourse can be resumed when the client feels up to it. 3. Light housework will provide needed exercise. 4. The baby's mouth should be examined for thrush.

Answer: 4 Explanation: 4. A breastfeeding mother on antibiotics should check her baby's mouth for signs of thrush, which should be reported to the physician.

The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important? 1. Describe the likely reaction of siblings to the new baby. 2. Discuss adaptation to grandparenthood by her parents. 3. Determine whether father-infant attachment is taking place. 4. Assist the mother in identifying the baby's behavior cues.

Answer: 4 Explanation: 4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.

A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: a."Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." b."Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." c."Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." d."Your baby will get cold stressed easily and needs to be bundled up at all times."

ANS: A "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him" is an accurate statement. Conduction is the loss of heat from the body surface to cooler surfaces, not air, in direct contact with the newborn. Evaporation is loss of heat that occurs when a liquid is converted into a vapor. In the newborn heat loss by evaporation occurs as a result of vaporization of moisture from the skin. Cold stress may occur from excessive heat loss, but this does not imply that the infant will become stressed if not bundled at all times. Furthermore, excessive bundling may result in a rise in the infant's temperature.

Nurses can prevent evaporative heat loss in the newborn by: a.Drying the baby after birth and wrapping the baby in a dry blanket. b.Keeping the baby out of drafts and away from air conditioners. c.Placing the baby away from the outside wall and the windows. d.Warming the stethoscope and the nurse's hands before touching the baby.

ANS: A Because the infant is wet with amniotic fluid and blood, heat loss by evaporation occurs quickly. Heat loss by convection occurs when drafts come from open doors and air currents created by people moving around. If the heat loss is caused by placing the baby near cold surfaces or equipment, it is referred to as a radiation heat loss. Conduction heat loss occurs when the baby comes in contact with cold objects or surfaces.

A woman complains of perineal pain. The nurse assesses swelling, but sees no other abnormalities. The woman does not wish pharmacological treatment. What suggestion by the nurse is most appropriate? A. Applying a covered ice pack to the perineum every 2 to 4 hours for 20 minutes B. Placing cool cabbage leaves on the woman's peri-pad C. Sitting on a donut-type pillow when out of bed D. Immersing in a sitz bath with a water temperature of 120°F (48.9°C)

ANS: A An ice pack, wrapped in cloth, can be applied to the perineum for 20 minutes every 2 to 4 hours for discomfort. Ice has vasoconstrictive and numbing effects. Cooled cabbage leaves can be placed against the woman's breasts to help with engorgement. Donut pillows are not recommended because they spread the buttocks and increase pain, especially if the woman has hemorrhoids. Sitz bath water should be no higher than 105°F (40.5°C).

The perinatal nurse recognizes that which common organism is responsible for postpartum infection manifesting with scant, odorless lochia? A. Beta-hemolytic streptococcus B. Chlamydia trachomatis C. Escherichia coli D. Treponema pallidum

ANS: A Endometrial infections caused by beta-hemolytic streptococcus are characterized by scant, odorless lochia.

What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus

ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.

The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet.

ANS: A To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.

A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache.

ANS: A When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.

Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct? a.Frequent feedings during predictable growth spurts stimulate increased milk production. b.The milk of preterm mothers is the same as the milk of mothers who gave birth at term. c.The milk at the beginning of the feeding is the same as the milk at the end of the feeding. d.Colostrum is an early, less concentrated, less rich version of mature milk.

ANS: A These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cow's milk e. Canned evaporated milk

ANS: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant's needs and powdered formula that is mixed as needed. Cow's milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.

A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion (Select all that apply)? a.Breast tenderness b.Warmth in the breast c.An area of redness on the breast often resembling the shape of a pie wedge d.A small white blister on the tip of the nipple e.Fever and flulike symptoms

ANS: A, B, C, E Breast tenderness, breast warmth, breast redness, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.

The nurse reminds the parents of a newborn that newborns must be protected from environments that are too cold or too hot because newborns have: Select all that apply. a.Very little subcutaneous fat b.Low metabolic rates c.Ineffective sweat glands d.Small fluid reserves e.Low red blood cells counts

ANS: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

Nursing care of the newly circumcised infant includes: Select all that apply. a.Wash penis with warm water. b.Wipe with alcohol swab. c.Gently remove the yellow crust formation. d.Apply diaper loosely. e.Dress with simple Band-Aid.

ANS: A, D Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a."I will gently pat the perineum dry rather than wipe." b."I will only use the perineal bottle after bowel movements." c."I will use cold water in the perineal bottle as I cleanse." d."I will use the perineal bottle without touching the perineum."

ANS: A, D The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements.

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: a. Washing the nipples and breasts with mild soap and water once a day. b. Using proper breastfeeding techniques. c. Wearing a nipple shield for the first few days of breastfeeding. d. Wearing a supportive bra 24 hours a day.

ANS: B Feedback A Washing the nipples and breasts daily is no longer indicated. In fact, this can cause tissue dryness and irritation, which can lead to tissue breakdown and infection. B Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples. C Wearing a nipple shield does not prevent mastitis. D Wearing a supportive bra 24 hours a day may contribute to mastitis, especially if an underwire bra is worn, because it may put pressure on the upper, outer area of the breast, contributing to blocked ducts and mastitis.

Which woman is at greatest risk for early postpartum hemorrhage (PPH)? a.A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress b.A woman with severe preeclampsia who is receiving magnesium sulfate and whose labor is being induced c.A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor d.A primigravida in spontaneous labor with preterm twins

ANS: B Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.

The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

Answer: 1 Explanation: 1. If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses.

A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Select all that apply. 1. Shooting pain between breastfeedings 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Pain radiating to the underarm area from the breast

Answer: 1, 2, 3 Explanation: 1. Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast becomes pink, flaking, and pruritic.

The postpartum nurse provides anticipatory guidance for the new mother as well as teaching on self-care and infant care before discharge. Which topics should be included? Select all that apply. 1. Role changes brought on by the addition to the family unit 2. The realities of having a new baby, and how it affects previous lifestyle 3. Potential complications such as infant colic and postpartum issues 4. Sexuality and contraception 5. Toilet-training and preschool options

Answer: 1, 2, 3, 4 Explanation: 1. It is helpful for the nurse to advise parents that they may experience feelings of uncertainty as they grow into the parental role and alter their family processes to accommodate the new family member. 2. Guidance is essential in assisting the family to cope with role changes and the realities of a new baby. 3. Guidance is essential in assisting the family to cope with potential complications such as infant colic and postpartum health issues. 4. It is important for the nurse to present information about changes that may affect sexual activity and to discuss the importance of contraception during the early postpartum period.

When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do? Select all that apply. 1. Ask the client to void before assessing the uterus. 2. Inform the client of the need for regular assessments. 3. Defer client teaching to another time. 4. Perform the procedures as gently as possible. 5. Take precautions to prevent exposure to body fluids.

Answer: 1, 2, 4, 5 Explanation: 1. Palpating the fundus when the woman has a full bladder may give false information about the progress of involution. Ask the woman to void before assessment. 2. The nurse should provide an explanation of the purposes of regular assessment to the woman. 4. The woman should be relaxed before starting, and procedures should be performed as gently as possible, to avoid unnecessary discomfort. 5. Gloves should be worn before starting the assessment.

Which findings would indicate the presence of a perineal wound infection? Select all that apply. 1. Redness 2. Tender at the margins 3. Vaginal bleeding 4. Hardened tissue 5. Purulent drainage

Answer: 1, 2, 4, 5 Explanation: 1. Redness is a classic sign of a perineal wound infection. 2. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 4. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 5. Purulent drainage is a classic signs of a perineal wound infection.

As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits: a.Decreased respiratory rate. b.Bradycardia followed by an increased heart rate. c.Mottled skin with acrocyanosis. d.Increased physical activity.

ANS: C The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurse's role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

The nurse is providing care to a patient 2 hours after a cesarean section. 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.

ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits.

A breastfeeding woman develops engorged breasts at 3 days' postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman: a.Skips feedings to let her sore breasts rest. b.Avoids using a breast pump. c.Breastfeeds her infant every 2 hours. d.Reduces her fluid intake for 24 hours.

ANS: C The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not feed adequately and empty the breast, the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that: a.The infant is protected from infection by immunoglobulins in the breast milk. b.The infant is not susceptible to the organisms that cause mastitis. c.The organisms that cause mastitis are not passed to the milk. d.The organisms will be inactivated by gastric acid.

ANS: C The organisms are localized in the breast tissue and are not excreted in the breast milk. The mother is just producing the immunoglobulin from this infection, so it is not available for the infant. Because of an immature immune system, infants are susceptible to many infections; however, this infection is in the breast tissue and is not excreted in the breast milk. The organism will not enter the infant's gastrointestinal system. This patient should be encouraged to empty her breasts fully every 2 hours, either by pumping or by breastfeeding.

The nursing faculty member explains to a class of nursing students the correct way to assist with perineal care (peri-care) after childbirth. Which action by a student nurse would warrant intervention by the faculty member? A. Has woman squirt warm water toward the front of the perineum B. Instructs the woman to wash her hands prior to peri-care C. Removes the peri-pad from back to front and appropriately disposes of it D. Washes the hands before assisting woman with her peri-care

ANS: C The peri-pad is removed from front to back to avoid contaminating the vagina with the part of the peri-pad that has come into contact with the rectal area. The other steps are appropriate.

At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a.Begin solid foods. b.Have a bottle of formula after every feeding. c.Add at least one extra breastfeeding session every 24 hours. d.Start iron supplements.

ANS: C Usually the solution to slow weight gain is to improve the feeding technique. Position and latch-on are evaluated, and adjustments are made. It may help to add a feeding or two in a 24-hour period. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle-feeding may cause nipple confusion and limit the supply of milk. Iron supplements have no bearing on weight gain.

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. What amount of blood loss does the postpartum nurse anticipate? (Select all that apply.) a.100 ml b.250 ml or less c.300 to 500 ml d.500 to 1000 ml e.1500 ml or greater

ANS: C, D The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 ml (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 ml (15% to 30% of blood volume). During the first few days after childbirth, the plasma volume further decreases as a result of diuresis. Pregnancy-induced hypervolemia (i.e., an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth.

A postpartum nurse has received an exchange report on the four following mother-baby couplets. Based on the provided information, which couplet should the nurse first assess? a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as "it" and that she requested to have her baby stay in the nursery so she could sleep. c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia. d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for postoperative pain management. Her vital signs are B/P 115/75, P 80, R 18 T 98.

ANS: c Feedback a. The priority need for this woman is breastfeeding assistance which does not require immediate attention. b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention. c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits. d. Based on data provided, this woman is stable, but should be assessed second.

Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor

ANS: c Feedback a. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. b. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. c. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains. d. Although this client is a gravida 4, she is a para 1. The nurse would not expect her to complain excessively of afterbirth pains.

The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

ANS: c Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

The clinical nurse recalls that the newborn has four mechanisms by which heat is lost following birth: evaporation, conduction, convection, and radiation. Which of the following are examples of heat lost via convection? (Select all that apply.) a. An infant loses heat when not dried adequately after birth b. An infant is placed on a cold scale c. An infant is placed under a ceiling fan d. An infant is placed near an open window

ANS: c, d Feedback a. Evaporation is the loss of heat that occurs when water is converted into a vapor, such as inadequately dried skin. b. Conduction is the loss of heat to a cooler surface by direct skin contact, such as occurs when the infant is placed on a cold surface. c. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan. d. Convective heat loss occurs when the neonate is exposed to drafts and cool circulating air, such as when being placed near an open window or fan.

A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery. Select the nursing actions for care of this patient. (Select all that apply.) a. Limit fluid intake to prevent nausea and vomiting. b. Assess fundus every 4 hours during the first 8 hours. c. Explain the importance of preventing an overdistended bladder. d. Provide assistance with ambulation.

ANS: c, d Fluid intake should be increased following a postpartum hemorrhage to decrease the risk of hypovolemia. The fundus should be assessed a minimum of every hour for the first 4 hours following a PPH. The woman needs to know the importance of preventing an overdistended bladder to decrease the risk of further hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic hypotension.

A mother refused to allow her son to receive the vitamin K injection at birth. Which of the following signs or symptoms might the nurse observe in the baby as a result? a. Skin color is dusky. b. Vital signs are labile. c. Glucose levels are subnormal. d. Circumcision site oozes blood.

ANS: d Feedback a. Dusky coloring is due to poor oxygenation. b. Labile vital signs can be caused by a number of things, including cold stress syndrome, sepsis, and poor oxygenation. c. Subnormal glucose levels can be caused by a number of things, including prenatal diabetes mellitus, cold stress syndrome, and sepsis. d. The circumcision may ooze blood due to the lack of vitamin K, which is required for the hepatic synthesis of blood coagulation factors II, VII, and X.

A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.

ANS: d Feedback a. The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed. b. RhoGam should be given no matter how old the fetus was. c. RhoGam must be administered before 72 hours postpartum. d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.

Heat loss through radiation can be reduced by: a. Closing door to room b. Warming equipment used on the neonate c. Drying the neonate d. Placing crib near a warm wall

ANS: d Feedback a. This is an example of preventing heat loss due to convection. b. This is an example of reducing heat loss due to conduction. c. This is an example of reducing heat loss due to evaporation. d. Placing the crib near a warm wall is an example of heat loss due to radiation.

The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

ANS: d If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate), and carboprost (Hemabate).