Chapter 15: Postpartum Adaptations

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

a. diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? a. touching b. writing c. pictures d. recognizing the meaning of words

a. touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.

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

b. Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

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

a. supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? a. taking-in phase b. taking-hold phase c. letting-go phase d. attachment phase

a. taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

Which action would most make the nurse believe that a postpartum woman is accepting a child well? a. She states she has named the child after a well-loved friend. b. She turns her face to meet the infant's eyes when she holds her. c. She comments that her baby has the most hair of any in the nursery. d. She asks the nurse to use her camera to take a photo of the child.

b. She turns her face to meet the infant's eyes when she holds her. An "enface" position is a mark of a woman who is interacting warmly with a newborn.

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

a. "You might try using a water-soluble lubricant to ease the discomfort." Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A nurse is making a home visit to a new mother who gave birth vaginally 5 days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks the nurse about the average weight loss for 5 days postpartum. Which information would the nurse incorporate into the response? a. 19 lb b. 9 lb c. 14 lb d. 24 lb

a. 19 lb The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb.

The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding? a. A process of developing an attachment and becoming acquainted with each other b. The skin-to-skin contact that occurs in the birth room c. An ongoing process in the year after birth d. Family growing closer together after the birth of a new baby

a. A process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.

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

a. Harm to self When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? a. Hold the baby frequently. b. Speak to his friends who have children. c. Read up on parental care. d. Have the client speak to the primary care provider on her husband's behalf

a. Hold the baby frequently. The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence? a. Perform Kegel exercises. b. Perform aerobic exercises. c. Reduce fluid intake. d. Frequently empty the bladder.

a. Perform Kegel exercises. The nurse should ask the client to perform the Kegel exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? a. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. b. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. c. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. d. Recommend rooming-in to foster attachment and confidence by the mother.

a. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as: a. attachment. b. engrossment. c. involution. d. engorgement.

a. attachment. When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smooths the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

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

a. bleeding Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

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

a. contraction of muscular fibers b. catabolism of the individual myometrial cells c. regeneration of the uterine epithelium Involution involves three retrogressive processes: contraction of the muscle fibers; catabolism of the individual myometrial cells; and regeneration of the uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off. At approximately 1 week after birth, the uterus shrinks in size by 50%; at the end of 6 weeks it should reach approximately its prepregnancy weight.

A nurse is providing discharge instructions to a postpartum client about possible complications after returning home. For which finding will the client contact the health care provider? a. increasing amount and darkening of the color of lochia b. passing clots smaller than 1 inch (2.5 cm) c. decreasing amount and lightening of the color of lochia d. palpating a firm fundus

a. increasing amount and darkening of the color of lochia Once the lochia has changed to pink, a change back to a darker color may indicate a complication. The client does not need to contact the health care provider for normal findings, such as a firm fundus, passing clots smaller than 1 in (2.5 cm), and decreasing amount of lochia that is lighter in color.

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

a. moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. a. restlessness b. feelings of worthlessness c. feeling overwhelmed d. sleeping well e. hunger

a. restlessness b. feelings of worthlessness c. feeling overwhelmed The symptoms of postpartum depression will last longer and are different than the baby blues. Some signs and symptoms of depression include feeling the following: restless, worthless, guilty, hopeless, moody, sad, and overwhelmed.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? a. showing increased confidence when caring for the newborn b. talking about her labor experience to others around her c. pointing out specific features in the newborn d. having feelings of grief or guilt

a. showing increased confidence when caring for the newborn Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue? a. "You may have intercourse until next month with no fear of pregnancy." b. "Ovulation may return as soon as 3 weeks after birth." c. "You will not ovulate until your menstrual cycle returns." d. "Ovulation does not return for 6 months after birth."

b. "Ovulation may return as soon as 3 weeks after birth." Ovulation may start as soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, she needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics? a. Have her fill out a questionnaire on the subject. b. Ask her questions and observe her caring for the baby. c. Since she has had a previous child, she should already know how to do most everything. d. Have her demonstrate how to do all the baby care tasks as well as her self-care tasks.

b. Ask her questions and observe her caring for the baby. The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.

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

b. BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.

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

b. Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

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

b. Demonstrating how to do cord care on the newborn When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.

A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? a. Restrict fluid intake to 2 L each day. b. Ensure the baby empties the breasts at each feeding c. Apply ice packs before a feeding. d. Wear a tight fitting bra at all times.

b. Ensure the baby empties the breasts at each feeding Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.

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

b. Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? a. Try to avoid carrying the baby for a few days. b. Maintain correct posture and positioning. c. Soak in a warm bath several times a day. d. Apply ice to the sore joints.

b. Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

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

b. Neglects to engage or provide care or show interest in infant. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with postpartum blues.

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

b. You should not lift anything heavier than your infant in its carrier. New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with.

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

b. hemorrhage The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments? a. breasts b. perineum c. lower extremities d. respiratory status

b. perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

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

b. postpartum depression The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? a. urinary overflow b. postpartum diuresis c. urinary tract infection d. trauma to pelvic muscles

b. postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? a. hematocrit 42% (0.42) b. white blood cell count 14,000/mm3 (14 ×10^9/L) c. hemoglobin 12.5 g/dL (125 g/L) d. platelets 350,000/µL (350 ×10^9/L)

b. white blood cell count 14,000/mm3 (14 ×10^9/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? a. At level of umbilicus b. 1 cm above the umbilicus c. 1 cm below the umbilicus d. At the symphysis pubis

c. 1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

After the birth of the newborn, the mother is ready to be discharged home. The client's mother is present and will remain with her for 1 month. The client's mother tells the nurse that her daughter will not be allowed to leave the house for the first month after the birth, based on the family's cultural customs. How should the nurse respond to this statement? a. Remind the client's mother that the woman needs to get out and get fresh air over the next month. b. Ask the client's mother why she is putting such restrictions on her daughter. c. Accept the mother's statement and perform discharge teaching accordingly. d. Explain to the client's mother that her daughter may have to go places in caring for the newborn.

c. Accept the mother's statement and perform discharge teaching accordingly. In some cultures, new mothers are not allowed to leave the home for at least 1 month to allow her opportunity to rest and keep her healthy. Because the client's mother informed the nurse that this is the family's cultural custom, the nurse should not try to talk the client or her mother out of their beliefs on caring for both the client and the newborn. Asking the client's mother why she is putting restrictions on her daughter is challenging and unprofessional.

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

c. Place an ice pack. The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? a. Acute pain related to afterpains or episiotomy discomfort b. Risk for infection related to multiple portals of entry for pathogens c. Risk for injury: postpartum hemorrhage related to uterine atony d. Risk for injury: falls related to postural hypotension and fainting

c. Risk for injury: postpartum hemorrhage related to uterine atony The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.

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

c. The mother is reluctant to touch the newborn for fear of hurting her. New parents are often nervous and unsure of themselves but bonding behaviors normally follow a pattern. Initially, the parents gently touch the newborn with their fingers, and then go to the extremities to inspect them. Making comments about the newborn's similarities in appearance to the parents is also commonly seen. Holding of the newborn in the en face position, where the parent is directly looking at the newborn, is seen in most families. A reluctance to touch the newborn is counterproductive for bonding since bonding relies on the interaction between the parent and the child.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? a. Run warm water over the breast in the shower. b. Massage the breasts when they are painful. c. Wear a tight, supportive bra. d. Express small amounts of milk when they are too full.

c. Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

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

c. a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 4 to 10. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

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

c. hemoglobin and hematocrit The health care provider will order hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia. A decreased result may indicate the woman has suffered post-delivery hemorrhage and is also common with cesarean deliveries. The maternal blood type will be determined before the delivery. The H&H may be ordered as part of the complete blood count or may be ordered separately. The complete blood count may be ordered to evaluate for infection if the client has a fever. The iron level may be ordered at a later date if the H&H continues to remain low after a few days, but is not a priority within the first 24 hours after de

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? a. increased white blood cell count b. stirrup injury during birth c. increased coagulation factors d. decreased red blood cell count

c. increased coagulation factors The woman is showing signs of thromboembolism or deep vein thrombosis, which is a risk for the postpartum client due to the increased hypercoagulable state that occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors that the body uses as a protective device; however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, the client should be evaluated for anemia. The stirrups should not cause an injury.

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? a. prolactin b. progesterone c. oxytocin d. estrogen

c. oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.

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

c. taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be? a. red b. pink c. yellowish white d. yellowish pink

c. yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

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

d. 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

Which assessment finding 1 hour after birth should be reported to the health care provider? a. Fundus of uterus is palpable at the level of the umbilicus. b. Fundus is displaced to the right, and bladder is hard. c. Large, bruised hemorrhoids are protruding from the anal opening. d. Lochia rubra is saturating a pad every 45 to 60 minutes.

d. Lochia rubra is saturating a pad every 45 to 60 minutes. The nurse should ask the woman to turn over so her buttocks can be inspected in order to ensure that blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or the woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her health care provider to be certain there is no cervical or vaginal tear, or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is a normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist the client in emptying the bladder. The health care provider should be notified if a catheter needs to be inserted and there are no standing prescriptions for an in-and-out cath following birth.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? a. yellowish-white lochia b. foul-smelling lochia c. easy to separate clots d. difficult to separate clots

d. difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? a. increased blood pressure b. increased cardiac output c. increased hematocrit level d. increased heart rate

d. increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading? a. lying flat in the bed on the back b. lying on the right side for 5 minutes c. standing next to the bed after 3 minutes d. sitting on the side of the bed for 2 minutes

d. sitting on the side of the bed for 2 minutes To get the most accurate reading on a 1-day postpartum client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.

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

a. postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

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

c. hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? a. "It takes about 3 days after birth for milk to begin forming." b. "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." c. "You may have developed mastitis. I'll ask the primary care provider to examine you." d. "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in."

a. "It takes about 3 days after birth for milk to begin forming." The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy, since midway through pregnancy she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day postpartum, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.

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

a. taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period.

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

b. the taking-hold phase The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation? a. Uterine atony b. Full bowel c. Bladder distention d. Poor bladder tone

c. Bladder distention Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: a. "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." b. "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." c. "I need to get your vital signs and check your fundus to be sure you are not going into shock." d. "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

d. "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

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

d. inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

Eight hours after delivery, the client is found to have a perineal hematoma. The health care provider prescribes insertion of a Foley catheter. The client does not understand why she needs a catheter, because she has voided twice since giving birth. Which responses by the nurse explain the need for a Foley catheter? Select all that apply. a. "If you are bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for you to void." b. "As the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later." c. "The hematoma can get larger and place pressure on your kidneys and decrease the amount of urine produced." d. "The Foley catheter is necessary to keep the blood out of your bladder and from contaminating your urine." e. "A Foley catheter will decrease the risk of developing a urinary infection while we are monitoring the condition of the perineum."

a. "If you are bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for you to void." b. "As the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later." With the presence of a perineal hematoma, there are two reasons for inserting a Foley catheter: (1) if there is continued bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for the patient to void; and (2) as the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later. The hematoma is not in proximity to the kidneys. The bleeding is in the tissue surrounding the urethra, not into the bladder. The placement of a Foley catheter actually increases the risk of a urinary tract infection

What two elements play the biggest role in becoming a mother after delivery of her newborn? a. Confidence and happiness with the pregnancy b. Love and attachment to the child and engagement with the child c. Planned and desired pregnancy and previous experience with infants d. Interactions with the child and support systems

b. Love and attachment to the child and engagement with the child A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? a. lochia serosa b. edematous vagina c. uterus 1 cm below umbilicus d. diaphoresis

c. uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.