Ricci, Kyle & Carman: Maternity and Pediatric Nursing, Second Edition: Chapter 15: Postpartum Adaptations; PrepU

A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response by the nurse is appropriate?

"After birth it is easier to develop an infection in the urinary system; we need to see you today." The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?

"I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?

"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration?

Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the patient drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?

Empty the breasts frequently. The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?

Hold the baby frequently. The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

Which action would lead the nurse to assess that a postpartal woman is entering the taking-hold phase of the postpartal period?

She did her perineal care independently. During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it.

True

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

The process by which the reproductive organs return to the nonpregnant size and function is termed what?

involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?

postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?

the taking-hold phase The taking-in phase is characterized by the woman's dependency on 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 characterized by the woman becoming more independent and 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. The binding-in phase is a distractor for this question.

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection hydramnios prolonged labor Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?

"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

A nurse is making an initial call on a new mother who gave birth to her third baby five days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

"It takes about 3 days after birth for milk to begin forming." The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy as, since midway through pregnancy, she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day post birth, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.

A client gave birth vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?

"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after birth.

Which instruction should the nurse provide to a breastfeeding woman experiencing breast engorgement?

"Take a warm shower just before feeding your infant." Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention

The nurse is assigned to a client on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?

1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

A nurse is caring for a postpartum client who has a temperature. Which temperature protocols would the nurse use to indicate a possible infection?

100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4º F (38º C) on 2 postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

Administer pain medications. "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response?

Ask the client why 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. Open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address concerns appropriately. Asking about supports at home implies that the nurse has made assumptions about why the client may not want to go home. Informing the care provider or telling the client that discharge is hospital policy is not appropriate at this time because the nurse has not addressed the underlying reason for the client's comment. The client may have safety-related concerns, undisclosed fears, or a need for increased support before discharge. It is imperative that the nurse not make assumptions but further explore concerns.

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?

Assist the woman in placing ice packs on her breasts. If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.

For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.

A client reports she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?

Encourage the client to eat more fiber rich foods. Encouraging fiber rich foods will help with prevention of constipation. The client needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.

A woman who has just given birth seems to be bonding with her newborn, despite the fact that earlier in labor she had expressed an intent to give the baby up for adoption. In this case, the nurse should encourage the mother to keep her baby.

False Do not attempt to change a woman's mind about keeping her child or placing the child for adoption during the postpartal period as she is extremely vulnerable to suggestion at this time, and such decisions are too long range and too important to be made at such an emotional time. Her earlier conclusion may be the sound one. Instead, offer nonjudgmental support. Be especially aware of your own feelings about this issue, to avoid influencing a woman's decision making unnecessarily.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?

Perform Kegel exercises. The nurse should ask the client to perform the Kegel exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.

During a postpartum exam on the day of birth, the woman reports that she is still so sore that she cannot sit comfortably. The nurse examines her perineum and find the edges of the episiotomy approximated without signs of a hematoma. Which intervention will be most beneficial at this point?

Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.

Which maternal reaction is the most concerning?

She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues".

While educating a class of postpartum clients before discharge home after birth, one woman asks when "will I stop bleeding?" How should the nurse respond?

The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks. The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week, but a white discharge may continue for up to 6 weeks after birth. Bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. The discharge may continue for up to six weeks, not just bleeding.

Which reason explains why women should be encouraged to perform Kegel exercises after birth?

They promote blood flow, enabling healing and muscle strengthening. Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.

The nurse is providing education to a mother who is going to bottle feed her infant. What information will the nurse provide to this mom regarding breast care?

Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

Bonding between a mother and her infant can be defined how?

a process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a year-long process, and the family growing closer together after the birth of a new baby is not bonding.

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?

attachment When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothes the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.

On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?

bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

bleeding Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning?

blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.

The nurse is concerned with the interactions between a mother and her 2-day-old infant. The nurse observes signs of impaired bonding and attachment. Which action should the nurse document as a cause for concern?

calling the baby it or they Many new parents will need assistance with diaper changes; this is not a flag for concern; making eye contact and breastfeeding are positive interaction behaviors; if the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?

decreased intra-abdominal pressure The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?

difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.

The nurse is assessing a breastfeeding mom 72 hours after birth. When assessing her breasts, the client reports bilateral breast pain around the entire breast. What is the most likely cause of the pain?

engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. The other problems do not typically develop until there is fully established breastfeeding

When caring for postpartum clients, the nurse would expect the birth attendant to prescribe what laboratory study the morning after the birth of the baby?

hemoglobin and hematocrit H&H Monitor the H&H and note the H&H before birth. Most practitioners prescribe a postpartum H&H on the morning after birth. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a Rho(D) immune globulin workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?

hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.

The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply.

involution of the uterus contraction of the cervix decrease of pregnancy hormones return of blood volume to prepregnancy level Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartal period.

A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which finding would the nurse expect to assess?

moderate lochia rubra with no clots During the first hour following birth, the nurse should find moderate lochia rubra with no clots. Lochia rubra with few clots or saturation of two or more pads within this first hour are not abnormal findings that require further investigation. Lochia alba appears around the 10th day postpartum.

Which lochia pattern should be reported immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains?

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?

taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which condition?

urinary tract infection The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during postpartum, diuresis causes weight loss during the first postpartal week, whereas iron deficiency causes anemia in the puerperium.

The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?

vessel damage during birth A woman's risk for thromboembolism increases due to her hypercoagulable state, vessel damage during birth, and immobility. The increase in white blood cell count is unrelated to her risk for thromboembolism. Coagulation factors remain elevated for 2 to 3 weeks postpartum. An episiotomy is not a risk factor for thromboembolism.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.