Maternal Postpartum Care 1.0
The nurse is developing a plan of care for a client who is in the "taking-in" phase after delivering a healthy baby boy. Which of the following should the nurse include in the plan? a. Provide the client with a nutritious meal. b. Teach baby care skills like diapering. c. Discuss the pros and cons of circumcision. d. Counsel her regarding future sexual encounters.
ANS: a a. Mothers are very hungry immediately after delivery. The nurse should provide the client with food.
Which of the following nursing actions are directed at promoting bonding? (Select all that apply.) a. Providing opportunity for parents to hold their newborn as soon as possible following the birth. b. Providing opportunities for the couple to talk about their birth experience and about becoming parents. c. Promoting rest and comfort by keeping the newborn in the nursery at night. d. Providing positive comments to parents regarding their interactions with their newborn.
ANS: a, b, d Parent bonding can be delayed by prolonged periods of separation from their child. The other three actions support parent bonding with their newborn.
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?
Assist the mother in identifying the baby's behavior cues.
Which strategies would the nurse utilize to promote culturally competent care for the postpartum client?
Examine one's own cultural beliefs, biases, stereotypes, and prejudices Respect the values and beliefs of others. Incorporate the family's cultural practices into the care.
The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse?
Help the client back to bed to check the fundus
To assess the healing of the uterus at the placental site, what does the nurse assess?
Type, amount, and consistency of lochia
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?
"Because of her age, this client will probably need extra teaching about the terminology for her anatomy."
The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response?
"Blood pooled in the vagina while you were in bed."
Which statement by a nursing student preparing to care for a postpartum lesbian mother would indicate the need for further teaching?
"I will have to adjust some of my discharge instruction for this mother."
A multiparous client delivered her first child vaginally 2 years ago, and delivered an infant by cesarean yesterday due to breech presentation. Which statement would the nurse expect the client to make?
"I'm having significantly more pain this time than with my last birth."
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?
"My Beta-strep culture's being positive might have contributed to this problem."
The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?
"My bleeding will remain red for about a month."
Multiparous women or women who are breastfeeding may experience
"afterpains" during the first few postpartum days.
The uterus descends how much per day?
1 cm per day. By day 14 not palpable.
The amount of flow is determined by the amount of lochia on a perineal pad after
1 hour
The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect?
1) Hematoma formation or bulging/shiny skin in the perineal area 2) Rise in the level of the fundus of the uterus 3) A boggy fundus that does not respond to massage
The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept?
1)"Talking to the baby is good because he'll recognize our voices." 2)"Holding the baby so we have direct face-to-face contact is good."
10 grams equals
10 milliliters of blood loss
The nurse expects an initial weight loss for the average postpartum client to be which of the following?
10 to 12 pounds
Women have an average blood loss of
200-500 mL related to the vaginal birthing experience.
Your patient gave birth to a 6-pound baby girl 6 hours ago. It was a spontaneous delivery. You note on your assessment of her perineum that there is some edema and slight bruising. She stated that her pain was at 1 on the pain scale. Your nursing action would be to: A. Continue applying ice to the perineum. B. Assist her with a sitz bath. C. Encourage her to keep her bladder empty. D. Administer ibuprofen 800 mg.
A
The hospital is developing a new maternity unit. What aspects should be included in the planning of the new unit to best promote family wellness?
A nursing care model based on providing couplet care
A patient who delivered vaginally and has a third degree laceration is being prepared for discharge. Which of the following instructions should the nurse include in her discharge teaching? Select all that apply. A. Drink at least 2 liters of fluid a day. B. Ambulate several times a day. C. Eat plenty of whole grain foods, and fruits and vegetables. D. Use suppositories to help promote regular, soft bowel movements.
A, B, C
13. 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 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.
2. 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 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.
Bonding is bidirectional from parent to infant and infant to parent. (T/F)
ANS: False Bonding is unidirectional from parent to infant. Attachment is bidirectional.
Eye movements are an example of newborn/infant style of communication. (T/F)
ANS: True Crying, cooing, facial expressions, eye movements, cuddling, and arm and leg movements are all examples of newborn/infant style of communication.
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.
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 c. Oxytocin is commonly used to control postpartum bleeding related to uterine atony.
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 d. Correct. The uterus on the average descends 1 centimeter per day.
Postpartum woman are at an increased risk of thrombus formation immediately following birth due to an increased __________ level
ANS: plasma fibrinogen Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient's risk of thrombus formation
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?
Administer a mild analgesic to help with breastfeeding. Administer a mild analgesic at bedtime to ensure rest. Offer a warm water bottle for her abdomen.
Secondary hemorrhage often occurs when?
After patient has been discharged
The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client?
An appointment with a mental health counselor
Which of the following symptoms would be an indication of postpartum blues?
Anger Mood swings Crying
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?
Apply cold packs to the breasts
The nurse is providing postpartum care to an obese client. As part of care for this client, the nurse should do which of the following?
Apply sequential compression devices Have the mother ambulate as early as possible Supervise breastfeeding Instruct the client on signs of infection
The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?
Ask the client how much contact she would like with the baby, and whether she wants to feed it.
The nurse assesses the postpartum client to have moderate lochia rubra with clots. Which nursing intervention would be appropriate?
Assess fundus and bladder status.
Assess uterus for what
Assess the uterus for location, position, and tone of the fundus.
A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client?
Avoid crossing the legs. Avoid prolonged standing or sitting. Take frequent walks.
Your patient, who gave birth to a 7-pound baby boy 24 hours ago, is complaining of uterine cramping (afterpains). This is her second baby and she is breastfeeding. Your assessment reveals a firm fundus at midline at 1 cm below the umbilicus. Select all of your initial nursing actions. A. Instruct the patient to bottle-feed for 36 hours or until the cramping has stopped. B. Place a warm blanket on her abdomen. C. Explain that these are normal for second-time mothers to experience. D. Offer the patient acetaminophen with codeine so she can continue to breastfeed.
B C
Which statements are true regarding coparenting. Select all that apply A. implies that the parenting roles are equal in the amount of child care responsibilities B. Consists of parental figures supporting each other in the rearing of their child C. Can be affected by the infants temperament D. Can be affected by the man's cultural beliefs
B. Consists of parental figures supporting each other in the rearing of their child C. Can be affected by the infants temperament D. Can be affected by the man's cultural beliefs
Factors that influence a man's transition to fatherhood include which of the following? select all that apply A. educational level B. Cultural expectations C. Socioeconomic status D. Support from partner
B. Cultural expectations C. Socioeconomic status D. Support from partner
A patient who delivered 20 hours ago reports a transient increase in her lochia when she ambulated to the bathroom to void this morning after sleeping for a few hours. The nurse performs an assessment and documents scant rubra, lochia with no clots, fundus firm 1 cm below the umbilicus. Which of the following nursing actions are appropriate at this time? A. Report this finding to the patient's health care provider immediately. B. Begin weighing and counting pads. C. Reassure the patient that this is normal. D. Obtain a physician's order to administer oxytocin.
C
You observe a new father gently touching his newborn son and spending time gazing at his son. These behaviors are characteristics of A. entrainment B. attachment C. engrossment D. bonding
C. engrossment
To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following?
Change peri-pads frequently
How does the nurse assess for Homans' sign?
Dorsiflexing the foot and inquiring about calf pain
Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery?
Edema and bruising of perineum Fundus firm and midline
Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis?
Elevate the affected limb
A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate?
Encourage sitz baths.
The nurse is caring for a client who plans to relinquish her baby for adoption. The nurse would implement which approach to care?
Encourage the client to express her emotions. Respect any special requests for the birth. Acknowledge the grieving process in the client. Allow access to the infant, if the client requests it.
The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client?
Expect that most visitors will be women. Uncover only the necessary skin when assessing.
The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client?
Frequency Suprapubic pain
When is Rh°(D) Immune Globulin -RhoGAM given?
Given IM at 28 weeks of gestation when the woman is Rh negative. And administered to Rh-negative women who have given birth to an Rh-positive neonate within 72 hours of birth.
Which of the following would be considered a clinical sign of hemorrhage?
Increasing pulse
Foul smelling lochia could indicate
Infection
A postpartum woman is at increased risk for developing urinary tract problems because of which of the following?
Inhibited neural control of the bladder following the use of anesthetic agents
Risk factors associated with increased risk of thromboembolic disease include which of the following?
Malignancy Diabetes mellitus Varicose veins
The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
Massage the uterine fundus until it is firm
A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect?
Mastitis
The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?
Methylergonovine maleate (Methergine)
The incidence of complications and discomforts in the first year postpartum is common and women may experience which of the following?
Pain Urinary incontinence Changes in mental health status This is the correct answer. Sleep deprivation
The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about?
Postpartum depression
The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?
Postpartum hemorrhage
The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following?
Prolonged labor Difficult birth Full bladder Infection
Which of the following behaviors noted in the postpartum client would require the nurse to assess further?
Responds hesitantly to infant cries.
Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take?
Review the documentation of the birth experience and discuss it with her
When is Rho immune globulin given?
Rho immune globulin is given to Rh-negative women at 28 weeks' gestation. A second injection of Rho immune globulin is given to the woman if she is Coombs' negative.
Which of the following conditions would predispose a client for thrombophlebitis?
Severe anemia
A nurse suspects that a postpartum client has mastitis. Which data support this assessment?
Shooting pain between breastfeedings Late onset of nipple pain Pink, flaking, pruritic skin of the affected nipple
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?
Steady trickle of blood
Assessment of fundus
Support the lower uterine segment by placing one hand just above the symphysis pubis. Locate the fundus with the other hand using gentle downward pressure. Determine the tone of the fundus: Firm (contracted) or soft (boggy). Measure distance between fundus and umbilicus with fingers. Determine location of fundus.
If uterus is deviated, soft, or elevated above umbilicus what should nurse do?
Tell patient to void- help her to the bathroom. Reassess. If unable to void- may need to cath.
The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion?
Tense tissues with severe pain
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?
The nurse explains the characteristics and cues of the baby when assessing him.
The nurse is planning care for three newly delivered adolescents and their babies. What should the nurse keep in mind when planning their care?
The baby's father should be encouraged to participate when the nurse is providing instruction.
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?
The baby's mouth should be examined for thrush.
On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following?
The taking-in period
The nurse is preparing a teaching brochure for Spanish-speaking postpartum clients. Which topics are critical for this population?
When and how to contact their healthcare provider
The nurse is assessing clients after delivery. For which client is early discharge at 24 hours after delivery appropriate?
Woman and baby who have had two successful breastfeedings
The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first?
Woman day of delivery, fundus firm 2 cm above umbilicus
subsequent breast engorgement
Women who breastfeed experience subsequent breast engorgement related to distention of milk glands that is relieved by having the baby suckle or by expressing milk.
If uterus shifted to side what could it indicate?
distended bladder
Pain measures for perineum pain
ice, lie on side, tighten gluteal muscles, wear peripads, Sitz baths after 24 hours- twice a day 20 mins each, med PER ORDER, topical PER ORDER
Primary engorgement
increase in the vascular and lymphatic system of the breasts, precedes the initiation of milk production. Breasts become larger, firm, warm, and tender, and the woman may feel a throbbing pain in the breasts. Primary engorgement subsides within 24-48 hours.
Before assessment
instruct woman to void, let her know you will be palpating her uterus, explain procedure, provide privacy, supine position and flat, and
Scant is
less than 1 inch on the pad
Light is
less than 4 inches on the pad
Moderate is
less than 6 inches on the pad
Lochia is assessed as
scant, light, moderate, or heavy
return of bright red bleeding may be sign of
secondary hemorrhage
orthostatic hypotension
sudden drop in the blood pressure when the woman stands up, which is due to decreased vascular resistance in the pelvis.
Clots should be examined for the presence of
tissue. Retained placental tissue can interfere with uterine involution and lead to excessive bleeding
The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." What response is best?
"You'll be wearing a sequential compression device until you start walking."
The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. What would the nurse suspect that the mother has?
Post-traumatic stress disorder
A new grandmother comments that when her children were born, they stayed in the nursery. The grandmother asks the nurse why her daughter's baby stays mostly in the room instead of the nursery. How should the nurse respond?
"Contact between parents and babies increases attachment."
A postpartum client has just received a rubella vaccination. The client demonstrates understanding of the teaching associated with administration of this vaccine when she states which of the following?
"I must avoid getting pregnant for 1 month."
The postpartum client expresses concern about getting back to her prepregnant shape, and asks the nurse when she will be able to run again. Which statement by the client indicates that teaching was effective?
"I should see how my energy level is at home, and increase my activity slowly."
The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching?
"If your incision becomes increasingly painful, call the doctor."
Which statement by a new mother 1 week postpartum indicates maternal role attainment?
"It works better for me to undress the baby and to nurse in the chair rather than the bed."
The breastfeeding client asks the nurse about appropriate contraception. What is the nurse's best response?
"It's possible to get pregnant before your menstrual period returns. Let's talk about some different options for contraception."
The nurse is performing discharge teaching for a newly delivered first-time mother and her infant on the 2nd postpartum day. Which statement by the mother indicates that teaching has been successful?
"Taking baths will help my perineum feel less sore each day."
During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following?
1)Adapt to altered lifestyles and family structure resulting from the addition of a new member 2)Restore physical condition 3)Develop competence in caring for and meeting the needs of her infant
At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following?
1)Anticipatory guidance about the realities of being a parent. 2)Parenting literature and reference manuals. 3)Phone numbers and locations of local parenting groups. 4)Phone numbers and names of postpartum doulas.
When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do?
1)Ask the client to void before assessing the uterus. 2)Inform the client of the need for regular assessments. 3)Perform the procedures as gently as possible. 4)Take precautions to prevent exposure to body fluids.
Which interventions can the nurse utilize to provide continuity of care for the postpartal client who experienced a complication and is now ready to return home?
1)Encourage the client to take advantage of home visits. 2)Make telephone calls as a follow-up to check on the client and newborn. 3)Provide information about postpartal support groups. 4)Supply information about postpartum expectations designed to meet the specific needs of a variety of families.
What information should the nurse include when teaching the postpartal client and partner about resumption of sexual activity?
1)Maternal fatigue is often a significant factor limiting the resumption of sexual intercourse. 2)Couples should be encouraged to abstain from intercourse until the episiotomy is healed and the lochial flow has stopped. 3)Postpartum women often experience vaginal dryness, and should be encouraged to use some kind of lubrication initially during intercourse.
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?
1)Obtain blood specimens for hemoglobin and hematocrit. 2)Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina.
Which factors would the nurse observe that would indicate a new mother's early attachment to the newborn?
1)Pointing out familial traits of the newborn 2)Displaying satisfaction with the infant's sex 3)Face-to-face contact and eye contact
Nursing interventions that foster the process of becoming a mother include which of the following?
1)Promoting maternal-infant attachment 2)Building awareness of and responsiveness to infant interactive capabilities 3)Preparing the woman for the maternal social role
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?
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
The nurse is teaching a new mother about ways to manage fatigue after she returns home. Which instructions should the nurse include?
1)Take frequent rest periods. 2)Nap when the newborn is sleeping. 3)Avoid overdoing housework and unnecessary chores. 4)Do not clean when infant is sleeping. 5)Utilize friends and family to provide help and support, such as cooking a meal.
What possible approaches should the nurse use to provide sensitive, holistic nursing care for the mother who is relinquishing her newborn?
1)Use active listening strategies to determine the client's needs. 2)Demonstrate empathy, concern, and compassion. 3)Provide nonjudgmental support and personalized care.
The nurse is preparing a woman in the early postpartum period for a fundal check. Select all appropriate nursing actions: A. Provide for privacy. B. Position the woman in high Fowler's position. C. Have the patient empty her bladder. D. Position the patient in the supine position
A, C, D
During your discharge teaching, you are evaluating if your patient needs information on contraception. Select the responses that indicate she needs additional information. A. "I will be breastfeeding for the next 6 months. We will start using a condom after I have my first period." B. "My husband is getting a vasectomy. We will be using condoms until his second semen analysis is negative for sperm." C. "I plan to have an IUD. We will be using condoms until I get an IUD." D. "I used a diaphragm prior to this pregnancy and plan to use my old one."
A, D
Factors that can hamper a couples transition to parenthood include which of the following? Select all that apply A. First experience with newborns B. Change of employment C. Adolescent father
A. First experience with newborns B. Change of employment C. Adolescent father
Your postpartum assignment includes a 15 year old first time mother who gave birth to a healthy baby girl 6 hours ago. The 16 year old father of the baby was present for the birth and is present while you are caring for the mother. Which nursing actions are appropriate? select all that apply A. Include the new father in infant care teaching sessions B. Ask the new father to tell you about his labor and birth experience C. Include the new father in teaching session on contraception D. Include the new father in teaching session on postpartum blues
A. Include the new father in infant care teaching sessions B. Ask the new father to tell you about his labor and birth experience C. Include the new father in teaching session on contraception D. Include the new father in teaching session on postpartum blues
You are providing discharge teaching to your patient. In addition to her newborn son, she has a 2 year old daughter. which will you include? select all that apply A. Stressing the importance of quality time with her daughter B. Instructing the woman to include the 2 year old in the care of her baby brother C. Explaining that all children experience some degree of sibling rivalry. D. Instructing the woman to explain to her daughter the reasons babies cry
A. Stressing the importance of quality time with her daughter B. Instructing the woman to include the 2 year old in the care of her baby brother C. Explaining that all children experience some degree of sibling rivalry. D. Instructing the woman to explain to her daughter the reasons babies cry
You are assigned a hearing impaired first-time mother. When you are entering the room, your patient is looking away from you. Which of the following is the most appropriate way to get her attention? A. flick the overhead lights on and off B. Make a loud noise as you enter C. Tap the woman on her shoulder D. Walk to her bed and wave your hand
A. flick the overhead lights on and off
The serosa stage of lochia usually occurs between day __________ and __________ and the lochia is a __________ or __________ color, and the amount is normally __________.
ANS: 1 - 4; 10; pink; brown; scant Lochia rubra (first stage) occurs during the first 3 days postpartum. Lochia rubra is bright red blood and is moderate to scant. Lochia alba (third stage) begins around the tenth day. The lochia is yellow to white in appearance and is scant in amount.
The postpartum period is the first __________ weeks following childbirth.
ANS: 6 Postpartum is the 6-week period of time following childbirth. It is a time of rapid physiological changes within the woman's body as it returns to a prepregnant state.
14. 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 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.
1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting
ANS: A a. It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant. b. There is no need for a client with PP psychosis to be on strict bed rest. c. Visitation is not usually restricted to the woman's partner. d. There is no need to monitor the client's toileting.
Mastitis is an inflammation of the __________.
ANS: Breast Mastitis is an inflammation or infection of the breast. This can occur when bacteria enter the breast through cracks around the nipple area.
15. A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment
ANS: C a. Postpartum blues usually occurs within the first few weeks of the postpartum period. Women experiencing postpartum blues will have mild mood swings, and they can take care of themselves as well as their baby. b. Women with PPD are predominately depressed and do not have mood swings. c. Postpartum psychosis is associated with a break from reality reflected in the woman hearing voices. d. The symptoms reported are reflective of a psychiatric disorder beyond maladaptive attachment.
12. 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 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.
3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit
ANS: D a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting. b. This woman's baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements. c. There is no evidence that this mother is high risk for altered coping. d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.
The postpartum nurse is caring for a couple who experienced an unplanned emergency cesarean birth. The nurse observes the following behaviors: Parents are gently touching their newborn. Mother is softly singing to her baby. Father is gazing into his baby's eyes. Based on this data, the correct nursing diagnosis is altered parent-infant bonding related to emergency cesarean birth. Cesarean birth can place the parents at risk for bonding, but based on the observed interaction with their newborn, the parents display positive signs of bonding. (T/F)
ANS: False
A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F
ANS: True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.
Metritis is an infection that usually starts at the placental site. T/F
ANS: True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.
Abruptio placenta is a risk factor for amniotic fluid embolism. T/F
ANS: True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations
The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth.
ANS: True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth.
9. Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 ½ hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage
ANS: a A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."
6. The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care
ANS: a Recognized risk factors for postpartum depression include an undesired or unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.
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 postpartum nurse caring for a 20-year-old G1 P0 woman who 3 hours ago delivered a healthy full-term infant, observes the woman who is lightly touching her baby girl with her fingertips but who seems to be uncomfortable holding her baby close to her body. Which of the following is an accurate interpretation of these observed behaviors? a. The woman is in the initial stage of maternal touch. b. The woman is in the taking-in phase. c. The woman is having difficulty in bonding with her baby. d. The woman needs to be medicated for pain.
ANS: a These are classical signs of the initial stage of Rubin's maternal touch.
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 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.
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 a. The client may be developing mastitis. She should apply warm soaks to the area.
A 16-year-old woman delivers a healthy, full-term male infant. The nurse notes the following behaviors 2 hours after the birth: Woman holds baby away from her body; woman refers to baby as "he"; woman verbalizes she wanted a baby girl; woman requests that baby be placed in the bassinet so she can eat her lunch. The most appropriate nursing diagnosis for this woman is: a. At risk for impaired parenting related to disappointment with baby as evidenced by verbalizing she wanted a girl b. At risk for impaired parenting related to nonnurturing behaviors as evidenced by holding baby away from body c. At risk for impaired mother-infant attachment as evidenced by woman requesting baby being placed in bassinet d. At risk for impaired mother-infant attachment related to disappointment as evidenced by calling baby "he"
ANS: a a. The potential is for impaired parenting related to disappointment in the gender of the baby.
A woman who gave birth 2 hours ago has a temperature of 37.9°C. Select all of the immediate nursing actions. a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patient's physician or midwife to report the elevated temperature.
ANS: a, b A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.
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.
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 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.
Which of the following nursing actions can assist a man in his transition to fatherhood? (Select all that apply.) a. Ask the man to share his ideas of what it means to be a father. b. Demonstrate infant care such as diapering and feeding. c. Engage couple in a discussion regarding each other's expectations of the fathering role. d. Provide the man with information on infant care.
ANS: a, b, c, d Each of these actions can assist the father in his transition. It is important for the man to be able to learn and practice infant care skills in a nonthreatening environment. It is also important for the man to be able to openly talk about his feelings regarding fatherhood and for the couple to identify mutual expectations of the fathering role.
Which of the following factors place a new mother at risk for parenting? (Select all that apply.) a. She is 17 years old. b. Family income is below the average income. c. Her parents live in the same city and are perceived as helpful. d. She dropped out of school at age 13.
ANS: a, b, d Adolescent parents may have a more difficult transition to parenthood because they have not made the transition to adulthood. Financial concerns can hamper the transition to parenthood because the focus of attention may be on where to get money to pay for daily living expenses versus on the care of their newborn. Decreased ability to read and comprehend information regarding child care may hamper the ability to gain knowledge about the care of their child.
Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake
ANS: a, c, d Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.
The nurse is caring for a postpartum woman who gave birth to a healthy, full-term baby girl. She has a 2-year-old son. She voices concern about her older child's adjustment to the new baby. Nursing actions that will facilitate the older son's adjustment to having a new baby in the house would include which of the following? (Select all that apply.) a. Explain to the mother that she can have her son lie in bed with her when he is visiting her in the hospital. b. Teach her son how to change the baby's diapers. c. Assist her son in holding his new baby sister. d. Recommend that she spend time reading to her older son while he sits in her lap.
ANS: a, c, d Two-year-olds enjoy being close to their mothers, including lying next to their mothers or being held. Changing diapers is not viewed as a pleasurable experience and is not developmentally appropriate for a 2-year-old. Children enjoy being able to hold their sibling and feeling "grown up."
7. Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.
ANS: b As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements with an automatic device, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.
5. 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.
he perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This stage of mothering is best described as: a. Taking in b. Taking hold c. Taking charge d. Taking time
ANS: b As the mother's physical condition improves, she begins to take charge and enters the taking-hold phase where she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe mother-infant interactions for signs of poor bonding, and if present, implement actions to facilitate attachment.
During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration, vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding
ANS: b The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate
The nurse notes that a new father gazes at his baby for prolonged periods of time and comments that his baby is beautiful and he is very happy having a baby. These behaviors are commonly associated with: a. Bonding b. Engrossment c. Couvade syndrome d. Attachment
ANS: b b. Correct. Characteristics of engrossment are visual awareness of baby, tactile awareness of baby, perception that baby is perfect, strong attraction to baby, feeling of strong elation, and increased self-esteem.
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 b. It is important to first assess for uterine atony or displaced uterus from full bladder.
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 b. The firm fundus should be 2 cm below the umbilicus.
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 b. The first nursing action for a boggy uterus is to massage the fundus.
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 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.
The nurse is caring for a recently immigrated Chinese woman in the postpartum unit. Based on cultural beliefs and practices of the woman, the nurse would anticipate which of the following? (Select all that apply.) a. The woman prefers cold water for drinking. b. The woman prefers not to shower. c. The woman prefers to have her female relatives care for her baby. d. The woman prefers to have her family bring her food to eat.
ANS: b, c, d In traditional Chinese beliefs and practices, the woman is to rest and female family members take care of the woman and her infant. During the first month, the woman is to avoid yin energy by eating specific foods and avoiding drinking or touching cold water.
Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.
ANS: b, d Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting.
4. 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.
10. The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter
ANS: c If the hematoma is less than 3 to 5 centimeters 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 centimeters may require incision and drainage with the possible placement of a drain.
A woman on the day of discharge from the postpartum unit requests clean towels so she can take a shower, asks a number of questions regarding breastfeeding, and shares that she is nervous about taking her baby home and not being able to remember everything she has been taught. These are behaviors associated with: a. Bonding b. Taking in c. Taking hold d. Attachment
ANS: c Correct. These are common behaviors of women in the taking-hold phase. Women during this phase have moved to being more independent and able to initiate self-care. They are highly interested in learning about the care of their baby but can easily become frustrated and discouraged when they do not immediately master a new skill.
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 c. The nurse should assess the perineum for signs of edema and ecchymoses.
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 c. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains.
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.
Which of the following nursing actions are directed at assisting men in their transition to fatherhood? (Select all that apply.) a. Encourage the woman to take on the major responsibility for infant care. b. Talk to the man, away from his partner, about his expectations of the fathering role. c. Praise the father for his interactions with his infant. d. Provide information on infant care and behavior to both parents.
ANS: c, d It is important to first have the couple discuss with each other their expectations of the fathering role. Once this has occurred, then the woman and nurse need to support the man in his role of infant care. Both parents need to receive information about infant care and infant behaviors, and both parents need to be praised for their interactions with their baby.
8. 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).
11. The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"
ANS: d The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions.
The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen
ANS: d Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.
Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health-care provider about Heather's headache. b. Dim the lights in Heather's room so that she is able to get some rest. c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli. d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.
ANS: d The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.
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 d. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.
The perinatal nurse provides information about postpartum depression to all families members because of the potential danger not only to the mother but also to the __________.
ANS: infant The earlier that postpartum depression is recognized and treatment begun, the better is the prognosis for a full recovery. The nurse should involve the family in helping the patient cope with her feelings and assisting with infant care.
A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse. The nurse's assessment findings are: Fundus firm and midline at umbilicus Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots Perineum intact, slight bruising Ice pack on perineum Vital signs are B/P 105/65, P 98, R 20, T 38° Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.
ANS: laceration; cervix; vagina Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.
When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) __________ bladder.
ANS: overdistended An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage.
A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum __________.
ANS: psychosis Postpartum psychosis is a rare but severe form of mental illness that severely affects not only the new mother, but the entire family. Postpartum psychosis may present with symptoms of postpartum depression. However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.
The development of a large hematoma can place the postpartum woman at risk for __________.
ANS: shock Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full." If the hematoma is large, signs of shock may be evident, and the patient may exhibit an absence of lochia and an inability to void.
The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased __________.
ANS: temperature 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.
Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production.
ANS: vascular; lymphatic Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands.
The nurse is caring for a client who had a cesarean birth 4 hours ago. Which interventions would the nurse implement at this time?
Administer analgesics as needed. Encourage leg exercises every 2 hours. Encourage the client to cough and deep-breathe every 2 to 4 hours. Encourage the use of breathing, relaxation, and distraction.
Which laboratory finding should the nurse assess further on a client 24 hours after delivery? 1. Hemoglobin 7.2 grams/dL 2. White blood cell count 20,000/mm3 3. Trace to 1+ proteinuria 4. Hematocrit 35%
Answer: 1 Rationale: A client with a hemoglobin of 7.2 grams/dL would most likely have significant signs and symptoms of anemia, and this could be life-threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. The hematocrit is within normal limits, and mild proteinuria or leukocytosis up to 30,000/mm3 are common in early postpartum. Cognitive Level: Analyzing Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is an abnormal laboratory finding warranting further investigation. Eliminate the option that presents normal data. Eliminate two others because they contain data commonly found in the postpartum. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 805-806.
Which assessment should alert the nurse to withhold the scheduled dose of methylergonovine maleate (Methergine) for a postpartum client and notify the health care provider? 1. Blood pressure 142/86 2. Apical pulse 56 3. Blood type O positive 4. Mother is planning to breastfeed
Answer: 1 Rationale: A potential side effect of Methergine is hypertension. If a client's blood pressure is elevated, the nurse should withhold the scheduled dose and notify the physician. An apical heart rate of 56 is within normal limits postpartum. Blood type and Rh factor are not related to the use of Methergine. The chosen method of feeding method is not impacted by the use of Methergine. Cognitive Level: Analyzing Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is an adverse effect of Methergine, an oxytocic drug. The correct answer is the option that contains a true statement about a side effect. Eliminate incorrect options because they include normal findings or data not related to Methergine use. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 834.
A new mother complains of "afterpains." The nurse's first action should be to do which of the following? 1. Administer an analgesic. 2. Advise her to stop breastfeeding until the pain stops. 3. Encourage her to empty her bladder. 4. Assess her vital signs.
Answer: 1 Rationale: Afterpains are anticipated in the postpartum client and are effectively treated with analgesics. It is unnecessary to stop breastfeeding, empty the bladder, or assess vital signs. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is afterpains, a common occurrence that can increase pain. The correct answer would be the option that contains a nursing action to effectively manage pain. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 807.
A client delivered 90 minutes ago. She is alert and physically active in bed. She states that she needs to go to the bathroom. What is the nurse's most appropriate response? 1. "I'll walk you to the bathroom and stay with you." 2. "I'll get a bedpan for you." 3. "It's important that you wipe yourself from front to back after urinating." 4. "Wipe the stitches back and forth to increase circulation."
Answer: 1 Rationale: Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should stay with the client the first time she ambulates after delivery to promote safety. Early ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region. It is unnecessary to use a bedpan. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The most therapeutic response would be the option that promotes client safety in the immediate postpartal period. Eliminate options that contain false statements as points of client education. Eliminate another as early ambulation is encouraged, not bedrest, to prevent circulatory stasis. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 830-831.
This is the first postoperative day for a client who had a cesarean delivery. The client asks the nurse why she has to get up and walk when it hurts her incision so much. What would the nurse include in a response? 1. Walking decreases the risk of blood clots after surgery. 2. Walking encourages deep breaths to blow off the anesthetic from surgery. 3. Early ambulation is important to stimulate milk production. 4. Walking will decrease the occurrence of afterpains.
Answer: 1 Rationale: Clients who have had a cesarean delivery are at risk for complications of surgery, including thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and other postoperative complications. Cognitive Level: Applying Client Need: Reduction of Risk Potential Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The positive wording of the question indicates that the correct answer is also a true statement. Use knowledge of the factors associated with increased risk of thromboembolic disease such as cesarean section and immobility to answer the question. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 846-848.
The nurse interprets that which factor in a client's history places the woman at greatest risk for postpartal endometritis? 1. Cesarean delivery after 24 hours of labor and failure to progress 2. Use of external fetal monitoring during labor 3. Ruptured membranes for four hours prior to delivery 4. Spontaneous vaginal delivery after eight hours of labor
Answer: 1 Rationale: Factors contributing to postpartum endometritis include the introduction of pathogens with invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of endometritis is greatest after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. The other options are neither invasive nor do they increase the client's risk for infection. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is risk for uterine infection. Eliminate the incorrect options because they include common noninvasive actions or data that represent normal birth experiences. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 892-893.
After delivery of a large-for-gestational-age infant, the nurse notes bright red blood continuously trickling from the client's vagina. Her fundus is firm and midline. The nurse suspects which of the following as the most likely cause of bleeding? 1. Lacerations 2. Hematoma 3. Uterine atony 4. Retained fragments of conception
Answer: 1 Rationale: Suspect lacerations if the client is bleeding and the fundus is firm. If the cause were uterine atony, the fundus would not be firm. When there are fragments of the placenta or the membranes, the uterus will not contract effectively. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The critical words in the question are continuous bleeding with a firm uterine fundus, a classic symptom of a laceration. Eliminate hematoma because bleeding would be concealed and two other options that would be associated with uterine atony. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 887.
A client has a temperature of 100.2°F four hours after delivery. What is the appropriate action for the nurse to take? 1. Encourage increased fluid intake. 2. Do nothing since this is an expected finding at this time. 3. Check the physician's orders for an antibiotic to treat the client's infection. 4. Medicate the client for pain.
Answer: 1 Rationale: Temperature elevation immediately after delivery is often caused by dehydration during labor. Increasing the client's fluid intake will usually decrease the temperature to within normal limits. There is no indication for analgesia or antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recognize that the focus of the question is dehydration fever after delivery. The correct answer would be the option that contains a nursing action to correct this minor and typically temporary finding. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 811-816.
The client is a 36-year-old woman, gravida 6 and para 6, who delivered a 7 pound, 14 ounce baby girl at term after an eight-hour labor. The client's vital signs are stable, and her lochia is bright red, heavy, and contains various clots; some are half dollar size. The nurse would consider the client to be at high risk for uterine atony for which reason? 1. Grandmultiparity 2. Large for gestational age baby 3. Labor of long duration 4. Advancing maternal age
Answer: 1 Rationale: Women that are parity of six or above (grandmultiparity) are at the greatest risk of uterine atony because of repeated distention of uterine musculature during pregnancy. Labor leads to muscle stretching, diminished tone, and muscle relaxation. The client's age is not a factor in uterine atony, the length of labor is not considered to be prolonged or precipitous, and the size of the baby is considered appropriate for gestational age, and is not considered to be macrosomic. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The focus of the question is risk identification for uterine atony. Eliminate two options as this client's infant is of normal size and labor was of average duration. Eliminate maternal age, which is not a risk factor for hemorrhage. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 888-892.
The home-care nurse is caring for a postpartal client and suspects the development of postpartum psychosis. Which client findings support the nurse's judgment? Select all that apply. 1. Has a history of a bipolar (manic-depressive) disorder 2. Reports voices telling her the baby is evil and must die 3. Can't remember details of delivery or when the infant fed last 4. Is tearful without an identifiable reason 5. Is calm and remains seated during the home visit
Answer: 1, 2, 3 Rationale: Postpartum psychosis usually becomes evident within three months of delivery. Delusions and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic woman's distorted thoughts about herself or the baby. The psychotic woman would typically display agitation, hyperactivity, and confusion. Adjustment reaction with depressed mood, commonly known as maternal or baby blues, occurs in 50-70% of women and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously about the 10th postpartal day. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The question is worded as a positive statement. The correct answer would be the options that contain true statements of assessment findings for postpartal psychosis. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 908.
The nurse would assess for which common causative factor in a client who shows signs of retarded uterine involution? Select all that apply. 1. The use of general anesthesia 2. Overdistended urinary bladder 3. Mother is a primigravida 4. Uterine infection 5. Prolonged labor
Answer: 1, 2, 4, 5 Rationale: Among the factors contributing to uterine subinvolution are prolonged labor (frequent contractions), general anesthesia (muscle relaxant), overdistended urinary bladder and uterine infection, among others. Being a primigravida is not necessarily associated with subinvolution. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct. Recall common factors that contribute to retarded uterine involution to choose correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 801.
Which interventions should be included when caring for a client with a midline episiotomy with a third-degree laceration? Select all that apply. 1. Increase fiber in diet. 2. Administer bisacodyl (Dulcolax) suppository. 3. Increase fluid intake. 4. Administer an oral stool softener. 5. Administer an enema.
Answer: 1, 3, 4 Rationale: A third-or fourth-degree perineal laceration involves the rectal sphincter, therefore suppositories, enemas, and rectal exams are contraindicated until the rectum heals. Increased fiber and fluids or use of stool softeners are appropriate to promote bowel elimination in all postpartum clients. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct Use knowledge of interventions and contraindications for a third-or fourth-degree laceration to make your selections. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 820-823.
The nurse should monitor which postpartum clients who are at high risk for thrombophlebitis? Select all that apply. 1. A client who had a cesarean delivery 2. A client of normal pre-pregnant weight 3. A client who has five children 4. A client who smokes cigarettes 5. A client who kept active during pregnancy
Answer: 1, 3, 4 Rationale: The postpartal woman is prone to develop superficial thrombophlebitis from increased clotting factors, increased number and adhesiveness of platelets during the postpartal period. Numerous factors place clients at risk. Among the most common are cesarean deliveries, lack of mobility, obesity, cigarette smoking, previous history, trauma such as leg stirrups during birth, varicosities, diabetic mothers, multiparas, and anemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct. Use knowledge of risk factors for thrombophlebitis to make your selections. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 902-903.
If the nurse suspects a uterine infection in the post-partum client, the nurse should make which priority assessment? 1. Pulse and blood pressure 2. Odor of the lochia 3. Episiotomy site 4. The abdomen for distention
Answer: 2 Rationale: An abnormal odor of the lochia indicates infection in the uterus. The vital signs may be affected by an infection, but that is not definitive enough to suspect a uterine infection. A distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus. Inspection of the episiotomy site would not provide information regarding a uterine infection. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The critical words in the question are uterine infection. The correct answer would be the option that includes an assessment specific to uterine infection. The three incorrect options should be eliminated because they are not specific assessments for uterine infection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 892-893.
The infant of a breastfeeding client was transferred to the neonatal intensive care unit because of respiratory distress. The nurse interprets that follow-up teaching has been effective when the client states which reason to pump the breasts? 1. Prevent breast engorgement 2. Stimulate the milk supply 3. Remove the infected milk 4. Keep the uterus contracted
Answer: 2 Rationale: Breast-milk production is based on supply and demand. The more the breasts are stimulated to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: The critical word in the stem of the question is effective, which tells you the correct option is also a true statement. Use knowledge of breastfeeding and how to stimulate milk production to aid your selection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 712-713.
A client who had a vaginal delivery had an episiotomy prior to birth. The maternal newborn nurse would evaluate the client's perineum following delivery is using which method? 1. REDA-redness, edema, discharge, approximation 2. REEDA-redness, edema, ecchymosis, discharge, approximation 3. REAA-redness, edema, approximation, assessment 4. RED-redness, edema, discoloration
Answer: 2 Rationale: Nursing assessment of the perineum includes the following observations, which are abbreviated as REEDA: redness, edema, ecchymosis, discharge, and approximation. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: Critical words are episiotomy and evaluation of perineum. Recall the mnemonic for perineal assessment to choose correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 820.
A client's vital signs following delivery are: (Day 1) BP 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; (Day 3) BP 114/80, T 101.6, P 80. The nurse should suspect which of the following about the client's status? 1. Is dehydrated 2. May have an infection 3. Has normal vital signs 4. Is going into shock
Answer: 2 Rationale: The vital signs are not normal. An elevation in body temperature greater than 100.4°F after the first 24 hours postpartum could indicate maternal infection. An elevated temperature within the first 24 hours is usually related to dehydration, although the possibility of infection still exists. Rising pulse and falling blood pressure rather than rising temperature is an indicator of hypovolemic shock. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The assessment data includes an abnormal and increasing temperature, a sign of infection. Eliminate options that suggest other complications. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 830-832.
While assessing the incision of a client two days after cesarean delivery, the nurse notes the skin edges around the incision are red, edematous, and tender to the touch. A scant amount of purulent drainage is noted. What is the most appropriate initial action by the nurse? 1. Cleanse the wound with povidone iodine (Betadine). 2. Notify the physician. 3. Document this expected response. 4. Observe the incision closely for the next 24 to 48 hours.
Answer: 2 Rationale: This client has signs of an incisional infection. The physician needs to be notified first so that treatment can be started as soon as possible. Betadine has not yet been ordered. Documentation should follow reporting. Continued observation would be an ongoing intervention. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of this question is the collection of assessment data indicating a change in the client's condition: development of infection. The correct answer would be the option that best provides for the safety of the client, reporting the abnormal findings so treatment can be instituted. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 848.
The nurse is assessing a client's fundus and finds it firm, two centimeters above the umbilicus and displaced to the right. What is the most appropriate intervention at this time? 1. Massage the fundus until firm. 2. Have the client void and reassess the fundus. 3. Notify the physician. 4. Start a pad count.
Answer: 2 Rationale: This client's fundus is already firm, so it is not appropriate to massage the fundus. It is also higher in the abdomen than expected, and it is displaced to the right, which is probably caused by a distended bladder. Having the client void may return the uterus to the expected position; palpating the fundus after voiding will confirm this finding. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The critical words in the question are firm but displaced uterine fundus, common findings with a full bladder. Eliminate options that do not focus on this condition. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 817-818.
Which intervention, if medically prescribed and then carried out by the nurse, would have the most direct effect on reducing postpartum hemorrhage? 1. Continuous fundal massage to decrease bleeding and contract the uterus 2. Trendelenburg position to facilitate cardiac function 3. Bladder catheterization to maintain uterine contraction 4. Administration of a tocolytic drug
Answer: 3 Rationale: A full bladder may cause uterine atony and contribute to bleeding. If a client has hemorrhaged, a Foley catheter may also be needed to allow accurate measurement of urine output, which is an indicator for kidney function. Overly aggressive stimulation of the fundus may cause decreased uterine tone; this is detrimental because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A tocolytic agent relaxes the uterus; in this case, an oxytocic drug to contract the uterus would be indicated. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: First, eliminate factors that cause uterine relaxation, which would increase bleeding. Next, recall that Trendelenburg position has harmful effects to eliminate it. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 885-892.
On the client's third postpartum day, the nurse enters the room and finds the client crying. The client states that she does not know why she is crying and she cannot stop. What is the most appropriate reply by the nurse? 1. "There is no need to cry, you have a healthy baby." 2. "Are you dissatisfied with your care? I will see that any issues are addressed." 3. "Many new mothers have shared with us their same confusion of feelings, would you like to talk about them?" 4. "This happens to lots of mothers, and be reassured that it will pass with time."
Answer: 3 Rationale: Creating an environment where a client and her family can discuss emotional concerns is essential. Sharing time with the new mother to discuss thoughts and feelings is important to clients. Responding with patronizing answers does nothing to assist the mother to talk about her thoughts and feelings and may increase her sense of isolation and feelings of inadequacy and despair. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternal-Newborn Strategy: The focus of the question is therapeutic communication. The correct answer would be the option that validates and explores the client's feelings. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 808, 907-908.
The nurse is reviewing infection control policies with a nursing student. The nurse knows that the teaching has been effective when the student states, "The best way to prevent postpartum infection starts 1. in the recovery room with strict use of sterile technique when palpating the fundus." 2. on the postpartum unit by teaching the client the principles of perineal care." 3. by limiting the number of sterile vaginal exams during labor." 4. when the client goes home by avoiding tub baths until the lochia stops."
Answer: 3 Rationale: Even when perfect sterile technique is used when doing a vaginal exam, organisms present on the perineum are transported into the vagina and close to the cervix. By limiting the number of vaginal exams, the risk is decreased. The option discussing technique is incorrect because clean technique, not sterile technique, is used when palpating the fundus. Teaching the client the principles of peri-neal care and avoiding tub baths until the lochia stops are correct answers, but not the earliest intervention a nurse could perform. Cognitive Level: Applying Client Need: Safety and Infection Control Integrated Process: Nursing Process: Evaluation Content Area: Maternal-Newborn Strategy: Critical words are best way to prevent postpartum infection. Knowledge of medical and surgical asepsis and preventing postpartum complications will aid in choosing the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 431-435.
A woman who delivered three weeks ago calls the postpartum unit with breastfeeding questions. She wants to know if she can continue to breastfeed while she has the flu. She states that she feels achy all over and has chills and a fever of 103°F. What other question is important for the nurse to ask? 1. "Have you been sleeping well?" 2. "Are you still experiencing vaginal flow?" 3. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" 4. "Do you have any swelling in your legs or visual disturbances?"
Answer: 3 Rationale: Mastitis most frequently occurs at two to four weeks after delivery with initial flu-like symptoms plus breast tenderness and redness. The client may be describing symptoms of a breast infection. Sleep, lochia, and edema with visual disturbances are not associated with breast problems. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is breastfeeding and the potential complication of mastitis. The correct answer would be the option that obtains further assessment data related to the breasts. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 899-900.
It is most important for the nurse to have which drug readily available when the client is being treated with heparin therapy for thrombophlebitis? 1. Calcium gluconate 2. Vitamin K 3. Protamine sulfate 4. Ferrous sulfate
Answer: 3 Rationale: Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. One option raises serum calcium levels; another is the antidote for warfarin, and the other option is an iron supplement. Cognitive Level: Applying Client Need: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is anticoagulation related to heparin use. The correct answer would be the option that contains a drug with an action to combat bleeding. Reference: Wilson, B., Shannon, M., & Shields, K. (2011). Pearson Nurse's drug guide 2011. Upper Saddle River, NJ: Pearson Education, p. 740.
The nurse is assessing a client 24 hours after delivery and finds the fundus to be slightly boggy and two centimeters above the umbilicus. What should be the nurse's priority nursing intervention? 1. Document this expected finding and check lochia. 2. Assess the mother's vital signs. 3. After having the mother void, gently massage the fundus until firm. 4. Notify the physician and document.
Answer: 3 Rationale: The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage and decrease one centimeter below the umbilicus each day. All nursing interventions presented are appropriate, but massaging the fundus until firm is the most important to prevent hemorrhage. Full urinary bladders can interfere with uterine contraction. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is the priority action to promote maternal safety and prevent hemorrhage related to a boggy uterus. The correct answer would be the option that contains a nursing action to prevent hemorrhage. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 801.
A new mother with mastitis is concerned about breastfeeding while she has an active infection. How should the nurse respond to the client's concern? 1. The infant is protected from infection by immunoglobulins in the breast milk. 2. The infant is not susceptible to the organisms that cause mastitis. 3. The organisms that cause mastitis are not passed in the milk. 4. The organisms will be inactivated by gastric acid.
Answer: 3 Rationale: The organisms are localized in breast tissue and are not excreted in the breast milk. The other answers are factually incorrect. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The wording of the question indicates that the correct option is also a true statement. Knowledge of the care of the woman with mastitis and the pathophysiology will aid in choosing correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 899-901.
The home health nurse is making a home visit to a postpartal client. The nurse would document and report which of the following as a symptom of infection? 1. Lochia that is pink tinged 2. Apical pulse of 68 3. Generalized abdominal tenderness 4. Oral temperature of 99.2°F
Answer: 3 Rationale: The signs of a postpartal infection would include a temperature of greater than 100.4°F on two successive days after the first 24 postpartal hours, tachycardia, foul-smelling lochia, and pain and tenderness of the abdomen. The pinkish lochia is normal, and the temperature might indicate a cold or breast milk coming in. Bradycardia would be an unrelated finding. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is an infection, an abnormal finding in the postpartum. Postpartal infections are usually located in the uterus. The correct answer would be the option that contains abnormal assessment data associated with uterine infection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 892-893.
Which sign of thrombophlebitis should the nurse instruct the postpartal client to look for when at home after discharge from the hospital? 1. Muscle soreness in her legs after exercise 2. Enlarging varicose veins in her legs 3. Localized posterior leg tenderness, heat, and swelling 4. New areas of ecchymosis
Answer: 3 Rationale: These are classic signs of thrombophlebitis that appear at the site of inflammation; the other signs listed are not. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: The wording of the question indicates the correct option is also a true statement. Knowledge of the signs and symptoms of thrombophlebitis will help to choose the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 902-907.
The nurse is caring for a client who has decided not to breastfeed. What should the nurse include in client teaching to promote lactation suppression? Select all that apply. 1. Applying warm compresses 2. Pumping the breasts 3. Applying ice bags 4. Using medication to suppress lactation 5. Binding the breasts, either with a snug bra or binder
Answer: 3, 5 Rationale: Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the breasts. Medications to suppress lactation are not recommended. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Knowledge of the ways to suppress lactation in the non-breastfeeding mother will help to answer the question correctly. The correct answers are options that include a true statement about a point of client education. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 816, 839-840.
The nurse is preparing to instruct a new mother on resuming sexual intercourse postpartum. The nurse should include which of the following in the teaching plan? Select all that apply. 1. Pregnancy is not possible prior to the first menses postpartum. 2. An IUD is an appropriate method of birth control in the early postpartum period. 3. Wait until the episiotomy has healed and the lochia has stopped before resuming intercourse. 4. Refrain from intercourse until the first menstrual period after delivery is completed. 5. A water-soluble lubricant may be used if necessary.
Answer: 3, 5 Rationale: Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases the risk of infection. Water-soluble lubricants can be used, if necessary. An IUD is contraindicated during the early postpartum period. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Use the process of elimination and look for statements that are true. Knowledge of client teaching for resumption of sexual activity after delivery will help to answer the question correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 803-804.
A postpartum client develops a temperature during her postpartum course. Which temperature measurement indicates to the nurse the presence of postpartum infection? 1. 99.0°F at 12 hours postdelivery that decreases after 18 hours 2. 100.2°F at 24 hours postdelivery that decreases the second postpartum day 3. 100.4°F at 24 hours postdelivery that remains until the second postpartum day 4. 100.6°F at 48 hours postdelivery that continues into the third postpartum day
Answer: 4 Rationale: A temperature elevation greater than 100.4°F on two postpartum days not including the first 24 hours meets the criteria for infection. This criterion is the most common standard in the United States. It is not abnormal for a postpartum client to run a low-grade fever in the first 24 hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. Postpartum nurses should assess other signs and symptoms of infection in addition to fever and WBCs when evaluating the possibility of infection in mothers who had epidural analgesia. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is assessment data that defines puerperal morbidity. This definition includes a time element (after 24 hours) and a threshold for elevated temperature (greater than 100.4°F). Eliminate incorrect options because they do not meet the definition for postpartal infection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, p. 892.
Which instruction should the nurse include in the discharge teaching plan to assist the postpartal client to recognize early signs of complications? 1. Expect to pass clots, which occasionally can be the size of a golf ball. 2. Report a decrease in the amount of brownish-red lochia. 3. Palpate the fundus daily to make sure it is soft. 4. Notify the health care provider of increased lochia or bright red bleeding.
Answer: 4 Rationale: An increase in lochia or a return to bright red bleeding after the lochia has changed to pink indicates a complication. The other statements are false. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The wording of the question indicates the correct option is also a true statement. Knowledge of complications for the postpartal client will aid in choosing the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 850-854.
A client delivered a 9 pound, 10 ounce infant assisted by forceps. When the nurse performs the second 15-minute assessment, the client reports increasing perineal pain and a lot of pressure. What action should the nurse take? 1. Apply ice to the client's perineum, reassuring the client that this is normal. 2. Call for assistance from another nurse. 3. Assess the fundus for firmness. 4. Check the perineum for a hematoma.
Answer: 4 Rationale: Bleeding into the connective tissue beneath the vulvar skin may cause the formation of vulvar hematomas, which develop as a result of injury to tissues with spontaneous as well as operative deliveries (use of forceps). One of the first signs of a hematoma may be complaint of pressure, pain, or an inability to void. An ice pack to the perineum can be used to reduce swelling, but a hematoma is abnormal and should be reported to the physician. The fundus should be assessed, but the client's complaints warrant perineal or vaginal assessment. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The question presents abnormal assessment data that warrants further assessment. The correct answer would be the option that includes an action for the nurse to take to obtain additional assessment findings related to perineal pain and pressure. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, pp. 887-889.
Despite the nurse's attempt to massage a boggy fundus, a postpartum client continues to pass several large clots in the presence of bright red lochia. The uterine fundus remains boggy and fundal massage and oxytocin (Pitocin) are not successful. What medication does the nurse expected to be prescribed next? 1. Dinoprostone (Cervidil) 2. Terbutaline sulfate (Brethine) 3. Magnesium sulfate 4. Carboprost (Prostin 15-M or Hemabate)
Answer: 4 Rationale: Cervidil is used to ripen the cervix before labor; terbutaline sulfate is a tocolytic, and could cause further muscle relaxation; magnesium sulfate is used to decrease contractions or prevent seizures; and Hemabate is a prostaglandin, used to manage uterine atony. Oxytocin remains the first-line drug, the prostaglandins now are more commonly used as the second-line drug, and carboprost (Prostin 15-M or Hemabate) is the most commonly used uterotonin. As many as 68% of clients respond to a single carboprost injection, with 86% responding by the second dose. Cognitive Level: Applying Client Need: Physiological Adaptation Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is a second-line agent to stimulate uterine contraction. Eliminate the three options that identify drugs that do not possess this action. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, p. 457.
A client is in the immediate postpartal period after delivery of a 9-pound, 14-ounce baby. The client is a gravida 6, para 5. The nurse notices some new blood stains on the top sheet and discovers the client lying in a pool of blood. The fundus is located above the umbilicus and is boggy. What would be the nurse's priority action? 1. Take the client's blood pressure 2. Have the client empty her bladder 3. Start an IV 4. Massage the uterus
Answer: 4 Rationale: Of the options given the only one that immediately affects the bleeding is uterine massage. It might be important to start an IV with oxytocin at a rapid rate, and to allow the client to empty her bladder; however, the first action is to massage the uterus to stop or slow down the blood flow. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is hemorrhage in the presence of uterine relaxation. The correct answer would be the option that contains a nursing action to contract the uterus and prevent further hemorrhage. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 886-887.
A client's prenatal laboratory findings reveal that she is not immune to rubella. The health care provider prescribes rubella vaccine prior to discharge. The nurse concludes that teaching about this medication is effective when the client makes which statement? 1. "I'll need another shot in one month and again in six months." 2. "This shot may cause a fever and make me vomit." 3. "I'll need another shot after each baby I have with Rh-positive blood." 4. "I should not get pregnant for at least three months after the vaccine."
Answer: 4 Rationale: The rubella vaccine is a live virus. If a client becomes pregnant within the first three months after administration, her fetus is at risk for congenital anomalies related to the virus. Women who are not rubella immune should be vaccinated postpartum, prior to discharge. Teaching should include an effective method of birth control and the importance of avoiding pregnancy for the next three months. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: The wording of the question indicates that the correct answer is also a true statement. Use knowledge of rubella immunizations in the postpartum period to aid in answering the question. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 839.
The nurse is caring for a woman who gave birth to a daughter yesterday, but greatly desired a son. Today she seems withdrawn, staying in bed and staring at the wall. What is the most appropriate intervention? 1. Monitor this normal response after delivery. 2. Refer the client for a psychiatric consultation. 3. Tell the client she should be thankful her baby is healthy. 4. Encourage the mother to verbalize her disappointment.
Answer: 4 Rationale: This client should be encouraged to verbalize her disappointment as the first step in resolving her negative feelings. The other responses are incorrect. This is not a normal response nor is it one that requires a psychiatric referral. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: Recognize that the data given in the question may be related to disappointment with the sex of the infant. The best response would be the option that facilitates therapeutic communication to encourage the client to express her feelings. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, p. 808.
Which of the following actions by a lactating client would the nurse support to help the client prevent mastitis? Select all that apply. 1. Apply vitamin E cream to soften the nipples. 2. Wear a tight, supportive bra. 3. When the client's nipples are sore, offer the infant a bottle. 4. Encourage the client to breastfeed her infant frequently. 5. Teach breastfeeding techniques soon after birth and reinforce as needed.
Answer: 4, 5 Rationale: Preventing stasis of the milk and emptying the breast frequently will help prevent mastitis. Vitamin E cream will not help to prevent mastitis. A supportive bra is helpful, but a bra that is tight will not be comfortable. Offering a bottle will reduce the milk supply if it occurs frequently and will not help mastitis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The question is worded in a positive manner, indicating that the correct options are items that will prevent mastitis. Eliminate one option immediately because of the word tight. Use knowledge about the prevention of mastitis to choose the correct answers. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 675-679.
Because postpartum depression occurs in 3 to 30% of postpartal women, the prenatal nurse assesses clients for risk factors for postpartum depression during the prenatal period. Which clients would the nurse consider to be at risk for postpartum depression? Select all that apply. 1. A client who is an unmarried primipara with family support 2. A client who has previously had postpartum blues 3. A client who is a primipara with documented ambivalence about her pregnancy in the first trimester 4. A client who is a primipara with a history of depression and lack of a supportive relationship 5. A client who is a primipara living alone and was consistently ambivalent about pregnancy
Answer: 4, 5 Rationale: Risk factors for postpartum depression include primiparity, ambivalence about maintaining the pregnancy throughout the pregnancy, history of previous depression or bipolar illness, lack of a stable support system, lack of a stable relationship with parents or partner, poor body image, and lack of a supportive relationship with parents, especially her father as a child. Ambivalence regarding pregnancy is a normal response in the first and into the second trimester, but should be resolved by the third trimester. Postpartum blues occurs in approximately 50 to 80% of postpartum women; the blues does not particularly indicate that a woman will develop postpartum depression. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is risk factors for postpartum depression. Eliminate two options that contain findings common in a normal pregnancy and a third because the presence of support can reduce the risk of psychological complications. Reference: Ladewig, P. A., London, M. L., & Davidson, M.R. (2010). Contemporary maternal-newborn nursing care (7th ed.).Upper Saddle River, NJ: Pearson Education, p. 908.
The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client?
Assist the client to the bathroom in 2 hours to void.
A nurse is providing discharge teaching to a postpartum patient who is bottle feeding. The patient asks the nurse when she should expect to have her period return. The nurse's best response is: A. "You can expect to have your period in 3-4 weeks." B. "Many women who choose not to breastfeed will have a period in 7-9 weeks after childbirth." C. "Your period will return at about 6 months post-delivery." D. "Bottle feeding suppresses ovulation, so as long as you bottle feed, you will not have a period."
B
Select the statements that are true regarding primary engorgement. A. Only women who are lactating will experience primary engorgement. B. It is caused by an increase in the vascular and lymphatic system of the breast. C. The breasts become large, firm, and warm to touch. D. It subsides within 24-36 hours.
B,C,D
your postpartum patient is a 25 year old white single woman who gave birth to a healthy infant. She is 36 hours post birth. you note that she holds her infant as a distance and refers to it as it. Based on this assessment, your initial nursing actions include A. Obtain referral for a social worker B. ask the woman to tell you about her pregnancy and childbirth experience C. teach her the importance of holding her baby close to her body. D. take her baby to the nursery so she can have some uninterrupted sleep.
B. ask the woman to tell you about her pregnancy and childbirth experience
To decrease the risk of orthostatic hypotension during the first few hours after the birth, the nurse should: A. Assist the patient to the bathroom by using a wheelchair. B. Break open an ammonia ampule and have the patient take a deep breath before getting up. C. Have the patient sit on the side of the bed for a few minutes before standing. D. Check the patient blood pressure before assisting her to the bathroom.
C
Your postpartum patient is 10 hours post birth. She experienced an uncomplicated labor and birth and her newborn is full term with apgar scores of 9 and 9. During your assessment you note that she was hungry and very interested in telling you about her birth experience You had to remind her to change and feed her baby. Base on this assessment, you determine that she is A. having difficulty bonding with her baby B. not concerned about her baby's needs C. in the taking-in phase D. in the taking-hold phase
C. in the taking-in phase
The nurse assists a patient who delivered vaginally 6 hours ago to the bathroom to void for the first time since delivery. The patient voids 65 mL of urine. The nurse's initial action is to: A. Document this as a normal finding. B. Encourage the patient to try to void again within the next 4-6 hours. C. Insert an indwelling Foley catheter. D. Palpate for bladder distention.
D
which 2 day postpartum woman has an abnormal finding that requires intervention? A. a 23 year old arabic woman who plans to breastfeed but wants to bottle feed until her milk comes in B. a 28 year old chinese woman who refuses to take a shower. C. a 20 year old japanese woman who has her mother care for her baby. D. a 19 year old caucasian woman who requests that her baby stay in the nursery so she can sleep.
D. a 19 year old caucasian woman who requests that her baby stay in the nursery so she can sleep.
LOCHIA RUBRA
Day 1-3. All lochia have "fleshy odor". Bloody with small clots
LOCHIA ALBA
Day 10. Yellow to white in color. Scant amount
LOCHIA SEROSA
Day 4-10. Pink or brown color. Scant amount
The postpartum client is about to go home. The nurse includes which subject in the teaching plan?
Diastasis of the recti muscles
The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following?
Frequent breastfeedings
The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following?
Help the new mother by allowing her to focus on resting and caring for the baby.
To actively involve the postpartal client during discharge teaching, the postpartum nurse applies which learning principle?
Interactive nursed-patient relationships
Clinical features of posttraumatic stress disorder (PTSD) include which of the following?
Irritability Flashbacks Difficulty sleeping
The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. To prevent or minimize abdominal distention, which of the following would the nurse encourage?
Leg exercises every 2 hours Abdominal tightening Ambulation
A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications?
Misoprostol Methergine
What maternity unit policies promote postpartal family wellness and shared parenting?
Mother-baby care or couplet care on the postpartum unit Skin-to-skin contact between the mother and baby and the father and baby On-demand feeding schedule for both breastfed and bottle-fed infants
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?
Nonsteroidal anti-inflammatory agents
Which of the following is a risk factor for urinary retention after childbirth?
Not sufficiently recovering from the effects of anesthesia
The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?
Obtain an order for a stool softener.
The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?
Offering the patient pre-medication 2 hours before the assessment
A client is preparing to take a sitz bath for the first time. What will the nurse do?
Place a call bell well within reach and check on the client frequently.
When caring for a new mother after cesarean birth, what complications would the nurse anticipate?
Pulmonary infection Deep vein thrombosis Pulmonary embolism
The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following?
Purulent, foul-smelling lochia
perineum is assessed every shift using the acronym
REEDA (redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration).
Which findings would indicate the presence of a perineal wound infection?
Redness Tender at the margins Hardened tissue Purulent drainage
A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action?
That the client would be placed on bed rest
The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention?
The client appears anxious, and describes pressure in her chest.
What is the advantage of a client using a patient-controlled analgesia (PCA) following a cesarean birth?
The client feels a greater sense of control, and is less dependent on the nursing staff.
The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior?
The client is exhibiting normal behavior for her culture.
A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn?
The client who continues to touch her baby with only her fingertips
The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage?
The client who had oxytocin augmentation of labor
The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately?
The client who reports hearing voices talking about the baby
The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer's solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action?
To assist the client to the bathroom
The nurse is planning discharge teaching for a postpartum woman. What information recommendations should the woman receive before being discharged?
To avoid overexertion To practice postpartum exercises To obtain adequate rest
9. You are assigned to a woman who is 2 hours' post-birth. She had an emergency cesarean section for an abruptio placenta. Based on this history, the woman is at risk for ________. Fill in the blank. A. Disseminated intravascular coagulation B. Retained placenta fragments C. Thrombosis D. Subinvolution of the uterus.
a
7. Which of the following should be included in postpartum discharge teaching regarding risk reduction for cystitis? Select all that apply. A. Drink a minimum of 3,000 mL of fluid per day. B. Change peripads at least every 3-4 hours. C. Eat foods low in acidity. D. Avoid caffeinated fluids.
ab
2. Mrs. Fischer is 2 days' post-birth. She calls the clinic and tells the triage nurse that she has a temperature and does not feel well. What additional assessment findings does the triage nurse need to obtain to assist in her nursing assessment? Select all that apply. A. When did she notice an increase in temperature and what is her temperature? B. Is she experiencing pain, and if so, where is it located? C. What is the amount of her fluid intake within the past 24 hours? D. What is the color and amount of her bleeding?
abcd
8. Which of the following factors place a woman at risk for thrombosis? Select all that apply. A. Obesity B. Physiological changes of pregnancy C. Metritis D. Cesarean birth
abcd
5. Signs and symptoms of postpartum depression include which of the following? Select all that apply: A. Sleep and appetite disturbance B. Uncontrolled crying. C. Delusions D. Feelings of guilt and/or worthlessness.
abd
1. Your patient is a 25-year-old gravida 1 woman who is 2 hours postpartum. You note on assessment that her fundus is firm and midline. She is experiencing a steady stream of blood. The bed linen under her is soaked in blood. Based on these findings and observations, you suspect that she is exhibiting early signs/symptoms of a postpartum hemorrhage related to: A. Uterine atony B. Laceration of the cervical or vaginal area C. Retained placental tissue D. Fibroids.
b
4. Women who experience mastitis should be instructed to: A. Stop breastfeeding until 48 hours after the start of antibiotic treatment B. Continue to breastfeed or massage and express milk from the affected breast. C. Wash nipples with antibiotic soap before each feeding session. D. Apply cream to nipples after each feeding until mastitis has resolved.
b
You are assigned to a woman who is 5 hours' post-birth. She gave birth to an 8-pound girl and experienced a 4th degree tear of the perineum. During your postpartum assessment, she informed you that she has rectal pressure and severe pain where she tore. Her level of pain is 10 on a pain scale of 0-10. You notice her perineum is intact with minimal bruising. Her blood pressure is 100/60 and pulse is 98. Based on this assessment data, select the best initial nursing action. A. Medicate her for pain. B. Notify her physician of your assessment data. C. Place an ice pack on the perineum. D. Assist her in ambulating.
b
After birth, the fundus will be located
between the umbilicus and symphisis pubis and is firm and midline
Lochia
bloody discharge from the uterus that contains sloughed off necrotic tissue, undergoes changes that reflect the healing stages of the uterine placental site
3. Foul-smelling lochia occurs: A. When beta-hemolytic Streptococcus is the primary organism associated with metritis B. Within the first 24 hours' post-birth related to metritis C. When the entire endometrium is infected. D. During the normal involution process.
c
Colostrum
clear, yellowish fluid, precedes milk production. higher in protein and lower in carbohydrates than breast milk. It contains immunoglobulins G and A that provide protection for the newborn during the early weeks of life.
6. During a six-week postpartum clinic visit, your patient tells you she is concerned about her husband. She tells you that he either stays late at work or goes out after work with his friends. When he is home, he is usually drinking beer while watching sports on TV. Which of the following is the most appropriate response? A. "These are common behaviors of men as they process the meaning of fatherhood. You just need to give him time to work through this life change." B. "These behaviors can indicate that your husband does not want to take on the responsibilities of being a father. You need to talk to him about his feelings regarding fatherhood." C. "These behaviors indicate that your husband is concerned about the added cost of having a newborn. You and your husband need to sit down and set up a budget." D. "These behaviors might indicate that your husband is depressed. You need to encourage him to see a mental health professional."
d
If boggy- nurse should
massage with palm of hand, give oxytocin PER ORDER, notify HCP or midwife if doesn't respond
Primary complication of breast feeding
mastitis
A primary complication is
metritis, which is an infection of the endometrial tissue
Afterpains
moderate to severe cramp-like pains that are related to the uterus working harder to remain contracted and/or to the increase of oxytocin that is released in response to infant suckling. The uterus needs to be in a contracted state during the postpartum period to decrease the risk of postpartum hemorrhage. The contracted uterine muscle compresses the open vessels at the placental site and decreases the amount of blood loss.
endometrium
mucous membrane that lines the uterus, undergoes exfoliation and regeneration after the birth of the placenta through the process of necrosis of the superficial layer of the decidua and regeneration of the decidua basalis into endometrial tissue.
Do primaparaous women experience discomfort from involution?
usually do not experience discomfort related to uterine contractions during the postpartum period
Large clots can interfere with
uterine contractions.
boggy uterus indicates
uterus is not contracting and places the woman at risk for excessive blood loss
Large clots should be
weighed and findings reported to the physician or midwife.
Heavy is
when the pad is saturated within 1 hour
The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart?
"Cesarean birth after extended labor with ruptured membranes."
A client who delivered 2 hours ago tells the nurse that she is exhausted and feels guilty because her friends told her how euphoric they felt after giving birth. How should the nurse respond?
"Everyone is different, and both responses are normal."
The nurse is providing education to the new family. Which question by the nurse is best?
"How have your breastfeedings been going?"
The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make?
"I am constantly tired. I feel like I could sleep for a week."
The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?
"Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed."
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?
"Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple."
The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?
"One minute I'm laughing and the next I'm crying."
The client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond?
"Sometimes the uterus relaxes and excessive bleeding occurs."
The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue?
"Voiding 2 or 3 times per day will help prevent a recurrence."