Unit 26: After Delivery

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: a. the level of the umbilicus. b. between the umbilicus and symphysis pubis. c. 1 cm below the umbilicus. d. 2 cm below the umbilicus.

a. the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a. one fingerbreadth above the umbilicus b. one fingerbreadth below the umbilicus c. at the level of the umbilicus d. below the symphysis pubis

b. one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect? a. bright red discharge b. pinkish brown discharge c. deep red mucus-like discharge d. creamy white discharge

b. pinkish brown discharge Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

The nurse is assessing the fundus of a client on postpartum day 1. What should the nurse expect when palpating the fundus? a. fundus 4 cm above symphysis pubis and firm b. fundus height 4 cm below umbilicus and midline c. fundus one fingerbreadth below umbilicus and firm d. fundus two fingerbreadths above symphysis pubis and hard

c. fundus one fingerbreadth below umbilicus and firm Because uterine contraction begins immediately after birth of the placenta, the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases one fingerbreadth or centimeter per day and will be palpable 1 cm below the umbilicus. For the second postpartum day, the uterus will be two fingerbreadths or centimeters below the umbilicus. The fundus should not be palpated 4 cm above the symphysis pubis, 4 cm below the umbilicus, or two fingerbreadths above the symphysis pubis on the second postpartum day. The fundus should not be hard.

Which condition should the nurse look for in the client's history that may explain an increase in the severity of afterpains? a. bottle-feeding b. diabetes c. multiple gestation d. primiparity

c. multiple gestation Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of afterpains. Bottle-feeding and diabetes aren't directly associated with increasing severity of afterpains, unless the client has delivered a macrosomic neonate.

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? a. prolactin b. progesterone c. oxytocin d. estrogen

c. 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.

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? a. "You might try using a water-soluble lubricant to ease the discomfort." b. "It takes a while to get your body back to its normal function after having a baby." c. "This is entirely normal, and many women go through it. It just takes time." d. "Try doing Kegel exercises to get your pelvic muscles back in shape."

a. "You might try using a water-soluble lubricant to ease the discomfort." Discomfort during sex 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 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? a. Ask the client to explain why she does not want to go home. b. Inform the primary care provider that the client does not want to go home. c. Tell the client that she must go home as per hospital policy. d. Ask the client if she has any support in the home.

a. Ask the client to explain 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 new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? a. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. b. Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge. c. Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it. d. Recommend rooming-in to foster attachment and confidence by the mother.

a. Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as a mother by going through a series of four developmental stages. What is one of them? a. achieving a maternal identity b. finding a way to get the new baby to conform to existing family interrelationships c. physical restoration and learning to get help in caring for the infant d. preparing for the infant before she conceives

a. achieving a maternal identity The woman adapts to her new role as a mother through a series of four developmental stages: 1. Beginning attachment and preparation for the infant during pregnancy 2. Increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period 3. Moving toward a new normal in the first several months 4. Achieving a maternal identity around 4 months

A postpartum client's care provider has prescribed a stool softener. When providing health education to the client, the nurse should teach the client to: a. drink plenty of fluids while taking the medication. b. limit intake of high-fiber foods. c. consider herbal alternatives. d. take the medication on empty stomach.

a. drink plenty of fluids while taking the medication. Stool softeners should be accompanied by adequate fluid intake. These medications do not need to be taken on an empty stomach and it is beyond the nurse's scope to recommend alternatives to a prescribed medication. Fiber intake should be encouraged.

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time? a. health-seeking behaviors related to care of newborn b. ineffective coping related to expectation to provide newborn care c. risk for altered family coping related to an additional family member d. risk for impaired parenting related to disappointment in the sex of the child

a. health-seeking behaviors related to care of newborn The new mother is asking the nurse to validate actions being performed while providing newborn care. The nursing diagnosis most appropriate for the new mother at this time would be health-seeking behaviors related to care of the newborn. The new mother is not demonstrating signs of ineffective coping. There is no information to support a risk for altered family coping or risk for impaired parenting.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? a. oral temperature 100.8° F (38.2° C) b. pulse rate 75 beats per minute c. respiratory rate 16 breaths/minute d. uterine fundus 1 cm below umbilicus

a. oral temperature 100.8° F (38.2° C) A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

When palpating for fundal height on a postpartum woman, which technique is preferable? a. placing one hand at the base of the uterus, one on the fundus b. placing one hand on the fundus, one on the perineum c. resting both hands on the fundus d. palpating the fundus with only fingertip pressure

a. placing one hand at the base of the uterus, one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breastfeeding, the nurse would identify which hormone that is responsible for milk production? a. prolactin b. estrogen c. oxytocin d. progesterone

a. prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? a. showing increased confidence when caring for the newborn b. talking about her labor experience to others around her c. pointing out specific features in the newborn d. having feelings of grief or guilt

a. showing increased confidence when caring for the newborn Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? a. taking-in phase b. taking-hold phase c. letting-go phase d. attachment phase

a. taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

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 postpartum restorative period is this client in? a. taking-in phase b. taking-hold phase c. letting-go phase d. rooming-in phase

a. 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 postpartum period.

A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis. The nurse would also expect to assess an elevation in which of the following? a. temperature b. blood pressure c. heart rate d. respiratory rate

a. temperature Additional assessment findings would include an elevation in the client's temperature. Elevation in blood pressure, heart rate, and respiratory rate are not findings associated with endometritis.

A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement? a. "I need to let the doctor know if my lochia begins to have a foul smell." b. "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." c. "My episiotomy should begin to heal and feel better over the next few weeks" d. "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know."

b. "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the health care provider needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul-smelling both indicate a possible infection and the physician needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

A postpartum client is experiencing painful hemorrhoids. After teaching the client about ways to obtain relief and comfort, the nurse determines that the teaching was successful based on which client statement? a. "I need to avoid using any type of stool softeners for bowel movements." b. "I should lie on my left side with my right hip and knee bent several times a day." c. "I should rub the area vigorously after each time after using the bathroom." d. "I need to keep my fiber intake low so I do not irritate the hemorrhoids."

b. "I should lie on my left side with my right hip and knee bent several times a day." Assuming a Sims position several times a day aids in good venous return to the rectal area and reduces the discomfort of hemorrhoids. Stool softeners and increased fiber intake would be appropriate because they can prevent the development of hardened stool, which can irritate hemorrhoids. Vigorous rubbing would irritate hemorrhoids.

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? a. "You would probably be more successful if you wrapped him in on a warm blanket." b. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." c. "Let me show you how to calm him down. I've been doing this for many years." d. "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?"

b. "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? a. "You must have an infection, so let me get a urine specimen." b. "Your body is undergoing many changes that cause your bladder to fill quickly." c. "Your uterus is not contracting as quickly as it should." d. "The anesthesia that you received is wearing off and your bladder is working again."

b. "Your body is undergoing many changes that cause your bladder to fill quickly." Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.

When assessing a client's uterine fundus during the fourth stage of labor, the nurse palpates a soft, uncontracted fundus. Which of the following would the nurse do next? a. Instruct the client to exercise. b. Gently massage the boggy fundus. c. Suggest complete bed rest. d. Suggest avoiding lifting weight.

b. Gently massage the boggy fundus. The nurse should gently massage a boggy fundus with the hand, maintaining the position of the second hand that is guarding the uterus, until the uterus becomes firm. Instructing the client to exercise, suggesting complete bed rest, and avoiding lifting heavy weight are not the most appropriate interventions when a boggy fundus is detected.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a. infection b. dehydration c. change in the temperature from the birth room d. fluid volume overload

b. dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A nurse is observing a postpartum woman and her partner interact with the their newborn. The nurse determines that the parents are developing parental attachment their newborn when they demonstrate which behavior? Select all that apply. a. frequently ask for the newborn to be taken from the room b. identify common features between themselves and the newborn c. refer to the newborn as having a monkey-face d. make direct eye contact with the newborn e. refrain from checking out the newborn's features

b. identify common features between themselves and the newborn d. make direct eye contact with the newborn Positive behaviors that indicate attachment include identifying common features and making direct eye contact with the newborn. Asking for the newborn to be taken out of the room, referring to the newborn as having a monkey-face, and refraining from checking out the newborn's features are negative attachment behaviors.

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? a. blood type b. folic acid level c. hemoglobin and hematocrit d. iron level

c. hemoglobin and hematocrit The health care provider will order hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia. A decreased result may indicate the woman has suffered post-delivery hemorrhage and is also common with cesarean deliveries. The maternal blood type will be determined before the delivery. The H&H may be ordered as part of the complete blood count or may be ordered separately. The complete blood count may be ordered to evaluate for infection if the client has a fever. The iron level may be ordered at a later date if the H&H continues to remain low after a few days, but is not a priority within the first 24 hours after delivery.

When assessing a client who is 5 days postpartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage? a. oliguria b. fundal tenderness c. rubra colored lochia d. increased rectal pressure

c. rubra colored lochia The nurse should monitor for rubra-colored lochia, malodorous vaginal discharge, and increased uterine cramping when actual hemorrhage occurs in a client experiencing late postpartum hemorrhage. Fundal tenderness is a sign of endometritis. Oliguria is suggestive of bacteremia in clients. Increased rectal pressure is a sign of postpartum hematoma in a client.

The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? a. to aid in maturing the newborn's sucking reflex b. to encourage the development of maternal antibodies c. to facilitate maternal-infant bonding d. to enhance the clearing of the newborn's respiratory passages

c. to facilitate maternal-infant bonding Breastfeeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.

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? a. cracking of the nipple b. improper positioning of infant c. inadequate secretion of prolactin d. inability of infant to empty breasts

d. 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.

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? a. Hold the baby frequently. b. Speak to his friends who have children. c. Read up on parental care. d. Have the client speak to the primary care provider on her husband's behalf

a. 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 intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? a. applying ice b. restricting fluids c. applying warm compresses d. administering bromocriptine

a. applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. 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.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? a. To monitor the mother's blood pressure to note any elevations b. To check for postpartum hemorrhage c. To determine if the mother's milk is coming in d. To answer questions the new parents may have

b. To check for postpartum hemorrhage If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distention. There are no anticipated elevations in the mother's blood pressure, nor should the mother's milk come in this early.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a. one fingerbreadth above the umbilicus b. one fingerbreadth below the umbilicus c. at the level of the umbilicus d. below the symphysis pubis

b. one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by about one fingerbreadth (about 1 cm) each day. So by the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? a. Content, lochia, place b. Location, shape, and content c. Consistency, shape, and location d. Consistency, location, and place

c. Consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? a. The urinary output is inadequate and the mother needs to drinks more fluids. b. The urinary output is inadequate suggestive of urinary retention. c. The urinary output is normal. d. The urinary output is above expected levels.

c. The urinary output is normal. Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void.

A nurse is completing a postpartum assessment. Which finding would alert the nurse to a potential problem? a. lochia rubra with a fleshy odor b. respiratory rate of 16 breaths per minute c. temperature of 101° F (38.3° C) d. pain rating of 2 on a scale from 0 to 10

c. temperature of 101° F (38.3° C) Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range. Some women experience a slight fever, up to 100.4º F (38º C), during the first 24 hours. A temperature above 100.4º F (38º C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Foul-smelling lochia or lochia with an unexpected change in color or amount, shortness of breath, or respiratory rate below 16 or above 20 breaths per minute would also be a cause for concern. The goal of pain management is to have the woman's pain scale rating maintained between 0 to 2 points at all times, especially after breastfeeding.

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? a. 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours b. 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day c. 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day d. 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum

d. 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4ºF (38ºC) on two 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 postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: a. shapeless. b. circular. c. triangular. d. slit-like.

d. slit-like. After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? a. "It might take up to a week for your bowels to return to their normal pattern." b. "I'll get a laxative prescribed so that you can move your bowels." c. "That's unusual. Are you making sure to eat enough?" d. "Let me call your health care provider about this problem."

a. "It might take up to a week for your bowels to return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? a. Reassess the client in 1 hour. b. Document the lochia as scant. c. Stop using a peri-pad. d. Massage the client's fundus.

b. Document the lochia as scant. "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: a. determines that the procedure is effective. b. helps support the lower uterine segment. c. aids in expressing accumulated clots. d. prevents uterine muscle fatigue.

b. helps support the lower uterine segment. The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The hand, usually the dominant hand that is placed on the fundus, helps to determine uterine firmness (and thus the effectiveness of the massage). Applying gentle downward pressure on the fundus helps to express clots. Overmassaging the uterus leads to muscle fatigue.

A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation? a. Massage the fundus. b. Take a blood pressure. c. Call the provider. d. Encourage the client to void.

a. Massage the fundus. When a client has heavy bleeding, the first action is to massage the fundus to stimulate it to contract and to control the amount of blood loss. The blood pressure will not change immediately and will not help to control the bleeding. If the fundal position is deviated, the nurse would palpate the bladder and if full, would encourage the client to void. The provider needs to be called, but not until the nurse has addressed the client's most urgent need.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a. applying ice b. restricting fluids c. applying warm compresses d. administering bromocriptine

a. 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.

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a. massaging the fundus firmly b. performing bimanual compressions c. administering ergonovine d. notifying the primary care provider

a. massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

The client, G5P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? a. Put on the call button to summon help. b. Gently massage the fundus until it tones up. c. Administer oxytocics to prevent uterine atony. d. Teach the woman to perform periodic self-fundal massage.

b. Gently massage the fundus until it tones up. After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the client. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? a. Apply warm compresses. b. Wear a well-fitting bra. c. Express milk frequently. d. Apply hydrogel dressing.

b. 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 are 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. a scant amount of lochia alba b. a moderate amount of lochia alba c. a moderate amount of lochia rubra d. a scant amount of lochia serosa

c. 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. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: a. scant. b. light. c. moderate. d. heavy.

c. moderate. Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.

A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading? a. lying flat in the bed on the back b. lying on the right side for 5 minutes c. standing next to the bed after 3 minutes d. sitting on the side of the bed for 2 minutes

d. sitting on the side of the bed for 2 minutes To get the most accurate reading on a 1-day postpartum client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.

The night shift LPN is checking on a woman who had a cesarean birth with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first? a. administer naloxone per the preprinted orders b. awaken the woman and instruct her to breathe more rapidly c. call the anesthesiologist from the room for orders d. perform bag-to-mouth rescue breathing at a rate of 12 per minute

a. administer naloxone per the preprinted orders Have naloxone readily available. The anesthesiologist orders naloxone administration if the respiratory rate falls below 10 to 12 per minute.

When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action? a. The fundus is firm and located at the level of the umbilicus. b. The fundus is firm and located one fingerbreadth below the level of the umbilicus. c. The fundus is firm and deviated sharply to the right side of the abdomen. d. The fundus is firm and located 1 fingerbreadth above the level of the umbilicus.

c. The fundus is firm and deviated sharply to the right side of the abdomen. In the immediate postpartum period, the fundus is regularly assessed. The fundus must be firm. A boggy fundus indicates uterine atony and will result in blood loss. The fundus is to be midline in the abdomen. A deviation to the side may indicate a full bladder. In the immediate hours after birth, the fundus may be found at one fingerbreadth above or below the umbilicus.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values? a. The client will need a transfusion, so the RN needs to be notified. b. The client will be tired, so encourage her to sleep whenever the baby sleeps. c. The health care provider needs to be notified of the latest lab values. d. These values are expected for a 1-day postpartum mother.

c. The health care provider needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.

When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? a. reciprocity b. engrossment c. bonding d. attachment

c. bonding The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? a. level with the umbilicus b. one fingerbreadth below the umbilicus c. two fingerbreadths below the umbilicus d. at the pubic bone

c. two fingerbreadths below the umbilicus Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by day 2, the fundal height is two fingerbreadths below the umbilicus.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? a. The flow contains large clots. b. The flow is over 500 mL. c. Her uterus is soft to your touch. d. The color of the flow is red.

d. The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? a. increasing oral fluid intake b. increasing intravenous fluids c. screening for bacteriuria in the urine d. encouraging the woman to empty her bladder completely every 2 to 4 hours

d. encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

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? a. diuresis b. lactation c. blood loss d. nausea

a. 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 the first postpartum week does not cause major weight loss.

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition? a. hemorrhoids b. hemorrhage c. thromboembolism d. cervical laceration

b. hemorrhage The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? a. demonstrates pleasure when touching or holding the newborn b. identifies imperfections in the newborn's appearance c. is able to distinguish his newborn from others in the nursery d. shows feelings of pride with the birth of the newborn

b. identifies imperfections in the newborn's appearance Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? a. ferrous sulfate b. methylergonovine c. docusate d. bromocriptine

c. docusate A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? a. Determine if the client is emptying her bladder. b. Ask the client when she last urinated. c. Perform an "in and out" catheter on the client. d. Educate the client on how to perform Kegel exercises.

d. Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? a. presence of lochia serosa b. frequent scant voidings c. fundus firm, below umbilicus d. milk filling in both breasts

b. frequent scant voidings Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

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? a. two fingerbreadths above the umbilicus b. at the level of the umbilicus c. two fingerbreadths below the umbilicus d. four fingerbreadths below the umbilicus

c. 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.

When developing a plan of care for a postpartum client, the nurse would identify which of the following as an expected outcome? a. difficulty providing care for the newborn b. foul-smelling lochia c. vital signs within acceptable limits d. evidence of urinary retention

c. vital signs within acceptable limits The nurse should identify vital signs within acceptable limits as an expected outcome for the postpartum client. Difficulty providing care for the newborn, foul-smelling lochia, and evidence of urinary retention are not expected outcomes for a postpartum client.

The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective? a. "If the drainage changes from clear to bright red, I am to call the doctor." b. "I will have large amount of vaginal drainage for at least several months." c. "An elevated temperature is normal during the first few weeks after delivery." d. "My drainage will fluctuate between bright red and dark red for several weeks."

a. "If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the client is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. The client will not have large amounts of drainage for several months. An elevated temperature indicates an infection. The drainage should not fluctuate between bright and dark red and could indicate retained placental fragments.

A client diagnosed with pelvic organ prolapse is being taught how to perform pelvic floor muscle exercises. During the teaching session, the client asks the nurse, "How do these exercises help?" Which response by the nurse would be most appropriate? a. "They help to increase the volume of your muscles, which leads to stronger muscle contraction." b. "They help to move the pelvic floor upward so that your symptoms eventually decrease." c. "The exercises increase the amount of blood that your muscles receive, making them less relaxed." d. "The exercises help you to establish regular bowel elimination patterns so you don't strain so much."

a. "They help to increase the volume of your muscles, which leads to stronger muscle contraction." The purpose of pelvic floor exercises is to increase the muscle volume, which will result in a stronger muscular contraction. The exercises do not move the pelvic floor upward, increase blood supply, or establish regular elimination patterns.

A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a. Assess vital signs. b. Assess the fundus. c. Notify the health care provider. d. Begin an IV infusion of Ringer's lactate solution.

b. Assess the fundus. The best safeguard against uterine atony is to palpate the fundus at frequent intervals to be assured that the uterus is remaining contracted. If bleeding persists, then a vital signs assessment and notification to the health care provider may be indicated. An intravenous infusion might be prescribed if bleeding continues.

A G4P4 mother calls the nurse's station reporting uterine pain following birth. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response? a. Tell her the physician will be notified of the unusual pain and subsequent action will be determined. b. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. c. Recommend that the client ambulate more to help relieve the pain. d. Encourage the mother to breastfeed to help relax the uterus.

b. Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multiparous mothers and occur when the uterus contracts and relaxes at intervals. Breastfeeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the physician.

When assessing a woman with pelvic organ prolapse, which of the following would the nurse be least likely to find? a. feeling of dragging in the vagina b. stress incontinence c. diarrhea d. dyspareunia

c. diarrhea Constipation and difficulty passing stool is a typical complaint associated with pelvic organ prolapse. A feeling of dragging in the vagina or "something coming down" is a common complaint of women with pelvic organ prolapse, as are stress incontinence and pain with sexual intercourse (dyspareunia).

The nurse is providing discharge instructions to a postpartum client after a vaginal birth. The nurse should inform the client that she may experience which normal finding? a. redness or swelling in the calves b. a palpable uterine fundus beyond 6 weeks c. vaginal dryness after the lochial flow has ended d. dark red lochia for approximately 6 weeks after the birth

c. vaginal dryness after the lochial flow has ended Vaginal dryness is a normal finding during the postpartum period due to hormonal changes. Redness or swelling in the calves may indicate thrombophlebitis. The fundus shouldn't be palpable beyond 6 weeks. Dark red lochia (indicating fresh bleeding) should only last 2 to 3 days postpartum.

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? a. "Your uterus is still shrinking in size; that's why you're feeling this pain." b. "Let me check your vaginal discharge just to make sure everything is fine." c. "Your body is responding to the events of labor, just like after a tough workout." d. "The baby's sucking releases a hormone that causes the uterus to contract."

d. "The baby's sucking releases a hormone that causes the uterus to contract." The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? a. increased blood pressure b. increased cardiac output c. increased hematocrit level d. increased heart rate

d. increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: a. inspect the perineum for lacerations. b. increase the flow of an IV. c. assess and massage the fundus. d. call the primary care provider or the nurse-midwife.

c. assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: a. puerperium. b. lactation. c. attachment. d. engrossment.

c. attachment. Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

A postpartum client calls the nurse into her room and asks her what to do with the "squirt bottle" she found in the bathroom. The client is referring to the peribottle used to clean her perineum. What instructions would the nurse provide the client to explain how to use it? a. Fill the bottle with hot, sudsy water and wash the perineum four times per day. b. Fill the peribottle with sterile water and cleanse area after stooling. c. Fill the peribottle with one-quarter strength vinegar water and clean the perineum after voiding. d. Fill the peribottle with warm water and squeeze it so water flows from front to back after using the restroom.

d. Fill the peribottle with warm water and squeeze it so water flows from front to back after using the restroom. Perineal care is very important to prevent infections, either endometriosis or an infected episiotomy. The proper use of the peribottle is to wash the perineum by squirting the warm water over the perineum from front to back after voiding or stooling. This should be done at least every 4 hours.