Maternal Newborn Postpartum

The nurse assisted with the birth of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?

Drying the infant with a warm blanket

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group."

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn."

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water."

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

"I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately."

The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?

Hemorrhage

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus until it is firm.

A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply.

Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs.

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul-smelling odor

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore.

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed.

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the obstetrician (OB).

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats per minute

The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action?

Increase hydration by encouraging oral fluids.