saunders maternal nursing flashcard app (postpartum)
b
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? a) infection b) hemorrhage c) chronic hypertension d) disseminated intravascular coagulation
d (If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute by face mask. Oxygen is used to decrease hypoxia. The client is also kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen)
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspected a pulmonary embolism. Which should be the initial nursing action? a) initiate an intravenous line b) assess the client's blood pressure c) prepare to administer morphine sulfate d) Administer oxygen 8 to 10 L/minute by face mask
b (Rationale: Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage)
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? a) providing sitz baths b) encouraging fluid intake c) placing ice on the perineum d) monitoring hemoglobin and hematocrit levels
c (Rationale: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the clients legs would not assist in managing uterine agony. Documenting the findings is an appropriate action, but it is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage)
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? a) Document the findings b) Elevate the client's legs c) Massage the fundus until it is firm d) Push on the uterus to assist in expressing clots
d (Rationale: Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons.)
The nurse evaluates the ability of a hepatitis B positive mother to provide safe bottle feeding to her newborn during postpartum hospitalization.. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? a) the mother requests that the window be closed before feeding b) the mother holds the newborn properly during feeding and burping c) the mother tests the temperature of the formula before initiating feeding d) the mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding
a (Rationale: A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision)
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? a) I will begin abdominal exercises immediately b) I will notify the health care provider if I develop a fever c) I will turn on my side and push up with my arms to get out of bed d) I will lift nothing heavier than my newborn baby for at least 2 weeks.
c (Rationale: Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed)
The nurse is assessing a client who is 6 hours postpartum after delivering a full term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? a) raise the head of the client's bed b) obtain hemoglobin and hematocrit levels c) instruct the client to request help when getting out of bed d) inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided
d (Rationale: Lochia, the discharge present after birth, is red for the first 1 ro 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal.)
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? a) The client with mild afterpains b) The client with a pulse rate of 60 beats/minute c) The client with colostrum discharge from both breasts d) The client with lochia that is red and has a foul smelling odor
d (rationale: A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Ambulation hourly increases risk for bleeding. Client assessment every 4 hours is too infrequent)
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? a) encourage ambulation hourly b) assess vital signs every 4 hours c) measure fundal height every 4 hours d) prepare an ice pack for application to the area
b (Rationale: During the 4th stage of labor, the maternal blood pressure me. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. the respiratory rate is slightly increased from normal.)
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? a) temperature of 100.4 b) an increase in the pulse rate from 88 to 102 beats/ minute c) a blood pressure change from 130/88 to 124/80 mm Hg d) an increase in the respiratory rate from 18 to 22 breaths/minute
a (Rationale: Because the client had has an epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation/ Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma)
The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of hematoma? a) change in vital signs b) signs of heavy bruising c) complaints of intense pain d) complaints of a tearing sensation
d (Rationale: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant= less than 2.5 cm (<1 inch) on menstrual pad in 1 hour; light = less than 10 cm (<4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (<6 inches) on menstrual pad in 1 hour;heavy = saturated menstrual pad in 1 our; excessive = menstrual pad saturates in 15 minutes. If the client is experiencing excessive bleeding, the nurse should notify the HCP in the event that postpartum hemorrhage is occurring)
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding intitally? a) document the finding b) encourage the client to ambulate c) encourage the client to increases fluid intake d) contact the health care provider and inform the HCP of this finding
a (Rationale: The priority nursing consideration for a client who delivered 2 hours ago who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. )
The nurse is planning care for a postpartum client who had vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? a) client pain level b) inadequate urinary output c) client perception of body changes d) potential for imbalanced body fluid volume
a, b, c, d (Rationale: Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day if not contraindicated, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast feeding or breast pump is important to empty the breast and prevent the formation of an abscess.)
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions would be included on the list? Select all that apply. a) wear a supportive bra b) rest during the acute phase c) maintain a fluid intake of at least 3000 mL/day d) continue to breast feed if the breasts are not too sore e) take the prescribed antibiotics until the soreness subsides f) avoid decompression of the breasts by breast feeding or breast pump
b (Rationale: If the uterus is not contracted firmly, the intial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage)
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? a) elevate the client's legs b) massage the fundus until it is firm c) ask the client to turn on her left side d) push on the uterus to assist in expressing clots
d (Rationale: Mastitis is inflammation of the breast as a result of infection. It generally is cause by an organism that enters through an injured area of the nipples, such as crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast feed every 2 to 3 hours)
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which client statement would indicate a need for further instruction? a) I should breast feed every 2 to 3 hours b) I should change the breast pads frequently c) I should wash my hands well before breastfeeding d) I should wash my nipples daily with soap and water
a, b, c, f
The nurse is providing postpartum instructions to a client who will be breast feeding her newborn. The nurse determines that the client had understood the instructions if she makes which statements? Select all that apply. a) I should wear a bra that provides support b) Drinking alcohol can affect my milk supply c) The use of caffeine can decrease my milk supply d) I will start my estrogen birth control pills again as soon as I get home. e) I know if my breasts get engorged , I will limit my breast feeding and supplement the baby f) I plan on having bottled water available in the refrigerator so I can get additional fluids easily
a (Rationale: The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breast because it tends to remove natural oils, which increases the chance of cracked nipples)
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? a) the diet should include additional fluids b) prenatal vitamins should be discontinued c) soap should be used to cleanse the breasts d) birth control measures are unnecessary while breast feeding
c (Rationale: Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when the walk. Palpable dorsalis pedis pulses is a normal finding.)
The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? a) paleness of the calf area b) coolness of the calf area c) enlarged, hardened veins d) palpable dorsalis pedis pulses
a (Rationale: After birth the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns within 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions)
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding return of bowel function? a) 3 days postpartum b) 7 days postpartum c) On the day of birth d) Within 2 weeks postpartum
b (Rationale: Hyperbilirubinemia is an elevated serum bilirubin level. At any serum bilirubin level, the appearance of jaundice during the first day of life indicates a pathological process. Early and frequent feeding hastens the excretion of bilirubin. Breast-feeding should be initiated within 2 hours after birth and every 2 to 4 hours thereafter. The infant should not be fed less frequently. Switching to bottle-feeding for 2 weeks or stopping breast-feeding permanently is unnecessary)
The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast fed. the nurse should provide which instruction to the mother? a) feed the newborn less frequently b) continue to breast feed every 2 to 4 hours c) switch to bottle feeding the infant for 2 weeks d) stop breast-feeding and switch to bottle-feeding permanently
d (Rationale: The client's temperature should be taken every 4 hours while she is awake. Temperature up to 100.4 F in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.)
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? a) document the findings b) retake the temperature in 15 minutes c) notify the health care provider d) increase hydration by encouraging oral fluids
c (Rationale: Normally a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine arony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notfy the HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation)
When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate? a) Document the findings b) Reassess the client in 2 hours c) Notify the health care provider d) Encourage increased oral intake of fluids