Maternal - Post-Partum

The nurse in the postpartum unit is caring for a mother after vaginal delivery of a healthy newborn. The client received epidural anesthesia for the delivery. One-half hour after admission to the postpartum unit, the nurse checks the client and suspects the presence of a vaginal hematoma. Which finding would be the best indicator of the presence of this type of hematoma?

Changes in vital signs

A postpartum nurse is performing an assessment on a client who delivered a viable newborn 2 hours ago. The nurse palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should the nurse expect to note at this time?

Dark red lochia

The nurse is evaluating the mother-infant bonding process during the postpartum period. What is an indication of a maladaptive interaction by the mother?

Encouraged the nurse to feed the baby because she continues to be too tired.

A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk to the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?

Grief

The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says "I can't even dress this baby!" After reassuring the client, the nurse determines that which would be an appropriate nursing action?

Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

The postpartum nurse is assigned to admit a client to the postpartum unit after delivery of a viable newborn. In the report, the nurse is told that the client had a placenta previa. Which possible client problem should be the priority for this client?

Hemorrhage

The postpartum nurse is assigned to admit a client to the postpartum unit following delivery of a viable newborn. In the report, the nurse is told that the client had a placenta previa. Which complication should the nurse monitor for as the priority for this client?

Hemorrhage

The nurse assigned to care for a postpartum client plans to promote parent-infant bonding. What should the nurse encourage the parents to do?

Hold and cuddle the infant closely.

The nurse notes that a client is delighted with her newborn infant, but the client confides to the nurse that she is really worried about not knowing how to care for her first-born child. What can the nurse conclude is the client problem?

Lack of understanding

The nurse in the postpartum unit is caring for a mother who received epidural anesthesia for the vaginal delivery of a healthy infant. On assessment of the mother, the nurse should suspect the presence of a vaginal hematoma if which finding is noted?

Low blood pressure

After an unplanned cesarean section, the nurse finds the client displaying emotional distress. The nurse notes that the woman is tearful, expressing bewilderment, sadness, and feelings of failure and regret because she could not deliver vaginally. The nurse determines that it is appropriate to address which problem at this time?

Low self-esteem

A woman with type 1 diabetes mellitus is in labor. Based on the knowledge of insulin and diabetes and pregnancy, the nurse will be prepared to care for a newborn infant who is likely to have which complication?

Macrosomia

The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?

Massage the fundus gently until it is firm.

The nurse is caring for a woman who is human immunodeficiency virus (HIV)-positive and delivered a newborn infant. In the postpartum period, which psychosocial assessment should the nurse initially address?

Maternal fears related to the newborn's status

The nurse in the postpartum unit assesses the temperature of a client who delivered a healthy infant 4 hours ago. The mother's temperature is 100.8° F. The nurse provides oral hydration to the mother and encourages fluids. Four hours later, the nurse assesses the temperature and notes that it is still 100.8° F. What is the appropriate nursing intervention at this time?

Notify the health care provider

The nurse obtains the vital signs on a mother who delivered a healthy newborn 2 hours ago and notes that the mother's temperature is 102° F. What is the appropriate nursing action at this time?

Notify the health care provider

A 10-day postpartum breast-feeding client telephones the postpartum unit complaining of a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?

Notify your health care provider because you may need medication.

A 10-day postpartum breast-feeding client calls the postpartum unit at the hospital to speak to the nurse and complains of a reddened, painful breast and an elevated temperature. Based on the client's complaints, the nurse should make which statement to the client?

Notify your health care provider, because you may need medication.

A second-day postpartum client with diabetes mellitus has scant lochia with a foul odor and a temperature of 101.6° F. The health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the health care provider should the nurse complete first?

Obtain culture and sensitivity of lochia and urine.

The nurse in the newborn nursery is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. In planning care for the newborn, what is the priority nursing action?

Obtain the newborn's blood type and direct Coombs results

The postpartum nurse is caring for a mother following delivery of her newborn. The nurse checks the perineum on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the client's fundus and notes that it is firm. On review of the client's record, the nurse also notes that an episiotomy was performed. Based on this data, which determination should the nurse make?

The bright red bleeding is abnormal and should be reported.

The nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal would be most appropriate for this client?

The client will be able to identify measures to prevent infection.

The nurse is monitoring a new mother for signs/symptoms of postpartum depression. Which observation, if noted in the new mother, would indicate the need for follow-up related to this form of depression?

The mother constantly complains of tiredness and fatigue.

The postpartum nurse is monitoring the amount of lochial flow in a client after delivery. The nurse understands that the accurate assessment of the amount of flow is determined by using which method?

Weighing the perineal pad before and after use and the amount of time between pad changes.

The nurse completing a care plan for a postpartum client should include which interventions related to prevention of excessive bleeding in the immediate postpartum period? Select all that apply.

1. Assess for bladder distention 2. Teach the client to massage her own fundus 3. Gently massage the fundus if the uterus becomes "boggy."

The nurse is discussing contraceptive methods with a postpartum client. The nurse tells the client that combined oral contraceptives are contraindicated if the client has a medical history of which conditions? Select all that apply.

1. Breast cancer 2. Coronary artery disease 3. Thromboembolic Diorders

The nurse is planning care for a client immediately after a vaginal delivery. Which interventions should the nurse plan to implement? Select all that apply.

1. Offer the client a warm blanket 2. Massage the uterus if it is boggy 3. Place an ice pack on the perineum

The nurse in the postpartum unit is assessing a newborn for signs of breast-feeding problems. Which findings indicate a problem? Select all that apply.

1. The infant exhibits dimpling of the cheeks. 2. The infant makes smacking or clicking sounds. 3. The infant falls asleep after feeding less than 5 minutes.

The nurse is counseling a couple after a stillbirth delivery. Which statements are appropriate for the nurse to share with the bereaved parents? Select all that apply.

1. What can i do for you? 2. I'm here, and i want to listen. 3. How are you doing with all of this?

The nurse is preparing to teach a new mother to breast-feed. Which factor is important to promote an effective and positive learning experience?

A positive nurse-client relationship.

A client is being discharged after having a cesarean section to deliver her newborn infant, and the nurse provides discharge instructions to the client. The nurse determines that the client needs additional teaching about postdischarge complications if the client states that she will report which finding?

A temperature that increases to above 102

A goal for a postpartum client has been developed that states, "The client will remain free of infection during her hospital stay." Which assessment data would support that the goal has been met?

Absence of fever

The nurse performs an assessment on a postpartum client who is beginning to experience respiratory distress. The nurse should expect the client to exhibit which early neurological sign?

Apprehensiveness

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, which approach should the nurse take as the first step to support the client psychologically?

Asses how the client perceived the event.

The nurse in the postpartum unit is developing a nursing plan of care for a client following cesarean delivery. The nurse documents which best intervention in the plan of care that will assist in preventing thrombophlebitis?

Assisting with frequent ambulation

It has been 12 hours since the client's delivery of a newborn. The nurse assesses the client for the process of involution and documents that it is progressing normally when palpation of the client's fundus is at which level?

At the level of the umbilicus

The nurse is performing an assessment on a mother who just delivered a healthy newborn. When checking the uterine fundus the nurse should expect to note that the fundus is positioned at which location?

At the level of the umbilicus

After delivery, the postpartum nurse instructs the client with known cardiac disease to call for the nurse when she needs to get out of bed or when she plans to care for her newborn infant. Which rationale is the basis for these instructions?

Avoid maternal or infant injury caused by the potential for syncope or overexertion.

The nurse has provided instructions to a new mother with a urinary tract infection regarding foods and fluids to consume that will acidify the urine. The nurse determines that further teaching is needed if the mother indicates that which fluid will acidify the urine?

Carbonated drinks

A woman with severe gestational hypertension delivered a healthy newborn infant and continued to receive magnesium sulfate therapy in the postpartum period. Twenty-four hours after delivery, the client began to urinate over 100 mL of urine every hour. What determination should the nurse make about this volume of urinary output?

Edema and vasoconstriction in the brain and kidneys have decreased.

A postpartum nurse obtains the vital signs on a mother who delivered a healthy infant 2 hours ago. The mother's temperature is 100° F (38° C). What should be the initial nursing action?

Encourage oral fluid intake

The nurse is planning for the initial visit between the parents and a newborn infant diagnosed with respiratory distress syndrome. What actions should the nurse include in the plan to best facilitate bonding during the visit?

Encourage the parents to touch their infant.

A mother is admitted to the postpartum unit after delivery of a healthy newborn. During the immediate postpartum period, when should the nurse plan to take the mother's vital signs?

Every 15 minutes during the first hour after birth

Which central nervous system withdrawal symptom can the nurse expect to observe in a neonate born to a drug-addicted mother?

Exaggerated reflexes

The nurse is caring for a postpartum client. Which finding should make the nurse suspect endometritis in this client?

Fever of 38 C, beginning 2 days postpartum.

A home care nurse provides instructions to a breast-feeding postpartum client who has developed breast engorgement. Which measure should the nurse tell the client to take?

Gently massage the breast from the outer areas to the nipple during feeding.

A client has just delivered a large-for-gestational-age (LGA) infant by the vaginal route. The client verbalizes concern regarding the infant's facial bruising and causing pain to the site if touched. Which therapeutic statement should the nurse make to alleviate the client's concerns?

I can show you how to gently stroke the face and not cause pain.

The nurse is preparing a postpartum client who had a cesarean delivery for discharge to home. Which statement by the client indicates a need for additional teaching before discharge?

I can start doing abdominal exercises as soon as i get home.

A mother who is breast-feeding her newborn infant is experiencing nipple soreness, and the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?

I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me.

A rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago. The nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?

I need to prevent becoming pregnant for 2-3 months after the vaccination.

The nurse has provided instructions to a postpartum client regarding postpartum exercises. Which statement by the client indicates an understanding of the exercises?

I should alternately contract and relax the muscles of the perineal area.

A new breast-feeding mother is seen in the clinic with complaints of breast discomfort. The nurse determines that the mother is experiencing breast engorgement and provides the mother with instructions regarding care for the condition. Which statement by the mother indicates an understanding of the measures that will provide comfort for the engorgement?

I will massage my breasts before feeding to stimulate letdown.

The nurse provides instructions about measures that will provide comfort to a breast-feeding mother who is experiencing breast engorgement. Which statement by the mother indicates an understanding of these measures?

I will massage the breasts before feeding to stimulate letdown

The nurse assigned to care for a lactating postpartum client should plan to provide which instruction to the client?

Increase caloric intake by 500 calories a day.

The nursing student is assigned to care for a postpartum client. The registered nurse reviews the nursing care plan developed by the student and asks the student to describe the process of involution. Which response by the student indicates an accurate description of this process?

Involution is a progressive descent of the uterus into the pelvic cavity occurring approximately 1 cm per day.

A neonatal intensive care unit (NICU) nurse teaches hand washing techniques to the parents of an infant who is receiving antibiotic treatment for a neonatal infection. The nurse determines that the parents understand the primary purpose of hand washing if which statement is made?

It is primarily done to reduce the possibility of transmitting an environmental infection to the infant.

Erythromycin ophthalmic ointment is prescribed for the newborn immediately after delivery. What should the nurse know about this ointment?

It is useful to protect the newborn from both Neisseria gonorrhoeae and Chlamydia.

During the initial maternal-infant bonding period following the delivery of the placenta, what is the nurse's primary responsibility?

Make sure the infant stays warm and is in no danger of slipping from the parent's grasp.

Which action by the breast-feeding client should lead the nurse to determine that the client is at risk of developing mastitis?

Offering 1 breast per feeding

A mother who is 2 days postpartum should be routinely assessed by the nurse for thrombophlebitis by specifically checking which parameter?

Pain in the calf area

Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery. Before administering the medication, the nurse reviews the client's history, knowing that what is a contraindication for this medication?

Persons who have experienced a severe reaction to human globulin.

The nurse is preparing to perform fundal massage on a client with uterine atony. How should the nurse perform this procedure?

Placing one hand just above the symphysis pubis and gently, but firmly, massaging the fundus in a circular motion.

A client who is breast-feeding her newborn is experiencing nipple soreness. What should the nurse suggest to the client to assist in relieving nipple soreness?

Position the infant with the ear, shoulder, and hip in straight alignment with the infant's stomach against the mother.

The nurse is observing the parents at the bedside of their small-for-gestational-age (SGA) infant, who was born at 27 weeks' gestation. The infant's mother states, "She is so tiny and fragile. I'll never be able to hold her with all those tubes." Considering this statement, which problem should the nurse identify for the mother?

Potential for compromised parenting

The nurse is instructing a postpartum client on the use of a sitz bath. What reasons should the nurse tell the client that sitz baths are prescribed?

Promote healing and provide comfort.

A client has just experienced a precipitate delivery. The nurse notes that the mother is lying quietly in bed and is avoiding physical contact with the newborn infant. Which appropriate action should the nurse take?

Provide support to the mother

The nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understanding when the client says that on the second day postpartum, the lochia should be which color?

Red

A breast-feeding mother has developed a temperature of 104° F and is experiencing shaking chills. The nurse further assesses the client for signs/symptoms of mastitis and observes for which finding?

Reddened and extremely tender breast tissue.

When instructing a postpartum client on the use of an ice pack, the nurse should tell the client that the ice pack will have which therapeutic effects?

Reduce the edema and numb the tissue.

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents take which actions?

Request to hold the infant after delivery.

A postpartum client asks the nurse when she can resume sexual activity. What is an appropriate nursing response?

Sexual activity can be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.

The nurse is monitoring a postpartum client for signs of complications. Which finding indicates a sign of potential bleeding?

Soft or boggy uterus

The nurse is developing a plan of care for a woman with amniotic fluid embolism (AFE) and has formulated a nursing problem of difficulty breathing due to blockage of the lungs from AFE. Which outcome would be appropriate for this client?

The woman will demonstrate an effective respiratory rate and have a normal gas exchange.

The nurse is planning care for a client with an intrauterine fetal demise. Which is an inappropriate goal for this client?

The woman will recognize that thoughts of worthlessness and suicide are normal after a loss.

The nurse provides instructions to a new mother who is about to breast-feed her newborn infant. The nurse observes the new mother as she breast-feeds for the first time and determines the mother needs further teaching if the new mother applies which technique?

Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth.

The nurse provides instructions to the postpartum client who has developed breast engorgement. Which instruction should the nurse provide to this client?

To gently massage the breast from the outer areas to the nipple during feeding.

A postpartum client with gestational diabetes is scheduled for discharge. During the discharge teaching, the client asks the nurse, "Do I have to worry about this diabetes anymore?" Which is the appropriate response by the nurse?

You will be at risk for developing gestational diabetes with your next pregnancy and also for developing diabetes mellitus.

A 2-day postpartum mother complains of severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing these complaints, the nurse immediately assesses which client area?

Vulva for hematoma

The nurse in the postpartum unit is reviewing the records of the clients on the unit. During the review, the nurse determines that which client is most at risk for developing endometritis following delivery?

An adolescent experiencing an emergency cesarean delivery for fetal distress.

The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?

Administer prescribed anticoagulant therapy.

The nurse is preparing to care for the mother of a preterm infant. When should the nurse plan to begin discharge planning?

After stabilization of the infant during the early stages of hospitalization.

The nurse is assigned to provide care to a client in labor and will care for the client throughout labor and into the postpartum period. The nurse assists in developing a plan of care and determines that which is the priority assessment in the fourth stage of labor?

Assessing the uterine funds and lochia

The nurse is assigned to provide primary care to a client in labor and will care for the client throughout labor and into the postpartum period. When developing a plan of care for a client in the fourth stage of labor, what should the nurse determine is the initial priority nursing assessment?

Assessing the uterine fundus and lochia

The nurse is caring for a woman in the postpartum unit. When the nurse checks the position of the fundus, the nurse notes that the fundus is displaced to one side. Which nursing action is appropriate?

Assist the client to empty the bladder

The nurse is assigned to care for a postpartum client. When collecting data regarding the new mother's parental anxieties, which statement by the mother suggests a potential problem with maternal attachment?

Why did this baby have to inherit my family's ugly toes?

A stillborn infant was delivered a few hours ago. After the birth, the family has remained together, holding and touching the baby. Which statement by the nurse would further assist the family in their initial period of grief?

Would you like to name your baby?