Postpartum Period - ML8 (1)

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? increased pulse rate uterine atony hypertension respiratory depression

uterine atony Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site.Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration.Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining nearby the client to assess for which problem? diuresis fainting fatigue hygiene needs

fainting Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.

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 herbal tea grape juice milk

orange juice Iron is best absorbed in an acid environment or with vitamin C. For maximum iron absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and therefore would have no effect on iron absorption.

The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound (2.72 kg) newborn after a 2-hour labor at 37 weeks gestation. For which complication will the nurse assess as a priority due to the increased risk in this client? postpartum hemorrhage delay in lactation postpartum infection delayed infant bonding

postpartum hemorrhage The client's labor was under 3 hours in length, which meets the definition for precipitous labor. This increases the risk for postpartum hemorrhage but decreases the risk for infection. The client is at early term (37 weeks) and gave birth vaginally without any noted complications, so there should be no delay in either lactation or infant bonding.

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 digest their milk more rapidly." "Formula-fed infants usually feed every 3 to 4 hours." "Formula-fed infants experience shorter periods between feedings." "Formula-fed infants demand to feed every 1.5 to 3 hours."

"Formula-fed infants usually feed every 3 to 4 hours." Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.

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 will consume 500 more calories each day than if I wasn't breast-feeding." "I'll include milk products in my diet." "I'll take all the same medications I was taking before my pregnancy." "I will drink 10 glasses of fluid every day."

"I'll take all the same medications I was taking before my pregnancy." The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate. The client should consult with her physician before taking any drugs while breast-feeding. She should increase her daily calories by 500, drink 10 glasses of fluid, and include milk products in her diet to increase her milk production and provide adequate nutrition for her neonate and herself.

A 30-year-old multigravida with prolonged rupture of membranes is diagnosed with endometritis 36 hours after birth of a viable neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100° F (37.8° C), pulse rate is 124 bpm, and respirations are 24 breaths/minute. The nurse should: Monitor the vital signs every 4 hours. Administer an analgesic as prescribed. Provide the client with clear liquids. Contact the primary care provider.

Contact the primary care provider. The nurse should contact the primary care provider immediately because the client is demonstrating danger signals of septic shock. Tachycardia, or a pulse rate greater than 120 bpm, and tachypnea, or respirations of 24 breaths/minute or higher, are both danger signs of septic shock. Hypotension, changes in the level of consciousness, and decreased urine output are later signs.Analgesics can assist the client's comfort but are not critical at this time.Providing the client with clear liquids does not address the life-threatening problem of septic shock.The vital signs should be monitored more frequently than every 4 hours if the client is developing septic shock.

The nurse is caring for several postpartum clients. Which client(s) will the nurse anticipate to be at risk for experiencing strong contractions after birth? Select all that apply. client who experienced a rapid (precipitous) labor client who is a primipara client who is breastfeeding client who is a multipara client who gave birth to a neonate weighing 12 lb (5.4 kg)

client who gave birth to a neonate weighing 12 lb (5.4 kg) client who is breastfeeding client who is a multipara Overstretching of the uterus is a risk factor for significant contractions, also known as afterbirth pains. Of the clients under the nurse's care, the grand multipara and the client who gave birth to a 12-lb (5.4-kg) neonate may have experienced overstretching. Delivering at 38 weeks does not increase the risk of overstretching the uterus. Breastfeeding causes the release of oxytocin and will result in stronger uterine contractions in comparison with bottle-feeding. A rapid labor is a risk factor for uterine atony and postpartum hemorrhage rather than strong contractions after birth.

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed? uterine rupture postpartum hemorrhage puerperal infection pyelonephritis urinary tract infection

postpartum hemorrhage Blood loss from the uterus that exceeds 500 ml in a 24-hour period is considered postpartum hemorrhage. If uterine atony is the cause, the uterus feels soft and relaxed. A full bladder can prevent the uterus from contracting completely, increasing the risk of hemorrhage. These symptoms are not characteristic of a urinary tract infection or pyelonephritis. Puerperal infection is an infection of the uterus and structures above; its characteristic sign is fever. Uterine rupture is a potentially catastrophic event during childbirth where the wall of the uterus ruptures. A uterine rupture is a life-threatening event for the mother and fetus.

A client gives birth to a stillborn neonate at 36 weeks gestation. When caring for this client, which strategy by the nurse would be most helpful? Be selective in providing the information that the client seeks. Let the client's partner decide what information the client receives. Encourage the client to see, touch, and hold the dead neonate. Provide information about possible causes of the stillbirth only if the client requests it.

Encourage the client to see, touch, and hold the dead neonate. When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for the client to bond with the dead neonate and allow the neonate to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the client's partner decide which information the client receives is inappropriate.

A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen orally. When does the nurse instruct the client to take the medication? immediately after a feeding before going to bed when providing supplemental formula midway between feedings

immediately after a feeding Taking ibuprofen 200 mg orally immediately after breastfeeding helps minimize the neonate's exposure to the drug because drugs are most highly concentrated in the body soon after they are taken. Most mothers breastfeed on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decreased by the next breastfeeding session. Taking the medication before going to bed is inappropriate because, although the mother may go to bed at a certain time, the neonate may wish to breastfeed soon after the mother goes to bed. If the mother takes the medication midway between feedings, then its peak action may occur midway between feedings. Breast milk is sufficient for the neonate's nutritional needs. Most breastfeeding mothers should not be encouraged to provide supplemental feedings to the infant because this may result in nipple confusion.

A primiparous client who is beginning to breastfeed her neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor? delayed meconium passage vitamin K, which the neonate lacks passive immunity from maternal antibodies more fat than breast milk

passive immunity from maternal antibodies Colostrum is a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals, vitamins, and maternal antibodies (e.g., immunoglobulin A). It is important for the neonate to receive colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk. Colostrum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern is established. Colostrum may speed, rather than delay, the passage of meconium.

A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. What factor/condition does the nurse believe is causing this experience? postpartum baby blues postpartum reaction postpartum depression postpartum anxiety

postpartum baby blues Postpartum baby blues occurs in up to 70% of women after the birth of a child. It is a mild depression and functioning of the woman is usually not impaired. Postpartum baby blues usually begins on days 3 to 10 postpartum. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks postpartum and up to 1 year following the birth of the baby. Postpartum reaction is usually a larger term to include postpartum depression, anxiety, and psychosis.

A nurse is explaining basic principles of asepsis and infection control to a client who has a respiratory tract infection following birth. The nurse determines the client understands principles of infection control to follow when the client makes which statement? "I must practice frequent hand washing." "I must use barrier isolation." "I must use individual client care equipment." "I must wear gloves when I handle my baby."

"I must practice frequent hand washing." Frequent handwashing is the most important aspect of infection control. The nurse can emphasize, monitor, and ensure this strategy for all who come in contact with this client. The use of gloves is not needed for clients caring for their own infants. The best practice is to restrict visitation if the client has a respiratory illness. If visitation is necessary, it is better if the client with the known infection wears the mask. Individual client care equipment is not needed in this situation.

While changing the neonate's diaper, the client asks the nurse about some red-tinged drainage from the neonate's vagina. Which response would be most appropriate? "It's of no concern because it's such a small amount." "Sometimes baby girls have this from hormones received from the mother." "The cause is usually related to swallowing blood during the birth." "This vaginal spotting is caused by hemorrhagic disease of the newborn."

"Sometimes baby girls have this from hormones received from the mother." The most appropriate response would be to explain that the vaginal spotting in female neonates is associated with hormones received from the mother. Estrogen is believed to cause slight vaginal bleeding or spotting in the female neonate. The condition disappears spontaneously, so there is no need for concern. Telling the mother that it is of no concern does not allay the mother's worry. The vaginal spotting is related to hormones received from the mother, not to swallowing blood during the birth or hemorrhagic disease of the neonate. Anemia is associated with hemorrhagic disease.

Four hours after cesarean birth of a neonate weighing 8 lb, 13 oz (4,000 g), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which standard of practice? VBAC is not possible, because the neonate was large for gestational age. A history of rapid labor is a necessary criterion for VBAC. A low transverse incision contraindicates the possibility for VBAC. VBAC may be possible if the client has not had a classic uterine incision.

VBAC may be possible if the client has not had a classic uterine incision. VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A health care provider (HCP) must be available, and a cesarean birth must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic.

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? cross-cradle hold football hold scissors hold cradle hold

football hold After a cesarean birth, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in semi-Fowler's position, supporting the neonate's head in her hand and resting the neonate's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neonate easy access to the mother's breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate's mouth placement, is used by the mother to hold the breast and support it during breastfeeding. The cross-cradle hold is done when the mother holds the neonate's head in the hand opposite from the breast on which the neonate will feed and the mother's arm supports the neonate's body across her lap. This position can be uncomfortable because of the pressure placed on the client's incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line.

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? Raise the head of the bed. Straight-catheterize the client for half of her urine volume. Ask the client to empty her bladder. Notify the charge nurse of the assessment findings. Call the client's primary healthcare provider for direction.

Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right of the abdomen. Nursing interventions would be completed before notifying the primary healthcare provider or charge nurse in a nonemergency situation. Raising the head of the bed is not helpful to change the position of the uterus.

The nurse is caring for a client who had a vaginal birth 24 hours ago. The client states, "I think I just passed some more placenta." How would the nurse respond? "That is not physically possible. You are probably experiencing postpartum hemorrhage." "Yes, the health care provider indicated you had some retained placenta that would pass." "Can you tell me more about what passed? Are you experiencing any other symptoms now?" "I am concerned that could actually have been a large clot. Do you mind if I assess you now?"

"I am concerned that could actually have been a large clot. Do you mind if I assess you now?" The priority is to determine if the client is experiencing increased bleeding and the passage of large clots. If the health care provider was aware of retained placental fragments, these would have been treated and not left for 24 hours. The nurse can ask the client more questions once the assessment begins, so the priority is voicing the concern to the client and asking to assess immediately. Telling the client she is experiencing "postpartum hemorrhage" is premature and could upset the client, so it is not the best therapeutic approach.

The nurse is caring for a client who underwent an episiotomy. What statement by the client indicates teaching was successful? "I should avoid sitting in chairs for the next 4 weeks and sit with my legs elevated." "I should refrain from using tampons until advised by my healthcare provider" "I should immediately report any itching at the site to the healthcare provider." "I should return to the healthcare provider in 2 weeks for suture removal."

"I should refrain from using tampons until advised by my healthcare provider" The nurse should emphasize the need to change peripads frequently and instruct the client not to use tampons until after seeing the healthcare provider (usually at the 6-week postpartum checkup). The client can sit in chairs, but adequate padding will increase comfort. Elevation of the legs is not directly related to the episiotomy care, but it can help if the client has peripheral edema. Episiotomy sutures are self-dissolving and do not need to be removed. Itching does not need to be reported; it is an expected sensation, especially as the sutures dissolve.

While observing a new mother interact with her first baby, the nurse observes that the client appears hesitant to care for the neonate. Which action would be most important for the nurse to do? Ask the client about her childhood experiences. Continue to provide praise and support to the client. Make a referral to the medical social worker. Contact the client's family members for support.

Continue to provide praise and support to the client. The new mother may seem hesitant to handle the neonate due to lack of experience. The role of the nurse is to continue to provide support, praise, and encouragement. The client needs emotional support, reassurance, reinforcement of appropriate behavior, and advice about how to manage.Hesitancy is common for the new mother. If the mother continues to be fearful or does not appear to be interested in caring for the neonate, then a referral may be warranted.Providing the mother with praise and support demonstrates that the nurse cares for the family. No indications are present that would demonstrate a need to ask about childhood experiences.While family support is important for all new mothers, the nurse should provide support and praise first. Mothers feel a sense of accomplishment as they gain experience in newborn care with the help of the nurse.

The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? Massage the client's fundus continuously. Place the neonate on the client's fundus. Encourage the mother to breastfeed the infant. Place the mother in a supine position.

Encourage the mother to breastfeed the infant. The nurse should encourage the mother to breastfeed the infant. Neonatal sucking will induce the release of natural oxytocin, which will help contract the uterus and control uterine bleeding.Placing the neonate on the client's fundus will help keep the neonate warm but will not help to control excessive uterine bleeding.Gentle massage will help contract the fundus. Continuous massage can actually decrease uterine tone and lead to increased bleeding.Placing the mother in a supine position has no effect on uterine tone.

A multiparous client at 24 hours postpartum is found to have a swelling and pain in her right leg. She demonstrates a positive Homan sign with discomfort. What should the nurse do next? Place a cold pack on the client's perineal area. Ask the client to ambulate around the room. Notify the client's health care provider (HCP) immediately. Place the client in a semi-Fowler's position.

Notify the client's health care provider (HCP) immediately. A pain and swelling may be indicative of thrombophlebitis. Redness at the site and may be more reliable as an indicator of thrombophlebitis. The nurse should notify the HCP immediately and ask the client to remain in bed to minimize the risk for pulmonary embolus, a serious consequence of thrombophlebitis should a clot dislodge. Placing an ice pack on the perineal area is inappropriate. However, ice to the perineum would be useful for episiotomy pain and swelling. The client does not need to be positioned in semi-Fowler's position but should remain on bed rest to prevent dislodgement of a potential clot.

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? The injection will provide immunity against the chickenpox. The vaccine prevents a future fetus from developing congenital anomalies. Pregnancy should be avoided for 4 weeks after the immunization. The client should avoid contact with children diagnosed with rubella.

Pregnancy should be avoided for 4 weeks after the immunization. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects to the fetus.The vaccine does not protect a future fetus from infection. Rather it protects the woman from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus.The vaccine will provide immunity to rubella, also known as German measles.The injection immunizes the client against the 3-day or German measles, not chickenpox.

Following a cesarean birth for abruptio placentae, a multigravid client tells the nurse, "I feel like such a failure. None of my other births were like this." Which factor is most important for the nurse to consider when responding to the client? The client will most likely have postpartum blues. The client's feeling of grief is a normal reaction. Maternal-infant bonding is likely to be difficult. This type of birth was necessary to save the client's life.

The client's feeling of grief is a normal reaction. Feelings of loss, grief, and guilt are normal after a cesarean birth, particularly if it was not planned. The nurse should support the client, listen with empathy, and allow the client time to grieve. The likelihood of the client experiencing postpartum blues is not known, and no evidence is presented. Although maternal-infant bonding may be delayed owing to neonatal complications or maternal pain and subsequent medications, it should not be difficult. Although the nurse is aware that this type of birth was necessary to save the client's life, using this as the basis for the response does not acknowledge the mother's feelings.

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 take all the missed doses as soon as she discovers the oversight. discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle.

discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure effectiveness and can increase the risk of adverse reactions.

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? poor coping skills postpartum "blues" postpartum depression postpartum psychosis

postpartum "blues" Postpartum "blues" are a normal, expected finding 2 days postpartum. About 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after giving birth. Postpartum depression and postpartum psychosis aren't seen until later than the second day postpartum. A statement by the client about not being able to care for her neonate or herself would indicate poor coping skills.

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? breath sounds desire to eat bowel sounds degree of pain

bowel sounds Before providing the client with a full liquid meal, the nurse should first assess for the presence of bowel sounds to evaluate the functioning of the client's gastrointestinal tract. After cesarean birth, the client is at risk for paralytic ileus or intestinal obstruction due to the effects of the surgery or anesthesia used.Assessing breath sounds, although an important assessment, would be indicated if the client was experiencing a respiratory problem. It has no relevance related to the client's eating.The client's desire to eat may or may not be present. The client's gastrointestinal function manifested by active bowel sounds indicates that the client can be allowed to eat.The degree of pain is an important assessment but not in relation to the client's diet.

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

"If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical assistance." "I have the hospital phone number if I have any questions." "I will continue my prenatal vitamins until my postpartum checkup or longer." "My fertility can return as early as 21 days after my baby's birth." "I know if I get fever or chills or change in lochia to call the health care provider." The nurse is responsible for providing discharge instructions that include signs and symptoms that need to be reported to the health care provider (HCP) as well as resources and follow-up for home care if needed. Phone numbers and health practices to promote healing, such as the use of prenatal vitamins, are also essential pieces of information. Fertility can return in as little as 21 days, especially among women who are not breastfeeding, so it is important to discuss the client's contraception plan. Although the client's mother may be helpful, the client's statement that she will be fine because her mother is coming indicates that she is unaware or ignoring information about valuable information and resources.

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that her breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure? Discontinue breastfeeding immediately and replace it with bottle-feeding during the night. Use her hand or a pump to express a small amount of breast milk before breastfeeding. Apply ice packs to the breasts for 20 minutes just before breastfeeding the newborn. Take a moderately strong analgesic after the infant breastfeeds on both sides.

Use her hand or a pump to express a small amount of breast milk before breastfeeding. The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breastfeed. Frequent feedings with complete emptying of the breasts should alleviate engorgement.There is no reason why the client needs to discontinue breastfeeding. Rather, more frequent breastfeeding is indicated.Ice packs can be used to relieve edema and pain but should be used between feedings not immediately before a feeding. Warm compresses may be used to help stimulate milk flow.Although the client's breasts are tender, this tenderness is a result of the engorgement. A strong analgesic will not alleviate breast engorgement. Expressing the milk and feeding the neonate are most effective in relieving the problem.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate? requesting an antibiotic order encouraging increased fluid intake administering aspirin as ordered reassessing vital signs every 15 minutes

encouraging increased fluid intake During the first postpartum day, mild dehydration commonly causes a slight temperature elevation; the nurse should encourage fluid intake to counter dehydration. Aspirin is contraindicated in postpartum clients because its anticoagulant effects may increase the risk of hemorrhage. Reassessing vital signs in 4 hours is sufficient to assess the effectiveness of hydration measures. The nurse should request an antibiotic order if the client's oral temperature exceeds 100.4° F (38° C), which suggests infection.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority? administering oxytocin as ordered reassessing the client in 1 hour massaging the uterus gently notifying the physician or nurse-midwife

massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

A client is breastfeeding her newborn infant. The client's nipples are red and bruised, and a small crack is visible on the right nipple. Which intervention should the nurse do next? Have the mother toughen her nipples with a course cloth three times a day. Instruct the mother to pump due to her baby's strong suck reflex. Assist the client to have the infant create a correct latch to the breast. Assess the baby for palate malformations.

Assist the client to have the infant create a correct latch to the breast. A good latch will be comfortable and should not cause redness, bruising, or cracks. Therefore, the nurse should intervene with the most probable cause of this complication; an incorrect latch. Whether a newborn has a cleft palate, a well-developed/strong suck reflex, or whether the mother has sensitive nipples, there should not be redness and ecchymosis to the areola.

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." "If things get difficult, don't feel guilty if you need to supplement with formula." "Speak to your employer to see if they'll allow you time to express milk while you're at work." "It's a challenge now, but you'll be an expert at breastfeeding by then!"

"You can develop and practice a plan now for expressing milk and feeding so you're ready." Telling the mother she will be an expert in 6 weeks is dismissive of the client's concern. Breastfeeding should continue for at least 6 months after birth, if possible, for maximum benefits, so the nurse should not encourage the client to use formula if she requests breastfeeding support. Breast milk can be pumped before and during work to give to the neonate. The nurse should inform the client that laws require time be provided for mothers to pump at work, so the employer cannot refuse the request. Pumping will also support continuous milk production. Developing a plan and practicing it prior to going back to work will help the mother feel more confident and worry less during the transition time.

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500 The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.

The nurse is assessing a client who had a cesarean birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds × 1 quadrant, fundus firm at umbilicus, lochia scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued, and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. What should the nurse do first? Encourage the client to begin caring for her baby. Give the client pain medication. Have the client use the incentive spirometry. Ambulate the client from the bed to the hallway and back.

Ambulate the client from the bed to the hallway and back. The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing flatus and begin peristaltic action in the gastrointestinal track. Medicating the client should be evaluated prior to ambulating, but it is probably too soon because the last dose was 3 hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incentive spirometry or asking the client to turn, cough, and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these interventions. Participating in infant care is another way to encourage the mother to move about, but the primary goal would be to have her walk on the unit, a more purposeful activity.

The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding? Assess the protein level of the urine using a dipstick at the bedside. Elevate the client's legs on two pillows, and restrict fluid intake. Document the finding, and complete routine postpartum assessment. Request kidney function tests including creatinine and urea levels.

Document the finding, and complete routine postpartum assessment. It is normal for the client to experience diuresis in the first 24 hours after birth (whether vaginal or cesarean). An amount of 3 liters in 24 hours is not unusual. Also, the client will have received IV fluids during labor, which increases input significantly. There is no indication of kidney dysfunction. If preecamplia is suspected, urine output would be decreased, not increased; this makes testing for protein unwarranted. The client may have edema present, for which elevating the legs can encourage further diuresis, but there is not reason to restrict fluid intake.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? Encourage the family to identify their frustrations and fears. Call the nurse manager to speak with the couple. Explain that the unit is short staffed and that the nurses are doing the best they can. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit.

Encourage the family to identify their frustrations and fears. This response will assist the family in identifying their frustrations and fears so the nurse can work toward resolving their issues. It is inappropriate to tell the client about staffing-related issues or to give them a time limit for which they are able to express their concerns. The nurse manager may need be brought into the situation but first the nurse should try to work toward resolving the issues with the clients.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? Call the nursery to ask which baby is missing. Go to the obstetrics unit to determine if they need help with the situation. Move to the entrance of the hospital and check each person leaving. Observe individuals in the area for large bags or oversized coats.

Observe individuals in the area for large bags or oversized coats. The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be a responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply. Offer to stay with the grieving parents. Remind the parents that there must have been something wrong with the baby. The nurse should control emotions so as to not upset the parents. Answer the parents' questions accurately. Provide an early opportunity for the couple to see the child if desired.

Provide an early opportunity for the couple to see the child if desired. Offer to stay with the grieving parents. Answer the parents' questions accurately. Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace.

The client is a 17-year-old single mother who has given birth. On her first postpartum day, the client seems overwhelmed with her new baby and asks the nurse how she is supposed to interact with her baby when all the baby does is eat and sleep. Which of the following actions would be most effective for the nurse to use to facilitate mother-infant attachment? Encourage the client to pay attention to her baby. Show the client how the baby initiates interaction with her and attends to her. Encourage the client to watch a video on attachment. Demonstrate different positions for holding the baby.

Show the client how the baby initiates interaction with her and attends to her. Teaching the client how her baby comes prepared to interact with her will help her see that they are in a reciprocal relationship. This will help the client identify in the future other cues the baby is using to communicate with her and will increase the opportunities for attachment. Encouraging the client to pay attention to her baby may imply that the nurse does not believe the client is appropriately responding to her baby. Encouraging the client to watch a video may imply that the nurse is not interested in communication or spending time with her. Demonstrating different positions for holding the baby may be part of the teaching to facilitate mother-infant attachment, but this is only a small portion of attachment measures and it is more appropriate to teach the client about her newborn's interaction cues.

The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the above is noted. Upon further examination, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery? bleeding on the brain causing a lump swelling on the dorsal area of the skull a cephalohematoma contained on the left side caput succedaneum on the left side of the head

a cephalohematoma contained on the left side The nurse notes a swelling, which does not cross the suture lines and is limited to the left side of the neonatal head. This is documented as a cephalohematoma. Caput succedaneum, a specific condition from the pressure of the birth, crosses the suture line and presents with diffuse edema. Identifying the condition is the best documentation. It is true that there is edema present but the documentation is inaccurate when it identifies the dorsal aspect. The documentation is also inaccurate in stating that there is bleeding on the brain.

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn? meconium aspiration hypoglycemia absence of lanugo increased amounts of vernix

increased amounts of vernix Vernix caseosa is a whitish substance that serves as a protective covering over the fetal body throughout the pregnancy. Vernix usually disappears by term gestation. It is highly unusual for a 12-day postmature baby to have increased amounts of vernix. A discrepancy between the estimated date of conception and gestational age by physical examination must have occurred. Meconium aspiration is a sign of fetal distress but does not coincide with gestation. The presence of lanugo is greatest at 28-30 weeks and begins to disappear as term gestation approaches. Therefore, an absence of lanugo on assessment would be expected with a postmature infant. Hypoglycemia can occur at any gestation, although it is associated with other conditions, including prematurity and small size for gestational age.

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? healing of the abdominal incision after cesarean birth adverse effects of the medications administered after birth flatulence accumulation after a cesarean birth release of oxytocin during the breastfeeding session

release of oxytocin during the breastfeeding session Breastfeeding stimulates oxytocin secretion, which causes the uterine muscles to contract. These contractions account for the discomfort associated with afterpains. Flatulence may occur after a cesarean birth. However, the mother typically would have abdominal distention and a bloating feeling, not a "cramping" feeling. Stretching of the tissues or healing may cause slight tenderness or itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners, commonly administered postpartum, typically do not cause cramping.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? supporting self-esteem concerns about the birth monitoring pain status and providing necessary relief assisting with parent-neonate bonding removing the initial dressing for incision inspection

removing the initial dressing for incision inspection Nursing care should never include removing the initial dressing put on in the operating room. Therefore, if a nurse performs this action, intervention is needed. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate and therefore incorrect answers to this question.

A mother is instructed to stimulate the rooting reflex when attempting to breast-feed her baby. Which action shows that the mother understands these instructions? stroking the neonate's cheek initiating the neonate's startle reflex to make sure the baby is aware giving the neonate water to check for swallowing turning the neonate's head to the side, causing the neonate to extend the extremities on that side

stroking the neonate's cheek The rooting reflex is a neonate's response to having his cheek stroked. The neonate will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The client demonstrates understanding of teaching if she tries to elicit this reflex. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. Water isn't indicated for neonates.

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of psychological adaptation? taking hold letting go taking in taking on

taking hold The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfilling infant care and needs. The taking in phase is the first period after birth where there is emphasis on reviewing and reliving the labor and birth process, concern with self, and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.

The nurse reviews the contraception choices of a bottle-feeding postpartum client prior to discharge. The client wants to know why she needs to wait to resume the use of oral contraceptives. What is the nurse's best response? "The risk for bleeding is increased from the progestin in combined hormonal contraceptives." "Clients cannot resume intercourse for 6 weeks after birth, so contraception is not needed." "The estrogen in combined hormonal contraceptives interferes with the involution process." "Combined oral contraceptives potentiate the risk for blood clots immediately after birth."

"Combined oral contraceptives potentiate the risk for blood clots immediately after birth." Pregnancy and the immediate postpartum period is a hypercoagulable state that puts clients at risk for blood clots. Taking a combined hormonal contraceptive would expose the client to estrogen and further increase the risk of blood clots. Clients are advised to wait a minimum of 3 weeks after birth before taking estrogen-containing contraceptives. Oral contraceptives do not significantly affect the involution process in non-breastfeeding women. For oral contraceptives to be effective, they must be started before intercourse resumes. While some practitioners may advise clients to wait 6 weeks before resuming intercourse, other providers advise clients that they may resume after they no longer have lochia. Progestin does not significantly increase the risk for bleeding after birth, and there are no restrictions for beginning progestin-based contraceptives in non-breastfeeding women.

A woman who is breastfeeding tells the nurse that she plans to return to work in 6 months and will probably wean her baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client? gradual decrease in milk supply as the baby nurses less wearing a tight breast binder to effectively suppresses lactation the need to request a prescription for a lactation suppressant natural diminishment in supply about 6 months after birth

gradual decrease in milk supply as the baby nurses less Over time, as the infant nurses less, the mother's milk supply diminishes normally. Gradual weaning by eliminating one feeding at a time over several weeks is the best recommendation.Lactation suppressants are no longer recommended because of the possible adverse effects, such as hypotension.Mechanical methods of suppressing lactation, such as a breast binder, are most effective when used as soon after childbirth as possible.The milk supply persists beyond 6 months after birth if the breasts are emptied regularly.

A multiparous client 48 hours postpartum who is breastfeeding tells the nurse, "I'm having a lot of cramping. This didn't happen when I nursed my first baby." Which would be the nurse's best response? "I'll notify your health care provider (HCP). It's possible there are some placental fragments remaining." "I need to check your lochia flow. You may have a clot that is being dislodged." "You must have gotten a heavy dose of oxytocin. It should wear off soon." "The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin."

"The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin." The cramping is caused by the baby's sucking and subsequent stimulation for the release of oxytocin. This cramping is normal. With each subsequent pregnancy, the uterus becomes "stretched" and the release of oxytocin causes the uterus to contract, resulting in the feeling of cramping that can become more severe with each birth. Continued moderate to large amounts of lochia rubra are indicative of retained placental fragments. Cramping indicates that the uterus is contracting and most likely firm. A boggy uterus, continued moderate to heavy lochia, mild vasoconstriction, and restlessness and anxiety suggest delayed postpartum hemorrhage due to subinvolution of the placental site, retained placental tissue, or infection. Most clients receive a standard dose of oxytocin after birth. Oxytocin has a duration of action of 60 minutes. Therefore, the effects of the drug would have worn off by 24 hours postpartum.

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? 7 days 12 hours 24 hours 2 to 4 days

2 to 4 days If the client begins breastfeeding early and often after birth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.

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 24 hours 12 hours 48 hours

72 hours For maximum effectiveness, Rho(D) immune globulin should be administered within 72 hours postpartum. Most Rh-negative clients also receive Rho(D) immune globulin during the prenatal period at 28 weeks' gestation and then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and give birth to Rh-positive neonates. If there is doubt about the fetus's blood type after pregnancy is terminated, the mother should receive the medication.

A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? Apply an ice pack to her perineum. Drink plenty of fluids. Perform perineal care after voiding or a bowel movement. Take a sitz bath.

Apply an ice pack to her perineum. A cold pack applied to an episiotomy during the first 24 hours after childbirth may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. Although perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection - not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn't relieve perineal discomfort.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client? "Alternate your breastfeeding with formula feeding to help you rest." "You can continue to breastfeed as long as you want to do so." "You will need to modify your technique by manually pumping your breasts." "You'll need to discontinue breastfeeding until the antibiotic therapy is stopped."

"You can continue to breastfeed as long as you want to do so." The client can continue to breastfeed as often as she desires. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding mothers. Manual pumping of the breasts is not necessary.

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 breast tenderness and mittelschmerz. 3 full days of elevated basal body temperature and clear, thin cervical mucus. return to preovulatory basal body temperature. basal body temperature increase of 0.1° F to 0.2° F (0.06° C to 0.11° C) on the 2nd or 3rd day of the cycle.

3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation.

During the immediate postpartum period after giving birth to twins, the client experiences uterine atony. What should the nurse do first? Increase the intravenous fluid rate. Assess the client for infection. Determine if the uterus has ruptured. Gently massage the fundus.

Gently massage the fundus. Uterine atony means that the uterus is not firm because it is not contracting. First, the nurse should gently massage the uterus in an effort to help contract the uterus and make it firm. Clients with multiple gestation, polyhydramnios, prolonged labor, or large-for-gestational-age fetus are more prone to uterine atony.Assessing for infection is inappropriate because puerperal infection is not associated with uterine atony.Determining if the uterus has ruptured is inappropriate because uterine atony is not a sign of uterine rupture.Increasing the intravenous fluid rate may be prescribed if the client develops symptoms of shock.

After instructing a primiparous client who is breastfeeding on how to prevent nipple soreness during feedings, the nurse determines that the client needs further instruction when she makes which statement? "I should air dry my breasts and nipples for 10 to 15 minutes after the feeding." "I shouldn't use a hand breast pump if my nipples get sore." "I should make sure the baby grasps the entire areola and nipple." "I should position the baby the same way for each feeding."

"I should position the baby the same way for each feeding." The mother needs further instruction when she says, "I should position the baby the same way for each feeding." This can contribute to sore nipples. The position should vary for each feeding to prevent repeated pressure on the same area each time. Grasping the entire areola and nipple will help to decrease nipple soreness. Air drying the breasts and not using a hand pump will help to decrease nipple soreness.

A client is preparing for discharge 48 hours after an uncomplicated vaginal birth. The client asks the nurse if there are any safe products to help make her feel "fresher" and reduce the odor of vaginal discharge. What is the nurse's best response? "It's normal to have this discharge. Changing your pad every few hours will help." "Using douches or perfumes on the perineum is not recommended." "I'd like to perform an assessment related to the discharge you describe." "It sounds like you don't feel fresh. Can you share with me more about these feelings?"

"I'd like to perform an assessment related to the discharge you describe." It is not normal for lochia to have a foul odor, so the nurse should not dismiss the comment. The nurse's priority is assessing the client for signs of infection. Although it is true that perfumes and douching should be avoided, this is discharge teaching the nurse can conduct after the assessment is complete. Asking the client to talk more about "not feeling fresh" is not a priority compared to determining if an infection is present.

A nurse is teaching a 1-week postpartum client about exercise and injury prevention. Which statement by the client requires further teaching? "Pelvic tilts will help my back." "I can perform muscle flexing and stretching." "I should do Kegel exercises." "I'm allowed to jog in place."

"I'm allowed to jog in place." The client requires additional teaching if she states that she may jog in place. Jogging can increase the amount of lochia rubra, which indicates new bleeding. Muscle flexing and stretching, Kegel exercises, and pelvic tilts are safe to do during the first 3 weeks postpartum. Stretching and flexing muscles relieves tension. Kegel exercises tone the muscles of the pelvic floor. Pelvic tilts strengthen the muscles of the lower back.

A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate? "Insert the diaphragm 4 hours before intercourse." "Leave the diaphragm in place for at least 6 hours after intercourse." "Remove the diaphragm immediately after intercourse." "You may use the diaphragm without spermicidal jelly or cream."

"Leave the diaphragm in place for at least 6 hours after intercourse." The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.

A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period? The hematocrit rises from 34% to 40%. The client's experiences transient tachycardia. The blood pressure sitting is 108/62 mm Hg and standing is 94/56 mm Hg. There is an increase in cardiac output by 10%.

The hematocrit rises from 34% to 40%. Hemoglobin and erythrocyte values vary during the early postpartum period but they should approximate or exceed prelabor values within 2 to 6 weeks. As extracellular fluid is excreted, hemoconcentration occurs with a concomitant rise in hematocrit. Puerperal bradycardia with rates of 50 to 70 beats per minute commonly occurs during the first 6 to 10 days of the postpartal period. A client can experience orthostatic hypotension due to blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which symptom should the nurse instruct the client to report to her primary caregiver? breakthrough bleeding within first 3 months of use blurred vision and headache decreased menstrual flow breast tenderness

blurred vision and headache Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the healthcare provider. Because these two effects in particular may result in cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.

When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when she says that she is at risk for developing which problem? choriocarcinoma ectopic pregnancy infertility multifetal pregnancies

choriocarcinoma A client who has had a hydatidiform mole removed should have regular checkups to rule out the presence of choriocarcinoma, which may complicate the client's clinical picture. The client's human chorionic gonadotropin (hCG) levels are monitored for 1 year. During this time, she should be advised not to become pregnant because this would be reflected in rising hCG levels. Ectopic or multifetal pregnancy is not associated with hydatidiform mole. Women who have molar pregnancies have fertility rates similar to the general population.

A multigravid client gave birth vaginally 2 hours ago. A family member notifies the nurse that the client is pale and shaky. Which are the priority assessments for the nurse to make? uterine infection and pain fundus and lochia blood glucose level and vital signs temperature and level of consciousness

fundus and lochia A client who is pale and shaking could be experiencing hypovolemic shock likely caused by blood loss. A primary cause of blood loss after the birth of an infant is uterine atony. Therefore, the priority assessments should be the fundus of the uterus for firmness and location. In addition, the amount of vaginal bleeding (lochia) should also be assessed. An immediate intervention for uterine atony is fundal massage that will help the uterus to contract and therefore stop additional bleeding. Assessing the client's level of consciousness does not require additional time and can be done by the nurse while the fundus and lochia are assessed. Obtaining vital signs, blood glucose, and temperature are important but should be done either after the fundus has been assessed and massaged or should be obtained by a second responder. Assessing for uterine infection and pain should be done after treatment for hypovolemic shock has been initiated.

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? uterus in the midline position firm, round uterus fundus two fingerbreadths above the umbilicus fundus one fingerbreadth below the umbilicus

fundus two fingerbreadths above the umbilicus Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor? overdistention of the uterus from hydramnios moderate fundal massage after birth trauma during labor and birth lengthy and prolonged second stage of labor

overdistention of the uterus from hydramnios The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that she had a long labor.

The community health nurse is providing education to a client who gave birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage? passing a quarter-sized clot foul smelling lochia peripad soaked over the course of 1 hour backache

peripad soaked over the course of 1 hour With a late postpartum hemorrhage (greater than 72 hours), women report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.

The nurse is caring for a client who is 22 hours postpartum and is saturating a peripad every 2-3 hours. What actions should the nurse take first? Instruct client to lie down and elevate legs. Interview the client about symptoms. Perform lying and standing blood pressure. Begin a pad count and weigh each pad.

Interview the client about symptoms. It can be considered normal for a postpartum woman to saturate one peripad in a 2-hour span in the first 24 hours. How clients tolerate the blood loss will vary greatly and depend on other factors such as hydration status. The nurse should first establish if the client has any symptoms such as lightheadedness or excessive fatigue that could indicate a problem. Based on the client's reports of symptoms, this helps better focus the subsequent assessments and degree of priority. All of the actions may also be performed but will be determined after the nurse asks about symptoms.

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? Ask the client to assume a side-lying position with the knees flexed. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Place the client on a bedpan in case the uterine palpation stimulates the client to void.

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position, and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.

After a dilatation and curettage (D&C) to evacuate a molar pregnancy, assessing the client for signs and symptoms of which signs and symptoms would be most important? chorioamnionitis hemorrhage urinary tract infection abdominal distention

hemorrhage After a D&C to evacuate a molar pregnancy, the nurse should assess the client's vital signs and monitor for signs of hemorrhage, because the surgical procedure may have traumatized the uterine lining, leading to hemorrhage. Urinary tract infections, not common after evacuation of a molar pregnancy, are most commonly related to urinary catheterization. Typically, urinary catheters are not used during evacuation of a molar pregnancy. The client should not experience abdominal distention because the contents of the uterus have been removed. Chorioamnionitis is an inflammation of the amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.

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? Ask if the client is bottle feeding. Have the client see the healthcare provider in 2 weeks. Assess the client's legs for thrombophlebitis. Assess the client's bleeding flow and color.

Assess the client's bleeding flow and color. The client is 2 weeks postpartum and the fundus should be deep in the pelvis. Six to 12 hours after birth, the fundus should be at the umbilicus. Then, each postpartum day, the fundus should decrease one finger breadth under the umbilicus. Bottle feeding will not affect the level of the fundus. Assessment of the client's legs will not affect the client's fundus level. However, bleeding and color will provide further assessment of the client's postpartum healing status. Waiting to 2 weeks for the client to see the healthcare provider is too long.

Under the supervision of a nurse, a nursing student completes a postpartum assessment for a client 1-day postpartum. What assessments cause the nurse to intervene? Select all that apply. elimination assessment Homan's sign assessment a bimanual exam perineal assessment lochia assessment

Homan's sign assessment a bimanual exam Lochia, perineal, and elimination assessments are all critical components of the postpartum assessment. It is important to perform a lower extremity assessment, noting any signs of a clot (warmth, redness, calf discomfort); however, the nursing student should not perform the Homan's sign test. It is not a diagnostic test, and dorsiflexion of the foot may cause the clot to become dislodged if there is a clot present, resulting in an embolus.

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? Call the obstetrician and ask to postpone the cesarean birth. Refuse to accept the new admission. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. Ask the administrative assistant to complete the new client's paperwork.

Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. A nurse in the labor and delivery unit can't safely care for three clients. Therefore, the nurse should notify the charge nurse that an additional staff member is needed to safely meet the needs of the increasing client census. Postponing the cesarean birth isn't the best option. Although asking the administrative assistant to assist with paperwork is appropriate, obtaining an additional nurse is a higher priority. The nurse can't refuse to admit a client in labor.

Which measure would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? emptying the bladder every 2 to 4 hours while awake avoiding the intake of acidic fruit juices until the treatment is discontinued limiting fluid intake to 1 L daily to prevent overload washing the perineum with povidone iodine after voiding

emptying the bladder every 2 to 4 hours while awake The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep her bladder empty. In addition, she should maintain adequate fluid intake; 3,000 mL/day is recommended. Intake of acidic fruit juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infection. The client should wear cotton underwear and avoid tight-fitting slacks. She does not need to wash with povidone iodine after voiding. Plain warm water is sufficient to keep the perineal area clean.

A client whose blood type is A- gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? ensuring that the client understands the procedure and signs a consent for the vaccination instructing the client that she won't need an additional vaccination after her next pregnancy documenting administration of the drug in the client's chart choosing an injection site that isn't tender

ensuring that the client understands the procedure and signs a consent for the vaccination Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent. The nurse should document the procedure after giving the injection. The nurse should advise the client that Rho(D) immune globulin administration will be needed after every pregnancy. Choosing an injection site that isn't tender isn't a priority.

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? removing any remaining milk left on the nipple with a soft washcloth smoothly pulling the nipple out of the mouth after 10 minutes keeping plastic liners in the brassiere to keep the nipple drier placing as much of the areola as possible into the baby's mouth

placing as much of the areola as possible into the baby's mouth Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties.

During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse? one with little knowledge of parent-neonate attachment one whose parent died recently one who lost a job recently one who is an only child

one whose parent died recently A person in the process of detachment, which is necessary after a parent's death, may have difficulty forming an attachment to a neonate. To promote parent-neonate attachment, the nurse must be aware of recent family events. The nurse can overcome a parent's lack of knowledge about attachment through teaching and by providing the appropriate environment. Although job loss is stressful, it's less of a barrier to attachment than parental loss. Being an only child has little or no effect on one's ability to form an attachment with a neonate.

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 guard you against my cold hands." "Gloves help protect you against infectious organisms." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."

"Gloves are required for standard precautions." Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse's cold hands, the nurse wears them primarily to maintain standard precautions, which is required by the Occupational Safety and Health Administration.

A nurse is caring for a breastfeeding client diagnosed with mastitis in one breast and prescribed antibiotics. What actions will the nurse recommend the client take related to breastfeeding? Feed from the unaffected breast before feeding from affected side. Apply a cold compress to the affected breast prior to feeding. Schedule breastfeeding so antibiotics are taken after feeding, not before. Apply a warm compress to affected breast prior to feeding.

Apply a warm compress to affected breast prior to feeding. To help relieve mastitis, the nurse should advise the client to use warm compresses and massage the affected area gently before and during breastfeeding. Cold compresses can be used after or between feedings for comfort; this will hinder milk release, though, so the client should not apply them before feeding. It will not be possible to schedule breastfeeding in relation to antibiotic administration; the client is encourage to feed on demand, at least every 2 to 3 hours. To help empty the affected breast, feedings should start with the affected side.

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? Inform the healthcare professional (HCP) that the client does not want to go home. Tell the client that she must go home as per hospital policy. Ask the client the reason she does not want to go home. Ask the client if she has any support in the home.

Ask the client the reason she does not want to go home. It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. This kind of open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address the client's concerns appropriately. Asking the client about supports in the home may imply that the nurse is making an assumption about the reason why the client may not want to go home. Informing the HCP or telling the client it is hospital policy is not appropriate at this time because the nurse is unsure of the underlying reason. This is particularly important because the client may have safety-related concerns, may have undisclosed fears, or may require increased support before being discharged. It is imperative that the nurse not make assumptions but further explore the client's concerns.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? Invite everyone into the large conference room to see the neonate. Discuss the unit's policy with the charge nurse. Teach the grandparents how to scrub and gown before entering the nursery. Notify security because the neonate's father is demanding to see his baby.

Discuss the unit's policy with the charge nurse. Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth of a viable neonate, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next? Review the client's records for the length of the third stage of labor. Ask the client if she passed clots with her previous births. Massage the client's fundus vigorously. Document this observation as a normal finding.

Document this observation as a normal finding. The passage of two small blood clots from a multiparous woman 1 hour after a vaginal birth is not an unusual occurrence. The nurse should continue to monitor the client and document this as a normal finding.The nurse should never massage a postpartum client's fundus vigorously because of the risk for uterine inversion and discomfort to the mother.Asking whether the client passed clots with her previous births is irrelevant.The length of the third stage of labor has no relation to whether or not the client passes clots.

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client? The client demonstrates an understanding of her physical needs related to labor and birth. The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment. The client demonstrates an understanding of the neonate's physical needs related to labor and birth. The client demonstrates the ability to care for the neonate completely by time of discharge.

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment. Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her neonate after teaching and demonstrating care techniques; discussing the childbirth experience won't help her to meet these needs.

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally? Perineal pad usage remains at 10 to 15 per day. Blood pressure drops as a result of the birth and changed circulatory load. Urine output remains about the same as in the client's prenatal period. The uterus is descending at the rate of one fingerbreadth per day.

The uterus is descending at the rate of one fingerbreadth per day. During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after childbirth. Usually, the client will need six to seven perineal pads per day at this time.

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 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? Stop breast-feeding permanently. Wear a loose-fitting bra to avoid constricting the milk ducts. Use a warm moist compress over the painful area. Take antibiotics until the pain is relieved.

Use a warm moist compress over the painful area. Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? a primiparous client at 48 hours after cesarean birth of a term neonate a multiparous client at 48 hours postpartum who is being discharged a multiparous client at 24 hours postpartum whose infant is in the special care nursery a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally

a primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally The primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client.

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway affixing a security bracelet that monitors movement to a neonate allowing volunteers to return neonates to the nursery affixing matching identification bands to the parents and neonate at birth

allowing volunteers to return neonates to the nursery The new nurse requires additional teaching if allowing volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures.

A client and her partner experienced a pregnancy loss at 28 weeks gestation. The nurse is aware that which of the following factors affects the couple's response to this loss? previous experience with children assigned meaning to the event support from a spiritual leader expectation of a healthy birth outcome

assigned meaning to the event It is important to gain some understanding of the parents' perception of their unique loss. The meaning of the loss is determined by familial and cultural systems of the parents. Previous experience with loss or loss of a pregnancy may affect the parents' response. Experience with children is not the factor. Expecting the potential of a loss and not a healthy birth outcome during pregnancy may prepare parents for the subsequent perinatal loss. Support from a spiritual leader may help some families, but not all families want this type of support.

The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is: currently prescribed lithium. human immunodeficiency virus (HIV) positive. being treated for active tuberculosis (TB). diagnosed with mastitis.

diagnosed with mastitis. A client with mastitis can continue to breastfeed, provided she is not taking antibiotics that are contraindicated in breastfeeding. A mother who has HIV or active TB is strongly discouraged from breastfeeding because of concerns about transmitting the infection to the neonate. Lithium, chemotherapy medications, and amiodarone are some of the few medications that are absolute contraindications to breastfeeding.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? shock infection disseminated intravascular coagulation (DIC) hemorrhage

hemorrhage A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage. It doesn't directly increase the risk of shock, DIC, or infection.

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 lochia alba lochia lochia serosa

lochia rubra For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? placenta previa hypertension severe pain uterine infection

placenta previa The client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesn't contract as well as the fundal part of the uterus; therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don't increase the client's risk for postpartum hemorrhage.

The nurse makes a home visit to a primigravid client on the fourth postpartum day after birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that she has not been sleeping well and has been hearing voices. The nurse determines that the client is most likely experiencing which condition? the "baby blues. postpartum depression normal reactions to being a new mother postpartum psychosis

postpartum psychosis The client's symptoms of insomnia, crying inconsolably, and hearing voices (hallucinations) are all symptoms of postpartum psychosis. The client needs immediate treatment to prevent injury to herself and the neonate. Postpartum psychosis occurs in about 1 in 1,000 pregnancies; thus, it is relatively rare but serious. Hospitalization, social support, and psychotherapy are used to treat postpartum psychosis. Prognosis for recovery is good, but the condition may recur with subsequent pregnancies.Although crying at times may be expected, ignoring a crying newborn and hearing voices are not normal reactions."Baby blues" is a transient condition; mothers experiencing this do not hear voices.Postpartum depression continues for several weeks or months after birth. Crying, sadness, and lack of appetite may be present, but the client does not hear voices.

A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching her about possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when she states that the adverse effects include which symptom? bleeding gums petechiae slow pulse epistaxis

slow pulse A slow pulse (bradycardia) is normal for the first 7 days postpartum as the body begins to adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of heparin therapy suggesting prolonged bleeding include hematuria, epistaxis, increased lochial flow, and bleeding gums. Typically, tachycardia, not bradycardia, would be associated with hemorrhage. Petechiae indicate bleeding under the skin or in subcutaneous tissue.

A client gave birth to a healthy full-term girl 2 hours ago by cesarean birth. When assessing this client which finding requires immediate nursing action? gush of vaginal blood when she stands up tachycardia and hypotension complaints of abdominal pain blood stain 2″ (5.1 cm) in diameter on the abdominal dressing

tachycardia and hypotension A rising pulse rate and falling blood pressure may be signs of hemorrhage. Lochia pools in the vagina of a postpartum woman who has been sitting and may suddenly gush out when she stands up. Immediate nursing action isn't required. A 2″ (5.1 cm) blood stain on a fresh surgical incision isn't a cause for immediate concern; however, the area of blood should be circled and timed. An increase in size of the blood stain and oozing of the surgical incision should be promptly reported to the physician. It's normal for a woman who has had a cesarean birth to feel pain at the incision site after her anesthesia has worn off.

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? letting-go phase taking-over phase taking-hold phase taking-in phase

taking-in phase The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking-hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.

A breastfeeding primiparous client asks the nurse how breast milk differs from cow's milk. The nurse responds by saying that breast milk is higher in which nutrient? sodium iron fat calcium

fat Breast milk has slightly higher fat content than cow's milk. Thirty to fifty-five percent of the calories in breast milk are from fat. In addition, breast milk has significantly more unsaturated fat, including fatty acids essential for brain development. Breast milk contains less iron than cow's milk does. However, the neonate absorbs more iron from breast milk than from cow's milk. Breast milk contains less sodium and calcium than does cow's milk.

The nurse is caring for a client 24 hours postpartum from a normal, vaginal birth. For which client reported symptom will the nurse prioritize further assessment? feeling warm and flushed feeling too excited to sleep feeling pain and warmth behind left knee feeling chilled and cold

feeling pain and warmth behind left knee Pain and warm behind knee may indicate thrombosis in popliteal vein, which would be of concern for a postpartum client. This subjective finding requires immediate intervention assessment due to the increased risk for deep vein thrombosis in the postpartum client. Maternal chills are a normal vasomotor response to the birth. An elevated temperature in the first 24 hours is also normal. Insomnia in the immediate postpartum period is common as the body adjusts to the release of endorphins.

In which phase of postpartum psychological adaption would discharge teaching regarding infant care most likely be successful? taking in resolution taking hold letting go

taking hold Beginning after completion of the taking-in phase, the taking-hold phase lasts about 4 to 5 weeks. At this time, the client is most ready to learn self-care and infant care skills.In the taking-in phase, the client focuses more on sleep.The letting-go phase is the final phase of postpartum psychological adaptation. This phase is characterized by readjustment, with the client viewing the infant as a separate being, refocusing on her relationship with her partner, and adjusting to the maternal role.Resolution is not considered an accepted phase of postpartum psychological adjustment.

A primipara calls the birthing unit 3 days after a vaginal birth. She tells the nurse that she is bottle-feeding and her breasts are swollen and painful. Which instructions would be appropriate? Avoid wearing a bra to allow the engorgement to subside. Wear a tight breast binder for the next 24 hours. Refrain from taking a shower with the water on the breasts. Use ice packs for 20 minutes every 3 to 4 hours.

Use ice packs for 20 minutes every 3 to 4 hours. Ice packs cause vasoconstriction and can provide temporary relief of breast engorgement for the bottle-feeding mother.Breast engorgement is transitory and usually disappears within a few days. A tight breast binder is not recommended because it can worsen the engorgement and restrict blood flow. A supportive bra should be worn at all times by both bottle-feeding and breastfeeding mothers.Taking a warm shower may help relieve some of the discomfort of the breast engorgement.

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 am a rotten mother. I just do not have any energy. Plus, my husband just got laid off from his job." The nurse observes that the client's appearance is disheveled. What would be the nurse's best response? "These feelings commonly indicate symptoms of postpartum blues and are normal. They will go away in a few days." "It's not unusual for some mothers to feel depressed after the birth of a baby. I'm going to contact your health care provider." "This may be a symptom of a serious mental illness. I think you should probably go to the hospital." "I think you're probably overreacting to the labor and birth process. You're doing the best you can as a mother."

"It's not unusual for some mothers to feel depressed after the birth of a baby. I'm going to contact your health care provider." The client is probably experiencing postpartum depression, and the health care provider (HCP) should be contacted. Postpartum depression is usually treated with psychotherapy, social support groups, and antidepressant medications. Contributing factors include hormonal fluctuations, a history of depression, and environmental factors (e.g., job loss). An estimated 50% to 70% of women experience some degree of postpartum "blues," but these feelings of sadness disappear within 1 to 2 weeks after birth. However, the client is voicing more than just sadness. Telling her that she is overreacting is not helpful and may make her feel even less worthy. She is not exhibiting symptoms of a serious mental illness (loss of contact with reality) and does not need hospitalization.

After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? 18 months 24 months 12 months 6 months

12 months A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.

The nurse from the nursery is bringing a newborn to a mother's room. The nurse took care of the mother yesterday and knows the mother and baby well. The nurse should implement which action to ensure the safest transition of the infant to the mother? Check the crib to determine if there are enough diapers and formula. Ask the mother if there is anything else she needs for the care of her baby. Assess whether the mother is able to ambulate to care for the infant. Complete the hospital identification procedure with mother and infant.

Complete the hospital identification procedure with mother and infant. The hospital identification procedures for mothers and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the mother and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother's ability to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the mother, but identification verification is a safety measure that must occur first.

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? Avoid stimulating the baby before feeding because it causes poor latching and aggressive sucking. Dry the nipples well after feeding to prevent fungal infection, which can increase soreness. Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth. Do not pull the baby off the breast during painful feeding; instead, reposition slightly and wait a few minutes.

Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth. The best approach to getting a good latch is to ensure the infant's mouth is wide open with the nipple angled slightly toward the roof of the mouth. The goal is for the infant to take a large mouthful of the breast. The client should air-dry her nipples after breastfeeding. An infection is not this client's issue. A sleepy infant is more likely to have poor latch, so stimulating the rooting reflex to have the infant open wide is encouraged. If latching is poor and the feeding is painful, the client should break the suction and try again.

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 early in the third trimester and end 1 month after childbirth. It should begin before conception and end 3 months after childbirth. It should begin at about 5 months' gestation and end at facility discharge. It should begin when the client learns she's pregnant and end after childbirth.

It should begin before conception and end 3 months after childbirth. Ideally, childbirth education should begin before conception (or as soon after conception as possible) and continue for about 3 months after the client gives birth. Beginning childbirth education later and ending it earlier wouldn't provide enough time for optimal preparation of the client and her partner.

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Send the colleague an anonymous card. It is a breach of confidentiality to share this information with the colleague. Share the feedback with the nursing colleague directly. Post accolades to the nurse at the nurses' station.

Share the feedback with the nursing colleague directly. It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.

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. The episiotomy site is probably infected. A hematoma will likely develop. The client has had a repair of a vaginal laceration.

The client needs application of an ice pack. An episiotomy that is edematous and slightly reddened 8 hours after birth is normal. Therefore, the nurse should offer the client an ice pack to provide some relief from the perineal pain for the first 24 hours. An infection is present if greenish, purulent drainage is observed from the site. The edema and discoloration of the episiotomy at this time after birth are normal and do not indicate that a hematoma is likely to develop. A laceration when repaired should appear intact with edges well approximated, clean, and dry.

During the first hour after a precipitous birth, the nurse should monitor a multiparous client for signs and symptoms of which complication? postpartum "blues" urinary tract infection intrauterine infection uterine atony

uterine atony Because birth occurs so rapidly and the fetus is propelled quickly through the birth canal, the major complication of a precipitous birth is a boggy fundus, or uterine atony. The neonate should be put to the breast, if the mother permits, to allow for the release of natural oxytocin. In a hospital setting, the health care provider (HCP) will probably prescribe administration of oxytocin. The nurse should gently massage the fundus to ensure that it is firm. There is no relationship between a precipitous birth and postpartum "blues" or intrauterine infection. Postpartum "blues" usually do not occur until about 3 days postpartum, and symptoms of postpartum infection usually occur after the first 24 hours. There is no relationship between a precipitous birth and urinary tract infection even though the birth has been accomplished under clean rather than sterile technique. Symptoms of urinary tract infection typically begin on the first or second postpartum day.

A 24-year-old primipara decides to breastfeed her baby but says, "I am worried that I will not be able to breastfeed my baby because my breasts are so small." What would the nurse include in the explanation to the client? The woman's motivation to breastfeed is more important than breast size. Because her breasts are small, she will have to feed the baby more often. Breast size poses no influence on a woman's ability to breastfeed a baby. Breast milk can be enhanced by occasional formula feeding.

Breast size poses no influence on a woman's ability to breastfeed a baby. Breast size is not important as long as there is glandular tissue to secrete the milk, although various factors can influence milk supply, such as suckling, emptying of the breasts, diet, exercise, rest, level of contentment, and stress. The fat in breast tissue plays no role in milk production.Breastfeeding and formula feeding at the same time can result in nipple confusion.The client's belief in her ability to breastfeed is important because women who lack motivation are more likely to discontinue breastfeeding.Women with small breasts do not produce less milk. Also, the size of the breast does not influence the neonate's ability to grasp the nipple. The frequency of feeding is determined by the baby's needs, not the size of the mother's breasts.

When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? strabismus resulting from neonatal maturation blindness secondary to gonorrhea chorioretinitis from cytomegalovirus cataracts from beta-hemolytic streptococcus

blindness secondary to gonorrhea The instillation of erythromycin into the neonate's eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate's eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.

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? urinary frequency hypertension diarrhea dizziness

dizziness Analgesics with narcotics have numerous side effects, including respiratory depression, dizziness, light-headedness, hypotension, and fainting. Other side effects include constipation, nausea and vomiting, and urinary retention.Hypotension, not hypertension, is a possible adverse effect of narcotic analgesics.Constipation, not diarrhea, is a possible adverse effect of narcotic analgesics.Urinary retention, not urinary frequency, is a possible adverse effect of narcotic analgesics.

A postpartum client is concerned about how long to keep her newborn at the breast. She has been timing her infant to nurse for 5 to 10 minutes on each breast during each feeding. Which of the following is an appropriate response from the nurse? "Duration of breastfeeding should be determined by the newborn's signs of satiety." "Nurse until the infant falls asleep." "Every infant will feed differently; however, most infants do not take enough when fed by breast." "Nurse for 10 to 20 minutes per breast." SUBMIT ANSWER

"Duration of breastfeeding should be determined by the newborn's signs of satiety." While many older babies can take in the majority of their milk in the first 5 to 10 minutes, this cannot be generalized to all babies. Newborns, who are learning to nurse and are not always efficient at sucking, often need much longer to feed. The ability to take in milk is also subject to the mother's let-down response. While many mothers may let down immediately, some may not. Some may eject their milk in small batches several times during a nursing session. It is best to allow the infant to suck until the infant shows signs of satiety such as self-detachment and relaxed hands and arms. Therefore, providing women with a specific timeline to breastfeed, such as 5 to 30 minutes, is not helpful, particularly if the infant does not have a deep latch and is not able to be satiated.

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? Assess the client's lochia for large clots. Continue to monitor the client's vital signs. Offer the mother an ice pack for her forehead. Notify the client's health care provider (HCP) about the findings.

Continue to monitor the client's vital signs. The nurse needs to continue to monitor the client's vital signs. During the first 24 hours postpartum, it is normal for the mother to have a slight temperature elevation because of dehydration. A temperature of 100.4° F (38° C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and her fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The HCP does not need to be notified at this time. An ice pack is not necessary because the client's temperature is within normal limits.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? Rub the nipples gently with lanolin cream. Offer the neonate a small amount of formula. Apply an ice cube to the nipples. Express a small amount of breast milk.

Express a small amount of breast milk. Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However, it may temporarily relieve the discomfort associated with breast engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary. Use of lanolin may cause sensitivity and irritation. Having frequent breastfeeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

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 bring chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling. Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. Assume a prone position, and then do push-ups by using the arms to lift the upper body. Start in a sitting position, then lie back, and return to a sitting position, repeating this five times.

Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles. After an uncomplicated birth, postpartum exercises may begin on the first postpartum day with exercises to strengthen the abdominal muscles. These are done in the supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks.

Which information would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate? Use brightly colored animals and cartoon figures on the wall. Move a brightly colored rattle in front of the baby's eyes. Maintain eye contact while talking to the baby. Paint the baby's room in bright colors accented with teddy bears.

Maintain eye contact while talking to the baby. Neonates like to look at eyes, and eye-to-eye contact is a highly effective way to provide visual stimulation. The parent's eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fix on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric figures are appropriate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimulation as eye-to-eye contact with talking. Brightly colored animals and cartoon figures are more appropriate at approximately 1 year of age.

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? By the end of the shift, the client will describe a safe home environment. The client will demonstrate self-care and infant care by the end of the shift. By discharge, the family will bond with the neonate. The client will state instructions for discharge during the first postpartum day.

The client will demonstrate self-care and infant care by the end of the shift. Educating the client about caring for herself and her infant are the two highest priority goals. Following birth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but it is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.

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 father of the newborn will need to have Rh-factor testing performed. The newborn will be monitored closely for possible sensitization blood reaction. The infant will require Rh immunoglobulin injection within 72 hours. The client will need Rh immunoglobulin injection within 72 hours.

The client will need Rh immunoglobulin injection within 72 hours. A mother who is Rh-factor negative should receive Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the client. During birth, the newborn's Rh-positive cells can enter maternal circulation. Ideally, the mother should have received a schedule of RhoGAM to prevent initial isoimmunization against fetal erythrocytes and the formation of antibodies. Since the newborn's Rh factor is known, the father's status is not relevant (but would be positive because Rh negativity is a recessive trait). The newborn is not given the RhoGAM; it is the mother who is at risk for a sensitization reaction.

As part of the postpartum follow-up, a nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information which assessment would the nurse make? A home assessment is necessary to assure the well-being of the mother and the neonate. The client's behavior represents signs of postpartum depression. The client is acting abnormally and her physician needs to be notified. This is expected behavior for a client 3 to 7 days postpartum.

This is expected behavior for a client 3 to 7 days postpartum. Normal processes during postpartum include the withdrawal of progesterone and estrogen and lead to the psychological response known as "the blues." Postpartum depression is a psychiatric problem that occurs later in postpartum and is characterized by more severe symptoms of inadequacy. Because the client's behavior is normal, notifying her physician and conducting a home assessment aren't necessary.

A woman who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when she reports that Rho(D) immune globulin has which action? protecting her next baby if it is Rh negative preventing antibody formation in her blood preventing antigen formation in her baby's blood preventing jaundice in her baby

preventing antibody formation in her blood Rho(D) immune globulin is given to new mothers who are Rh negative and not previously sensitized and who have given birth to an Rh-positive infant. Rho(D) immune globulin must be given within 72 hours of the birth of the infant because antibody formation begins at that time. The vaccine is used only when the mother has borne an Rh-positive infant—not an Rh-negative infant. Rho(D) immune globulin is not given to a newborn and does not affect antigen formation. Administering Rho(D) immune globulin after birth reduces risk of hyperbilirubinemia in newborns from future pregnancies, but it will not reduce the risk to the current newborn.

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

rubra Lochia rubra is a red discharge that occurs 1 to 3 days after birth. It consists almost entirely of blood with only small clots and mucus. Lochia alba is a creamy white or colorless discharge that occurs up to 14 days' postpartum and may continue for up to 6 weeks. Lochia serosa is a pink or brownish discharge that occurs 3 to 10 days postpartum. Thrombic isn't a term used to describe lochia.

During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? the taking-in phase the letting-go phase the binding-in phase the taking-hold phase

the taking-hold phase The taking-in phase is the period after birth characterized by the women's dependency and passivity with others. Maternal needs are dominant and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is the period after birth characterized by a woman becoming more independent and most interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together.

A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, "How could God do this to me? I've never done anything wrong." Which response by the nurse would be most appropriate at this time? "It's not God's fault. It was an accident." "God can handle your anger. It's okay." "You're a strong person. You'll get through this." "I know you're angry. It's so hard to lose your baby."

"I know you're angry. It's so hard to lose your baby." Acknowledging the anger and its source encourages communication about the client's feelings. Although anger at God is common after a loss, the client is displacing the anger that she needs to deal with more directly. Telling the client that the miscarriage was an accident or that she is a strong person and will get through this ignores the client's feelings of anger and loss, thereby cutting off communication.

After 2 days of breast-feeding, a postpartum client reports nipple soreness. Which client statement indicates an understanding of measures to help relieve nipple soreness? "I should lubricate my nipples with expressed milk before feedings." "I will apply soap directly to my nipples and then rinse." "I will apply warm compresses to my nipples just before feedings." "I will dry my nipples with a soft towel after feedings."

"I should lubricate my nipples with expressed milk before feedings." Measures that help relieve nipple soreness in a breast-feeding client include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feedings, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.

A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond? "It dilates the urethra." "It constricts the urinary sphincter." "It stimulates the smooth muscle of the bladder." "It inhibits the skeletal muscle of the bladder."

"It stimulates the smooth muscle of the bladder." Bethanechol stimulates the smooth muscle of the bladder causing it to release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle.

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

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

The nurse returns the newborn to the new mother after obtaining assessment data and performing newborn interventions. The nurse recognizes the best evidence of positive bonding when the mother: gently taps the baby's back after feeding. asks the nurse many questions about caring for the infant. takes multiple photos of the infant to share on social media. engages in direct eye contact with the infant.

engages in direct eye contact with the infant. Successful, effective maternal-newborn bonding is thought to occur when the mother take the en face position, looking directly at her newborn's face with direct eye contact. Patting the newborn after feeding encourages burping, but it not indicative of bonding. Asking questions signals readiness to learn, but not bonding. Taking photos and sharing them does not enhance the physical contact needed for bonding.

A client and her partner just experienced spontaneous bleeding at 11 weeks gestation, which resulted in the loss of the fetus. The couple wonders if the bleeding could have been caused from the client working long hours in a stressful work environment. What is the most appropriate response from the nurse? "I can understand your need to find an answer to what caused this. Let's talk about this further." "Your spontaneous bleed is not work related." "It is hard to know why a woman bleeds during early pregnancy." "There must have been something wrong with the pregnancy. Why don't you discuss this more with your physician."

"I can understand your need to find an answer to what caused this. Let's talk about this further." Talking with the couple may assist them to explore their feelings further. The couple may search for a cause of a spontaneous early bleed so they can plan knowledgeably for future pregnancies. However, even with modern technology and medical advances, a direct cause cannot usually be determined.

A multigravida prenatal client with a history of postpartum depression tells the nurse that she is taking measures to make sure that she does not suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? liver functions mood status current medications fetal growth

current medications St. John's wort, an herbal supplement commonly used to treat mild depression, interacts with many medications, making them less effective. If the client is already taking a prescription antidepressant, she can be at risk for serotonin syndrome. St. John's wort is not known to cause fetal growth or liver problems. It would be important to assess the client's mood after determining if the client is at risk for medication interactions.