Postpartum

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and her breasts are soft. She has scant lochia and she is voiding sufficiently. The client reports pain in her lower back. What should the nurse do next?

Administer a prescribed mild analgesic.

On the second postpartum day after a cesarean birth, the client reports having gas pains. What should the nurse should instruct the client to do?

Ambulate more often.

A multigravida 30-year-old woman has given cesarean birth to a healthy term neonate due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client's urinary catheter and observes that the client's urine is slightly red-tinged. What should the nurse do next?

Contact the client's health care provider (HCP) for further orders.

A client is a gravida 1, para 0. During the first 24 hours after birth, she doesn't show consistent interest in her neonate. What should the nurse do next?

Document these expected behaviors of the taking-in period.

The nurse is caring for a primigravida who gave birth to a viable neonate 2 hours ago under epidural anesthesia. The new mother has a midline episiotomy. Which finding by the nurse would warrant further assessment?

two perineal pads soaked with blood within 30 minutes

In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal birth with a midline episiotomy. The client asks, "I've heard recommendations about when to resume intercourse have changed since my last baby. What are they saying now?" When should the nurse instruct the client that she can resume sexual intercourse?

when lochia flow and episiotomy pain have stopped.

A client gave birth to a neonate with spina bifida. The client was informed during her pregnancy that this situation could occur. The nurse giving a report on the client states that the client's decision to continue with the pregnancy was selfish and that the neonate will suffer. How should the nurse proceed in caring for this client and her neonate?

Accept the client's decision and care for her as any other client.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

The nurse is caring for a client 24 hours postpartum from a normal, vaginal delivery, and identifies which assessment finding and requiring immediate intervention?

Patient reports pain and warmth behild left knee

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate?

The client needs application of an ice pack.

One day after a client gives birth, the nurse performs a postpartum assessment. Which finding indicates a need for further evaluation?

The patietn reporting uterine tenderness

A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge, which assessment would be most important?

constipation

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement?

postpartum "blues"

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

A nurse is caring for a 1-day postpartum client. The progress note below informs the nurse that the client is in which phase of the postpartum period?

taking in

The nurse, while shopping in a local department store, hears a multiparous woman say loudly, "I think the baby is coming." After asking someone to call 911, the nurse assists the client to give birth to a term neonate. While waiting for the ambulance, the nurse suggests that the mother initiate breastfeeding, primarily for what reason?

to contract the mother's uterus

A nurse is discussing discharge instructions with a client. Which statement indicates that the client understands the resources and information available if needed after discharge? Select all that apply.

"My fertility can return as early as 21 days after my baby's birth." "I have the hospital phone number if I have any questions." "If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "I know if I get fever or chills or change in lochia to call the health care provider." "I will continue my prenatal vitamins until my postpartum checkup or longer."

When caring for a post partum client, the student nurse correctly recalls which expected progression of lochia?

Rubra, then serosa, then alba

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate.

A multiparous client, 28 hours after cesarean birth, who is breastfeeding has severe cramps or afterpains. The nurse explains that these are caused by which factor?

release of oxytocin during the breastfeeding session

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.

A nurse observes several interactions between a client and her neonate son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply.

Talks and coos to her son. Cuddles her son close to her.

During the fourth stage of labor, the client should be assessed carefully for

uterine atony.

A nurse is preparing to perform a postpartum assessment on a client who gave birth 5 hours ago. Which precaution should the nurse plan to take for this procedure?

washing the hands and wearing gloves

The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The nurse begins the catheterization process, and the client states, "I forgot to tell the nurse I get hives to betadine." The nurse should take which steps in order of priority from first to last? All options must be used.

Clean povidone-iodine from client's vaginal area. Notify the health care provider (HCP) prescribing catheterization. Document the incident. File an incident report.

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains?

G3, P3 client who is breastfeeding her infant

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony

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

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

A primiparous client is on a regular diet 24 hours postpartum. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle?

The mother can bring the daughter any foods that she desires.

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after administering the medication, which finding should alert the nurse to the development of a possible side effect?

dizziness

Antenatal laboratory testing revealed a negative rubella antibody for a client admitted to the postpartum unit. Which action takes priority for this client during early puerperium?

rubella counseling and immunization with live rubella virus vaccine

A client who's breast-feeding has a temperature of 102° F (38.9° C) and complains that her breasts are engorged. Her breasts are swollen, hard, and red. Which action by the client requires intervention?

Applying a breast binder to support the breasts

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first?

Gently massage the fundus.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on her perineum. However, her perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?

Administer pain medication per prescription.

A client one day post-cesarean birth requests pain medication, stating her pain is 8 out of 10 when the nurse enters the room to perform her shift assessment. Which action by the nurse is most appropriate.

Administer the ordered pain medication, explaining to the patient that she will be back within the hour to examine her.

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

While caring for a multiparous client 4 hours after 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. Her fundus is firm, midline, and at the level of the umbilicus. What should the nurse do?

Continue to monitor the client's vital signs.

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.

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally?

The uterus is descending at the rate of one fingerbreadth per day.

A nurse is palpating the uterine fundus of a client who gave birth to a neonate 8 hours ago. Identify the area where the nurse should expect to feel the fundus.

The uterus would be palpable at the level of the umbilicus between 4 and 24 hours after birth. The fundus of the uterus should be palpated for position and firmness.

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed her neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness?

placing as much of the areola as possible into the baby's mouth

While the nurse is palpating the breasts of a client who is breastfeeding her 12-hour-old neonate, what is an expected finding?

soft breasts that are not tender to touch

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend?

every 2 to 3 hours for the first 48 hours

Following postpartum discharge teaching by the nurse, which statement by the client indicates an understanding of how to provide self-care?

"I should contract my buttocks before sitting or rising."

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain."

A nurse is providing discharge teaching to a postpartum client. Which instruction is the priority to include in the teaching?

"If you have excessive vaginal bleeding, massage your fundus and call the physician."

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

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 she ambulated to the bathroom after sleeping for 4 hours, her 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.

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The mother is bottle-feeding her baby. Which client finding indicates a problem at this time?

firm fundus at the symphysis

A nurse is assessing the parent-neonate attachment of postpartum clients. Which finding most indicates a need for further evaluation?

Limited parent-neonate contact immediately after birth

Approximately 15 minutes after giving birth to a viable term neonate, a multiparous client has chills. What should the nurse do next?

Provide the client with a warm blanket.