MNB PassPoint - Postpartum Period

The nurse is providing teaching to an expectant mother about breastfeeding. What statement made by the mother would require immediate follow-up by the nurse?

"I have been HIV positive for 4 years."

A client calls the public health nurse with concerns that her one-month-old breastfed infant is not gaining weight as rapidly as her friend's newborn, who is the same age and formula-fed. What is the most helpful response by the nurse?

"I hear that you're concerned. Can you tell me more about your baby's growth pattern?"

After instructing a primiparous client who is bottle-feeding about burping, which client statement indicates that the client needs further teaching?

"I will burp the baby after 15 minutes of feeding them formula."

A female client who gave birth to a healthy baby 6 hours ago is having cramps in their legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?

Notify the health care provider (HCP).

A registered nurse (RN) calls in sick, leaving an RN and two nursing assistants to care for twelve postpartum clients. How should the RN on the postpartum floor respond to the staffing issue?

Notify the supervisor and request that another RN be assigned to the unit.

A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?

"Gloves are required for standard precautions."

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning their neonate?

"Gradually eliminate one feeding at a time."

The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care?

Assess the client's bleeding flow and color.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that they have been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing the baby?

Express a small amount of breast milk.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization.

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) of which finding?

saturating a pad in less than an hour

A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?

taking-in phase

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse?

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby."

A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate?

"Leave the diaphragm in place for at least 6 hours after intercourse."

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.

A postpartum client tells the nurse she is constipated. Which response by the nurse is best?

"Add more fruits, vegetables and fluid to each meal"

The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant?

"Formula-fed infants usually feed every 3 to 4 hours."

Which client statement indicates effective teaching about burping a breastfed neonate?

"When I switch to the other breast, I will burp the baby."

The nurse is caring for a client 2 days post-cesarean section who is scheduled for discharge today. The client states, "I do not want to go home." What response by the nurse is most appropriate?

Ask the client the reason she does not want to go home.

While caring for a multiparous client 4 hours after the vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. The fundus is firm, midline, and at the level of the umbilicus. What should the nurse do?

Continue to monitor the client's vital signs.

The nurse is documenting medication administration at the bedside and realizes docusate sodium was administered to the wrong postpartum client. Which action should the nurse take first?

Disclose the error to the client.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next?

Document this observation as a normal finding.

The nurse is caring for a new breastfeeding client who is experiencing poor latching and sore nipples. What direction would the nurse offer to best address this breastfeeding issue?

Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth.

A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. What instructions would be most appropriate to include in the plan of care?

Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

During a home visit to a breastfeeding primiparous client 1 week after birth, the client tells the nurse that their nipples have become sore and cracked from the feedings. Which instruction should the nurse give the client?

Position the baby with as much of the areola as possible in the baby's mouth.

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the client and their partner to do?

Relate to each twin individually to enhance the attachment process.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours.

The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time?

Ask the client to empty her bladder.

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake?

six to eight wet diapers by the fifth day

A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after birth. What priority outcome criteria should the client achieve?

The client will void more than 30 mL/hour without urinary retention beginning 1 hour after birth.

A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method?

The implants provide effective, continuous contraception that isn't user dependent.

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy."

While assisting a primiparous client with their first breastfeeding session, the nurse should instruct the client to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple?

Brush the neonate's lips lightly with the nipple.

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?

Catheterize the client.

A primiparous client who is bottle-feeding their neonate at 12 hours after birth asks the nurse, "When will my menstrual cycle return?" Which response by the nurse would be most appropriate?

"It will probably be 6 to 10 weeks before it starts again."

During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client says, "I have been crying a lot the last few days. I just feel so awful. I'm a rotten parent. I just do not have any energy. Plus, my spouse just got laid off from their job." The nurse observes that the client's appearance is disheveled. What would be the nurse's best response?

"It's not unusual for some parents to feel depressed after the birth of a baby. I'm going to contact your health care provider."

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response?

"Medroxyprogesterone needs to be administered every 12 weeks."

The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is:

diagnosed with mastitis.

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?

hemorrhage

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further?

perineal lacerations

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by

3 full days of elevated basal body temperature and clear, thin cervical mucus.

A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?

Stop the flow of urine while urinating.

The client is one day postpartum with an episiotomy. Teaching includes medications commonly used for the local relief of perineal pain due to episiotomy and/or laceration. Which medications does the nurse include in the client's teaching concerning pain? Select all that apply.

benzocaine witch hazel

A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?

"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."

A client who is 6 months postpartum asks the nurse about an effective method of birth control. What is the nurse's most appropriate response?

"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding."

The nurse provides health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding their neonate. Which client statement indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

A client's estranged partner arrives to visit the client's newborn because he believes he is the child's father. How does the nurse respond to the visitor?

"Please wait at the nurse's station while I discuss your desire to visit with the client."

The mother of a neonate expresses concern about how to continue breastfeeding when she returns to work in 6 weeks. How should the nurse respond?

"You can develop and practice a plan now for expressing milk and feeding so you're ready."

After suction and evacuation of a complete hydatidiform mole, a 28-year-old multigravid client asks the nurse when they can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long?

12 months

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth?

72 hours

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that person doing who lost their baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate?

Explain to the client that "nurses are not allowed to discuss other clients on the unit."

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that their breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?

Express a small amount of breast milk before breastfeeding.

A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage the client care assignment?

Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients.

On the first postpartum day after a cesarean birth, the client is prescribed a full liquid diet as tolerated. Before providing a full liquid breakfast, the nurse should assess which factor?

bowel sounds

At which time should the nurse anticipate assisting a client to breastfeed their neonate?

during the neonate's first period of reactivity

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which problem?

fainting

Which oral contraceptive is considered safe for use while breastfeeding because it will not affect the breast milk supply once breastfeeding has been well established?

progestin

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and they are experiencing chills. During palpation of the uterus, the client indicates that they are very sore. The nurse should further assess the client for which problem?

puerperal infection

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

removing the initial dressing for incision inspection

On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described?

rubra

A primiparous client who gave birth 3 days ago is to be discharged on heparin therapy. After teaching the client about the possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when they state that the adverse effects include which symptom?

slow pulse

While assessing the fundus of a multiparous client 36 hours after the birth of a term neonate, the nurse notes a separation of the abdominal muscles. What should the nurse should tell the client?

to perform exercises involving head and shoulder raising in a lying position

A postpartum primiparous client is having difficulty breastfeeding their infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when they make which statement?

"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."

A postpartum client decides to bottle-feed her neonate. Which client statement indicates the need for further teaching about preventing engorgement?

"Taking hot showers can help reduce engorgement."

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

A breastfeeding client asks a nurse ways to prevent mastitis. What is the nurse's best response?

Breastfeed frequently to prevent milk stasis and engorgement.

The nurse is providing breastfeeding teaching to a client 36 hours postpartum prior to discharge. The nurse recognizes an audible suck-swallow cycle during breastfeeding. Which intervention should the nurse perform next?

Reinforce the technique with the mother.

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when they ambulated to the bathroom after sleeping for 4 hours, their dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation?

The increased lochia occurs from lochia pooling in the vaginal vault.

Which finding requires further intervention in a mother who's breast-feeding?

The neonate's lips smack.

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area.

A multigravida prenatal client with a history of postpartum depression tells the nurse that they are taking measures to make sure that they don't suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications

The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications?

deep breathing and coughing exercises every 2 hours

A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to

discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.

While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest?

football hold

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

fundus two fingerbreadths above the umbilicus

A client at 4 weeks postpartum tells the nurse that they cannot cope any longer and are overwhelmed by their newborn. The baby has old infant formula staining the clothes and under the neck. The client does not remember when they last bathed the baby and states they do not want to care for the infant. The nurse should encourage the client and spouse to call their health care provider (HCP) because the client should be evaluated further for which complication?

postpartum depression

A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client?

risk for infection

Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when they state which effect is the purpose of the drug?

to prevent further blood clot formation