Unit 3 OB
3. The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation? 1.Blood pressure may be elevated from prenatal conditions. 2.Respirations are increased due to activity of labor. 3.Changes in blood pressure may not be an immediate sign. 4.Heart rate may increase with intensity of labor.
3.
1. The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room? 1.Ask the patient how many peripads she considered to be "soaked." 2.Collect blood in calibrated, under-buttocks drapes for vaginal birth. 3.Place a basin at the foot of the delivery table to catch any blood. 4.Rely on the primary health care provider's estimate of blood loss.
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7. The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take? 1.Continue to apply ice to the area for 24 hours. 2.Monitor vital signs and report any abnormal readings. 3.Contact the primary care provider for further evaluation. 4.Relieve pressure by placing patient in a side-lying position.
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The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, "I think that my baby is deformed inside and we have to fix him." Which risk factor is most strongly related to possible postpartum psychosis (PPP)? 1.Separation from the baby's father 2.Personal history of bipolar disorder 3.Prolonged labor resulting in cesarean 4.Loss of first child from a heart defect
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The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply. 1. Temperature increase from 99.8°F to 100.5°F 2. Incisional tenderness with palpation 3. Increased margins of incisional redness 4. Notably warm skin around the incision 5. Serosanguinous drainage from the suture line
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Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications? Increase Decrease Remain the same as before pregnancy Remain the same as during pregnancy
2. The placenta produces the hormone human placental lactogen, an insulin antagonist. After birth, the placenta, the major source of insulin resistance, is gone. Insulin needs decrease and women with type 1 diabetes may only need one-half to two-thirds of the prenatal insulin during the first few PP days.
The nurse is collecting information during a follow-up OB appointment with a patient who delivered 3 months ago. The patient reports her partner has become cynical, irritable, and verbally abusive. The nurse will screen for which risks related to paternal postnatal depression (PPND)? Select all that apply. 1. The father exhibited depression during the pregnancy. 2. The birth of this fourth child was unexpected and unplanned. 3. The father expresses feeling bored and underappreciated in his job. 4. The father is recently estranged from his parents and siblings. 5. The mother experienced a prolonged labor and a cesarean birth.
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The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply. 1. Foul-smelling lochia 2. Hot, red, painful breasts 3. Mild headache 4. Not sleeping well 5. Frequent, painful urination
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The labor and delivery unit nurses are adopting methods to reduce the number of women who develop postpartum depression. Research from Dennis and Dowswell (2013) provides evidence-based suggestions regarding beneficial interventions. Which suggestions do the nurses consider? Select all that apply. 1. Telephone-based peer support 2. Partner report of symptoms 3. Interpersonal psychotherapy 4. Teaching for self-recognition of problems
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2. The nurse is aware the greatest source of bleeding during childbirth occurs following detachment of the placenta. Which physiological change takes place immediately after the expulsion of the placenta to decrease the amount of blood loss?1.Contractions of the uterine myometrium 2.Factor VIII complex increases during gestation 3.Platelet activity increases before labor and delivery 4.Fibrin formation increases before the birth occurs
1.
Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? Peripheral vascular disease Hypothyroidism Hypotension Type 1 diabetes
1. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.
A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: 1. Every 30 minutes during the first hour and then every hour for the next two hours. 2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. 3. Every hour for the first 2 hours and then every 4 hours 4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.
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The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management? 1.Application of hot packs to the perineal area 2.Information applicable to medication therapy 3.Instructions to improve circulation by ambulating 4.Medicating for pain above level 4 on a 0 to 10 scale
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concerns about uterus 2-3 days pp
2 finger breaths above the umbilicus
Which measure would be least effective in preventing postpartum hemorrhage? Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered Encourage the woman to void every 2 hours Massage the fundus every hour for the first 24 hours following birth Teach the woman the importance of rest and nutrition to enhance healing
3. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.
6. The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately? 1. The uterus is displaced. 2.The uterine fundus is boggy. 3.Small clots are expressed with massage. 4.Peripad weighs 100 g within 15 minutes.
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9. The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected? 1. "If your nipples are cracked, you will need to stop breastfeeding." 2. "Pump your milk and throw it away until the infection is gone." 3. "The baby gave you an infection and needs to be on antibiotics." 4. "Continuing to breastfeed will help clear up the condition."
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4. The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol? 1.Increased patient restlessness. 2.Manifestations of severe pain. 3.Development of abnormal vital signs. 4.Patient requests water for extreme thirst.
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5. The nurse is assisting the primary care provider with the third stage of a vaginal delivery. The patient is multiparous, experienced a precipitous birth, and has a history of hypertension. Which medical prescription does the nurse anticipate for this patient?1.Methylergonovine 2.Fresh frozen plasma 3.Carboprost-tromethamine 4.Magnesium sulfate
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The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient? 1.Prescriptions for antidepressant/antipsychotic drugs 2.Discharge to home with 24-hour observation in place 3.Immediate hospitalization in a psychiatric unit 4.Prescribed neonate visits during in-patient treatment
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To be considered a PPH, what would the estimated blood loss have to be for a C-section? A) < 550 ML B) > 600 ML C) > 1000 ML D) < 900 ML
C
Which measure would be least effective in preventing postpartum hemorrhage? A) Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered B) Encourage the woman to void every 2 hours C) Massage the fundus every hour for the first 24 hours following birth D) Teach the woman the importance of rest and nutrition to enhance healing
C
When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) A) The father should take over care of the baby, because postpartum blues are exclusively a female problem. B) Get plenty of rest. C) Plan to get out of the house occasionally. D) Asking for help will not foster independence. E) Use La Leche League or community mental health centers.
*B) Get plenty of rest.* *C) Plan to get out of the house occasionally.* *E) Use La Leche League or community mental health centers.* Rationale: Suggestions for coping with postpartum blues include: · Remember that the "blues" are normal and that both the mother and the father or partner may experience them. · Get plenty of rest; nap when the baby does if possible. Go to bed early, and let friends and family know when to visit and how they can help. (Remember, you are not "Supermom.") · Use relaxation techniques learned in childbirth classes (or ask the nurse to teach you and your partner some techniques). · Do something for yourself. Take advantage of the time your partner or family members care for the baby—soak in the tub (a 20-minute soak can be the equivalent of a 2-hour nap), or go for a walk. · Plan a day out of the house—go to the mall with the baby, being sure to take a stroller or carriage, or go out to eat with friends without the baby. Many communities have churches or other agencies that provide child care programs such as Mothers' Morning Out. · Talk to your partner about the way you feel—for example, about feeling tied down, how the birth met your expectations, and things that will help you (do not be afraid to ask for specifics). · If you are breastfeeding, give yourself and your baby time to learn. · Seek out and use community resources such as La Leche League or community mental health centers.
The maternity nurse promoting parental-infant attachment should incorporate which appropriate cultural beliefs into the plan of care? (Select all that apply.) A) Asian mothers are encouraged to return to work as soon as possible. B) Jordanian mothers have a 40-day lying-in after birth. C) Japanese mothers rest for the first 2 months after childbirth. D) Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. E) Encourage Vietnamese mothers to cuddle with the newborn.
*B) Jordanian mothers have a 40-day lying-in after birth.* *C) Japanese mothers rest for the first 2 months after childbirth.* Rationale: Asian mothers must remain at home with the baby up to 30 days after birth and are not supposed to engage in household chores, including care of the baby. Jordanian mothers have a 40-day lying-in after birth, during which their mothers or sisters care for the baby. Japanese mothers rest for the first 2 months after childbirth. Hispanic practice involves many food restrictions after childbirth, such as avoiding fish, pork, and citrus foods. Vietnamese mothers may give minimal care to their babies and refuse to cuddle or further interact with the baby to ward off "evil" spirits.
The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment? A) Talks and coos to her son B) Seldom makes eye contact with her son C) Cuddles her son close to her D) Tells visitors how well her son is feeding
*B) Seldom makes eye contact with her son* Rationale: The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Talking and cooing to her son is a normal infant-parent interaction. Cuddling is a normal infant-parent interaction. Sharing her son's success at feeding is a normal infant-parent interaction.
In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior? A) The parents have difficulty naming the infant. B) The parents hover around the infant, directing attention to and pointing at the infant. C) The parents make no effort to interpret the actions or needs of the infant. D) The parents do not move from fingertip touch to palmar contact and holding.
*B) The parents hover around the infant, directing attention to and pointing at the infant.* Rationale: Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. Reluctance to name the baby is an inhibiting behavior. Failure to interpret the actions and needs of the infant is an inhibiting behavior. Lack of fingertip, palmar touch, and holding represents an inhibiting behavior.
A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: A) foster an active role in the baby's care. B) provide time for the mother to reflect on the events of and her behavior during childbirth. C) recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D) promote maternal independence by encouraging her to meet her own hygiene and comfort needs.
*B) provide time for the mother to reflect on the events of and her behavior during childbirth.* Rationale: Once the mother's needs are met, she would be more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach. *The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition.*
Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care? A) PPD symptoms are consistently severe. B) This syndrome affects only new mothers. C) PPD can easily go undetected. D) Only mental health professionals should teach new parents about this condition.
*C) PPD can easily go undetected.* Rationale: PPD symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.
When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A) express a strong need to review events and her behavior during the process of labor and birth. B) exhibit a reduced attention span, limiting readiness to learn. C) vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D) have reestablished her role as a spouse/partner.
*C) vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn.* Rationale: *One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth.* Reviewing events and behavior during labor/birth and exhibiting reduced attention span/limited readiness to learn are characteristic of the taking-in stage, which lasts for the first few days after birth. Re-establishing role as spouse/partner reflects the letting-go stage, which indicates that psychosocial recovery is complete.
Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: A) tell the woman she can rest after she feeds her baby. B) recognize this as a behavior of the taking-hold stage. C) record the behavior as ineffective maternal-newborn attachment. D) take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.
*D) take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.* Rationale: The woman should not be told what to do and needs to care for her own well-being. *The taking-hold stage occurs about 1 week after birth.* Because the woman needs to rest does not indicate ineffective maternal-newborn attachment. The behavior described is typical of this stage and not a reflection of ineffective attachment unless it persists. Mothers need to reestablish their own well-being to effectively care for their baby.
Select all of the physiological maternal changes that occur during the PP period. Cervical involution ceases immediately Vaginal distention decreases slowly Fundus begins to descend into the pelvis after 24 hours Cardiac output decreases with resultant tachycardia in the first 24 hours Digestive processes slow immediately.
1 and 3. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.
On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? Ask the client to empty her bladder Straight catheterize the client immediately Call the client's health provider for direction Straight catheterize the client for half of her uterine volume
1. A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.
A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? Massage the fundus until it is firm Elevate the mothers legs Push on the uterus to assist in expressing clots Encourage the mother to void
1. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.
A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: Assess for hypovolemia and notify the health care provider Begin hourly pad counts and reassure the client Begin fundal massage and start oxygen by mask Elevate the head of the bed and assess vital signs
1. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.
During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make? The client appears interested in learning about neonatal care The client talks a lot about her birth experience The client sleeps whenever the neonate isn't present The client requests help in choosing a name for the neonate.
1. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate. The other options describe the phase in which the mother relives her birth experience.
Which of the following findings would be expected when assessing the postpartum client? Fundus 1 cm above the umbilicus 1 hour postpartum Fundus 1 cm above the umbilicus on postpartum day 3 Fundus palpable in the abdomen at 2 weeks postpartum Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2
1. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in the abdomen after day 10.
A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. Take the prescribed antibiotics until the soreness subsides. Wear supportive bra Avoid decompression of the breasts by breastfeeding or breast pump Rest during the acute phase Continue to breastfeed if the breasts are not too sore.
2, 4, and 5. Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, 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 the 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 breastfeeding or pumping is important to empty the breast and prevent formation of an abscess.
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: One the day of the delivery 3 days PP 7 days PP within 2 weeks PP
2. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A temperature of 100.4*F An increase in the pulse from 88 to 102 BPM An increase in the respiratory rate from 18 to 22 breaths per minute A blood pressure change from 130/88 to 124/80 mm Hg
2. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.
Which of the following physiological responses is considered normal in the early postpartum period? Urinary urgency and dysuria Rapid diuresis Decrease in blood pressure Increase motility of the GI system
2. In the early PP period, there's an increase in the glomerular filtration rate and a drop in the progesterone levels, which result in rapid diuresis. There should be no urinary urgency, though a woman may feel anxious about voiding. There's a minimal change in blood pressure following childbirth, and a residual decrease in GI motility.
Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: Amount of lochia Blood pressure Deep tendon reflexes Uterine tone
2. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.
When performing a PP 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 of the following nursing actions is most appropriate? Document the findings Notify the physician Reassess the client in 2 hours Encourage increased intake of fluids.
2. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vajayjay. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.
On which of the postpartum days can the client expect lochia serosa? Days 3 and 4 PP Days 3 to 10 PP Days 10-14 PP Days 14 to 42 PP
2. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? Obtain hemoglobin and hematocrit levels Instruct the mother to request help when getting out of bed Elevate the mother's legs Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of light-headedness and dizziness have subsided.
2. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.
A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? Paleness of the calf area Enlarged, hardened veins Coolness of the calf area Palpable dorsalis pedis pulses
2. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.
A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? Prothrombin time Internationalized normalized ratio Activated partial thromboplastin time Platelet count
3. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the INR are used to monitor coagulation time when warfarin (Coumadin) is used.
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? Complaints of a tearing sensation Complaints of intense pain Changes in vital signs Signs of heavy bruising
3. Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? Ask the client to turn on her side Ask the client to lie flat on her back with the knees and legs flat and straight. Ask the mother to urinate and empty her bladder Massage the fundus gently before determining the level of the fundus.
3. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.
Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? Retained placental fragments Urinary tract infection Cervical laceration Uterine atony
3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria may be present.
Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? Applying ice Applying a breast binder Teaching how to express her breasts in a warm shower Administering bromocriptine (Parlodel)
3. Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk.
A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: Dysuria, ecchymosis, and vertigo Epistaxis, hematuria, and dysuria Hematuria, ecchymosis, and epistaxis Hematuria, ecchymosis, and vertigo
3. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.
A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: Monitor fundal height Apply perineal pressure Prepare the client for surgery. Reassure the client
3. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? Hypertension Cervical and vaginal tears Urine retention Endometritis
3. Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.
Which type of lochia should the nurse expect to find in a client 2 days PP? Foul-smelling Lochia serosa Lochia alba Lochia rubra
4.
Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health? Mothers with diabetes who breast-feed have a hard time controlling their insulin needs Mothers with diabetes shouldn't breastfeed because of potential complications Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.
4. Breastfeeding has an antidiabetogenic effect. Insulin needs are decreased because carbohydrates are used in milk production. Breastfeeding mothers are at a higher risk of hypoglycemia in the first PP days after birth because the glucose levels are lower. Mothers with diabetes should be encouraged to breastfeed.
A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? "I need to take antibiotics, and I should begin to feel better in 24-48 hours." "I can use analgesics to assist in alleviating some of the discomfort." "I need to wear a supportive bra to relieve the discomfort." "I need to stop breastfeeding until this condition resolves."
4. In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.
Parents can facilitate the adjustment of their other children to a new baby by: A) having the children choose or make a gift to give to the new baby on its arrival home. B) emphasizing activities that keep the new baby and other children together. C) having the mother carry the new baby into the home so she can show him or her to the other children. D) reducing stress on other children by limiting their involvement in the care of the new baby.
*A) having the children choose or make a gift to give to the new baby on its arrival home.* Rationale: Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.
Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? The vaccine is safe in clients with egg allergies Breast-feeding isn't compatible with the vaccine Transient arthralgia and rash are common adverse effects The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects
4. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common adverse effects of the vaccine.
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? 1. Retake the temperature in 15 minutes 2. Notify the physician 3. Document the findings 4. Increase hydration by encouraging oral fluids
4. The mother's temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: One peripad per day Two peripads per day Three peripads per day Eight peripads per day
4. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases? Depression phase Letting-go phase Taking-hold phase Taking-in phase
4. The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires support from staff and relatives. The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as the infants care. The letting-go phase begins several weeks later, when the mother incorporates the new infant into the family unit.
Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? A) Peripheral vascular disease B) Hypothyroidism C) Hypotension D) Type 1 diabetes
A
The 4 "T's" of PPH are: 1. Trauma 2. Toxins 3. Travel 4. Tissue 5. Threads 6. Thrombin 7. Tears 8. Tone A) 1, 4, 6 & 8 B) 1, 5 7 & 8 C) 1, 2, 3 & 6 D) 3, 4, 5 & 6
A
What are four risk factors for PPH (arising during pregnancy)? A) Previous PPH; polyhydramnios; multiple pregnancy; anaemia conditions B) Abruptio placenta; mollydominos, grand multi; iron deficiency C) Intrauterine death; abracadabra placenta, previous pph, iron deficiency. D) Placenta praevia; polyhydramnios, outeruterine death, hyroplanes E) A & C
A
3. The antidote administered to reverse magnesium toxicity is ______________.
ANS: calcium gluconate Calcium gluconate is the antidote necessary to reverse magnesium toxicity. The nurse caring for this patient should keep calcium gluconate in the room along with secured, syringes and needles.
12. Which assessment finding should convince the nurse to "hold" the next dose of magnesium sulfate? a. Absence of deep tendon reflexes b. Urinary output of 100 mL total for the previous 2 hours c. Respiratory rate of 14 breaths/min d. Decrease in blood pressure from 160/100 to 140/85
ANS: A Feedback A Because absence of deep tendon reflexes is a sign of magnesium toxicity, the next scheduled dose should not be administered. Calcium gluconate is the antidote that should be administered. B An hourly output of less than 30 mL could indicate toxicity. C A respiratory rate of less than 12 breaths/min could indicate toxicity. D Decrease in blood pressure is an expected side effect of magnesium sulfate.
17. Rh incompatibility can occur if the woman is Rh negative and her a. Fetus is Rh positive b. Husband is Rh positive c. Fetus is Rh negative d. Husband and fetus are both Rh negative
ANS: A Feedback A For Rh incompatibility to occur, the mother must be Rh negative and her fetus Rh positive. B The husband's Rh factor is a concern only as it relates to the possible Rh factor of the fetus. C If the fetus is Rh negative, the blood types are compatible and no problems should occur. D If the fetus is Rh negative, the blood type with the mother is compatible. The husband's blood type does not enter into the problem.
24. Which laboratory marker is indicative of disseminated intravascular coagulation (DIC)? a. Bleeding time of 10 minutes b. Presence of fibrin split products c. Thrombocytopenia d. Hyperfibrinogenemia
ANS: B Feedback A Bleeding time in DIC is normal. B Degradation of fibrin leads to the accumulation of multiple fibrin clots throughout the body's vasculature. C Low platelets may occur with but are not indicative of DIC because they may result from other coagulopathies. D Hypofibrinogenemia occurs with DIC.
Thromboembolic conditions that are of concern during the postpartum period include (Select all that apply.) Amniotic fluid embolism (AFE) Superficial venous thrombosis Correct Deep vein thrombosis Correct Pulmonary embolism Correct Disseminate intravascular coagulation (DIC)
An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. DIC is an imbalance between the body's clotting and fibrinolytic systems. It's a pathologic form of clotting that consumes large amounts of clotting factors.
The client has just given birth to full-term twins. One twin was stillborn. The nurse concludes that this family will need to do which of the following? 1. Simultaneously grieve the loss of one infant while becoming attached to the other. 2. Be passive in accepting the death in order to form an attachment to the living infant. 3. Control their emotions to prevent undue stress for the surviving twin. 4. Minimize the time spent with the dead infant to facilitate attachment to the survivor.
Answer: 1 Rationale: The loss of one twin with the survival of the other creates a complex psychological situation. The family must go through the grief work associated with the fetal loss while simultaneously beginning attachment with the surviving infant. These mothers are at higher risk for a pathological grief reaction because of the complexity of the task. The parents do not need to be passive in accepting the death. The parents do not need to control their emotions. It is beneficial for the parents to spend time with the dead infant to help the loss be more real and begin the grieving process. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The core focus of the question is a family simultaneously experiencing joy and loss at the time of birth. The correct answer is the option that provides support for effective coping with both experiences. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
Which of the following tokens of remembrance would be appropriate for the nurse to provide to parents who are grieving the death of their infant? 1. Lock of hair, footprints 2. Baptism or naming 3. Visit from chaplain 4. Sympathy card from staff
Answer: 1 Rationale: Tokens of remembrance such as a lock of hair, photos, or a card with the infant's footprints or handprints help the parents accept the reality of their infant's death and facilitate the grieving process. Baptism, naming, a visit from a chaplain, or a sympathy card from staff may bring comfort to the family, but are not tokens of remembrance. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Critical words in this question are tokens of remembrance, physical objects belonging or connected to the lost child. Eliminate incorrect options as they do not represent a physical reminder of the child that died. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The nurse is making assignments for the next shift. The nurse assigns the same nurse to the family experiencing a fetal loss as cared for them yesterday because continuity of care will have which benefit? 1. Decrease the family's need to interact with many others. 2. Increase support for the family. 3. Prevent the family from needing to ask questions. 4. Facilitate dependence on the nurse.
Answer: 2 Rationale: Continuity of care increases support through trust and familiarity. A new nurse assigned to this family would not know and understand the details of the loss, and would have to take extra time in obtaining a history that could otherwise be used to assess for coping with the loss. Continuity of staff assignment is not intended to decrease interactions with others, prevent the family from needing to ask questions, or facilitate dependence on the nurse. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is facilitation of grief work for the client. The correct answer would be the option that supports the family in the time of loss. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? 1. Encourage him to discuss this with his wife first. 2. Dress the infant in a t-shirt and diaper and let him hold the infant. 3. Tell him that it would be better not to hold the infant. 4. Give him the photographs of the infant that the nurse took instead.
Answer: 2 Rationale: Holding a stillborn helps the family to accept the infant's death as real, and thus facilitate the grieving process. There is no reason for the father to discuss this with the wife first. It is a false statement to tell the father that it would be better not to hold the infant. Giving photographs provides a lasting memory, but this should be done in addition to letting the father hold the child. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Implementation Content Area: Maternal-Newborn Strategy: The focus of the question is facilitation of the grief work. The correct answer would be the option that contains a nursing action to encourage the client (father) to validate the death of the infant and facilitate his grief work. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The nurse plans to facilitate bereavement after a fetal demise in utero by doing which of the following? 1. Protecting the parents from having to see the dead fetus 2. Encouraging culturally determined naming and burial practices 3. Encouraging the client to tell the older children nothing 4. Avoiding the financial stress of an autopsy
Answer: 2 Rationale: Naming the child and having the newborn baptized or participating in other religious ceremonies or rituals also facilitates grief work and acceptance of the loss. Parents need to see and hold their infant to accept the reality of the child's birth and death. Older children must have the death explained to them in developmentally appropriate terms. Autopsy can sometimes provide an answer to the cause of the fetal death, and should be undertaken, if the parents request it or if law requires it. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is facilitation of effective coping at the time of fetal loss. Eliminate incorrect options as they avoid the death and hinder the grief process. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 205, 341, 525-526, 788-789.
The client being seen for a postpartal exam after delivering a stillborn girl six weeks ago asks the nurse, "When will I feel normal again?" The nurse's reply reflects the understanding that grief work takes approximately how long? 1. Two to three months 2. About one year 3. Four to six months 4. Not more than eight months
Answer: 2 Rationale: The stages of grief must be worked through in order to resolve a fetal loss. This process takes about a year for most people. The other options represent less accurate, briefer timeframes. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Knowledge of the normal period of grief and loss will help to choose the correct response. Recall that adjustment to loss can be a slow process to help guide your selection. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The nurse interprets which of the following as somatic complaints of a postpartal woman who is grieving for her deceased infant? Select all that apply. 1. Tingling on the back of the neck and hearing a baby's cry 2. Heaviness in the chest and fatigue 3. Increased taste sensitivity and deep sleep 4. Stiffness in the legs and arms 5. Weight loss and decreased appetite
Answer: 2, 5 Rationale: Somatic complaints during the grieving process include sighing, weight loss, decreased appetite, restless sleep, fatigue, choking, shortness of breath, throat or chest tightness, abdominal pain, weakness in the legs, or generalized weakness. Tingling on the back of the neck, hearing a baby's cry, increased taste sensitivity, deep sleep, and stiffness in the arms and legs are not somatic complaints during the grieving process. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is somatic symptoms of grief. The correct answers would be options that contain a true statement of a physical (somatic) symptom of grief. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
Which statement indicates to the nurse that the client is expressing somatic symptoms of the grieving process? 1. "If our doctor hadn't insisted on doing that extra blood work our baby would be alive now." 2. "I told God I'd never again smoke another cigarette if our baby could just be born alive." 3. "I feel nauseated and don't want to eat. Please take the tray out of my room." 4. "My mother can't stop crying. She says she feels like she failed me by letting this happen to me."
Answer: 3 Rationale: Somatic symptoms of grief can be expressed in any physiologic system of the body. Common gastrointestinal symptoms include nausea, vomiting, anorexia, weight loss, or overeating. The other options do not include physiologic symptoms. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Critical words are somatic symptoms of the grieving process, which refers to physical expressions of grief. The correct answer would be the option that contains a physical symptom. Reference: Venes, D., & Ridge, H. (Eds.) (2009). Taber's cyclopedic medical dictionary (21st ed.). Philadelphia, PA: F.A. Davis, p. 2154.
The nurse who is reviewing all subjective and objective prenatal assessment data interprets that which data is an indicator of intrauterine fetal death? 1. Diminished fetal activity over a three-day period 2. A bluish discoloration in the vaginal and cervical mucosa 3. Absence of fetal heart tones and fetal movement 4. Mother saying "the baby is just not moving today"
Answer: 3 Rationale: The only definitive sign of fetal death is absence of fetal heart tones and no fetal activity on the ultrasound. Diminished fetal activity over recent days is suspicious, but is not an indicator of intrauterine fetal death. A bluish discoloration in the vaginal and cervical mucosa has no significance. Lack of fetal movement for a single day is not an indicator of intrauterine fetal death. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The focus of the question is objective data to determine fetal death. Recall that only absence of fetal heart tones and fetal movement as diagnosed by ultrasound are absolute signs. Reference: Ricci, S. (2008). Essentials of maternity, newborn and women's health nursing (2nd ed.). Philadelphia, PA: Lippincott Williams and Wilkins, pp. 634-635.
The plan of care for a pregnant client who experienced an unexplained intrauterine fetal demise during her last pregnancy should include which of the following? Select all that apply. 1. Education about the causes of intrauterine fetal demise for both parents 2. Encouragement to think positively and not dwell on the previous fetal loss 3. Support for increased fears as this fetus reaches the gestational age of the previous fetal loss 4. Facilitation of grieving of the lost fetus through carrying a photo and a lock of hair at all times 5. Asking open-ended questions to determine how the parents are coping and identify any concerns
Answer: 3, 5 Rationale: Parents report increased stress around the time of the previous fetal loss during subsequent pregnancies. The nurse should provide support as indicated. The nurse should ask open-ended questions to determine the parents' stress level, how they are coping and to discover any client concerns. Educating the client about causes of intrauterine fetal demise serves no purpose and may increase anxiety about the current pregnancy. Encouraging the client to think positively and not dwell on losses is nontherapeutic and does not acknowledge any client concerns. Clients grieve in various ways and carrying a photo and lock of hair at all times may not be needed or desired. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: Knowledge of parents' reaction during subsequent pregnancies will aid in answering the question correctly. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-533.
The client who experienced a perinatal demise states, "Sometimes I feel like I left my baby somewhere, and can't remember where she is. Then I remember that she isn't alive." The nurse interprets that this client is experiencing which of the following? 1. Anticipatory grieving 2. Disorientation 3. Reorganization 4. Searching and yearning
Answer: 4 Rationale: During the searching and yearning phase of grieving, parents yearn for their deceased infant, are preoccupied with thoughts of the lost infant, and will have physical manifestations such as aching arms, or looking for the infant. The client does not have anticipatory grieving as the loss has already occurred. The client shows no evidence of being disoriented to person, place, or time. The client has not yet reached a state of reorganization after the infant's demise. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Diagnosis Content Area: Maternal-Newborn Strategy: The core focus of the question is the searching and yearning phase of grieving. Eliminate incorrect options that do not contain true statements about this phase of grieving. Reference: Ladewig, P. A., London, M. L., & Davidson, M.R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The client has given birth to a full-term stillborn male as a result of placental abruption. The grandparents have come to visit. The nurse anticipates that the grandparents will do which of the following? 1. Role model acceptance about the fetal loss 2. Experience a more intense grief reaction than the parents 3. Avoid talking about the dead fetus 4. Go through the same grief phases as the parents
Answer: 4 Rationale: Grandparents grieve the loss of the grandchild as well as feel pain at the suffering of their child in response to the loss. The grandparents may not be role models about how to accept fetal loss, especially if they have no experience with it. The grandparents' grief reaction is not likely to be more intense than that of the parents. The grandparents are not expected to avoid talking about the dead fetus. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The client includes the entire family system in this question. The correct answer would be the option that contains a true statement about the grief experience for all family members. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The mother of a stillborn infant tells the nurse that she feels like she is missing a part of herself. The nurse understands that this is not related to which of the following? 1. Parents simultaneously grieving and resolving their attachment to the lost infant 2. The unborn child having been incorporated into a mother's physical and emotional being 3. A significant loss of self-esteem that often occurs with both parents after perinatal loss 4. Mothers of stillborns finding a way to justify their desire to become pregnant again
Answer: 4 Rationale: Loss of self-esteem is reported by both parents after fetal loss. During pregnancy, the fetus is incorporated into the pregnant woman's view of self both physically and emotionally, and a fetal loss is often viewed as a loss of a body part similar to an amputation. Parents form an attachment to the unborn child during pregnancy, and must terminate this attachment when the child is stillborn while also grieving the death of their child. Stating she feels like she is missing a part of herself is not a method of justifying a desire to become pregnant again. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Critical words are she is missing a part of herself and is not related to, which means that the answer is not correctly related to grief and loss. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-533.
The family is experiencing a fetal loss. Which statement indicates that the nurse's teaching about family involvement in the birthing process needs clarification? 1. "We can have our child baptized." 2. "We can decide not to stay on the postpartal unit after the birth." 3. "We will be able to name our infant." 4. "We should have the funeral through the mortuary the hospital uses."
Answer: 4 Rationale: Parents have options for nearly all decisions regarding their delivery and postpartal care, including whether or not to use sedatives during labor, naming the infant, rituals or religious rites or sacraments, and which funeral home to plan or hold the funeral or memorial service. The hospital staff can facilitate the mortuary's involvement, but should not recommend one over another or tell the family that the hospital endorses one. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Teaching and Learning Content Area: Maternal-Newborn Strategy: Recall nursing care of parents who have experienced a loss to aid in answering the question correctly. Because the stem of the question contains the critical words "needs clarification," the correct option will be a statement that is incorrect. Reference: Ladewig, P. A., London, M. L., & Davidson, M.R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-526, 788-789.
The client who had a stillborn infant at term has come to the clinic for her postpartal exam accompanied by her husband. What should the nurse anticipate at this time? 1. Both parents will express their grief in the same way. 2. The parents will use similar coping mechanisms. 3. The parents will be in the same grief work stage. 4. The parents will have differences in how they are grieving.
Answer: 4 Rationale: The parents will often be in different stages of grief, using different coping mechanisms, and expressing their grief differently. Women tend to be more verbal in their grieving, while men tend to be more internalizing with their grief. The nurse's role is to facilitate communication between the parents and let them know that these differences are both normal and expected. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: Three options are similar because the same experience is occurring for both parents; these options should be eliminated. It is more likely that the dissimilar option is the correct answer. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 525-532.
Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: A) Amount of lochia B) Blood pressure C) Deep tendon reflexes D) Uterine tone
B
The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A) Place her on a bedpan to empty her bladder B) Massage her fundus C) Call the physician D) Administer Methergine 0.2 mg IM which has been ordered prn
B
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: A) Normal B) Indicates the presence of infection C) Indicates the need for increasing oral fluids D) Indicates the need for increasing ambulation
B
When performing a PP 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 of the following nursing actions is most appropriate? A) Document the findings B) Notify the physician C) Reassess the client in 2 hours D) Encourage increased intake of fluids
B
Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect: bladder distention. uterine atony. constipation. hematoma formation. Correct
Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
The priority nursing intervention for a woman who suffered a perineal laceration is to: apply a cold compress. establish hemostasis. Correct administer analgesia. administer a stool softener.
Bleeding should be stopped first. After bleeding has been controlled, the care of the woman with lacerations of the perineum includes analgesia administration, hot or cold applications, and stool softeners. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.
A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? A) Massage the fundus B) Place the mother in the Trendelenburg's position C) Notify the physician D) Record the findings
C
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? A) Hypertension B) Cervical and vaginal tears C) Urine retention D) Endometritis
C
Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A) Retained placental fragments B) Urinary tract infection C) Cervical laceration D) Uterine atony
C
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? A) Retake the temperature in 15 minutes B) Notify the physician C) Document the findings D) Increase hydration by encouraging oral fluids
D
After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: A) She had a precipitate birth B) This was an extramural birth C) Retained placental fragments must be expelled D) Multigravidas are at increased risk for uterine atony
D
In which of these cases could you diagnose PPH following vaginal delivery: 1. > 500 blood loss over 24 hrs 2. hypotension 3. tachycardia A) 1 & 3 B) 2 C) 3 D) 1
D
What types of trauma during labor and birth would lead to PPH risk? A) Instrumental assisted birth (vacuum or forceps) B) C-Section C) Lacerations of the cervix or vaginal wall D) All of the above
D
Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? A) Cervical laceration B) Clotting deficiency C) Perineal laceration D) Uterine subinvolution
D
Which postpartum infection is most often contracted by first-time mothers who are breastfeeding? Endometritis Wound infections Mastitis Correct Urinary tract infections (UTIs)
Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding. UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.
Which postpartum conditions are considered medical emergencies that require immediate treatment? Inversion of the uterus and hypovolemic shock Correct Hypotonic uterus and coagulopathies Subinvolution of the uterus and idiopathic thrombocytopenic purpura Uterine atony and disseminated intravascular coagulation (DIC)
Inversion of the uterus and hypovolemic shock are considered medical emergencies. A hypotonic uterus can be managed with massage and oxytocin. Coagulopathies should be identified before delivery and treated accordingly. Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment. ITP can be safely managed with corticosteroids or IV immunoglobulin. DIC and uterine atony are very serious obstetric complications; however, uterine inversion is a medical emergency requiring immediate intervention.
The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: call the woman's primary health care provider administer the standing order for an oxytocic palpate the uterus and massage it if it is boggy Correct assess maternal blood pressure and pulse for signs of hypovolemic shock
The most important nursing intervention is to stop the bleeding. Once the nurse has applied firm massage of the uterine fundus, the primary health care provider should be notified or the nurse can delegate this task to another staff member. This intervention is appropriate after assessment and immediate steps have been taken to control the bleeding. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Vital signs will need to be ascertained after fundal massage has been applied.
Nursing care management for mothers and fathers suffering grief from the loss of their baby includes: (Select all that apply.) using therapeutic communication and caring techniques. Correct listening as parents tell their story of loss and grief. Correct avoiding asking any questions about the loss of parents. giving advice from personal experiences. insisting parents name the baby in order to be remembered.
The nurse should utilize therapeutic communication and caring techniques. The nurse should listen patiently while people tell their story of loss and grief. It may be necessary to ask questions that help people talk about their grief. The nurse should resist the temptation to give advice or use clichés in offering support. A caution about naming is important. Naming is an individual decision that should never be imposed on parents. Beliefs and individual needs vary greatly, sometimes based upon cultures and religious preferences as well.
Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to: acidify the urine by drinking three glasses of orange juice each day. maintain a fluid intake of 1 to 2 L/day. empty her bladder every 4 hours throughout the day. perform perineal care on a regular basis. Correct
Urine is acidified with cranberry juice. The woman should drink at least 3 L of fluid each day. The woman should empty her bladder every 2 hours to prevent stasis of urine. Keeping the perineum clean will help prevent a urinary tract infection.
Herbal remedies have been used with some success to control PPH after initial management. Some herbs have homeostatic actions, whereas others work as oxytocic agents to contract the uterus. What herbal remedy is a commonly used oxytocic agent? Witch hazel Lady's mantel Blue cohosh Correct Yarrow
Witch hazel is a homeostatic herb. Lady's mantle is a homeostatic remedy. Blue cohosh, cotton root bark, motherwort, and shepherd's purse are oxytocic agents that promote uterine contraction. Yarrow is not an oxytocic agent, it is a homeostatic.
What type of milk is present in the breasts 7 to 10 days PP? Colostrum Hind milk Mature milk Transitional milk
4. Transitional milk comes after colostrum and usually lasts until 2 weeks PP
If continued bleeding occurs during the third stage with a contracted uterus, the cause is most likely to be: A) Cervical and perineal Lacerations B) Placental abruption C) Uterine atony D) Cervical Polyp
A
REEDA
Redness Edema Ecchymosis Discharge Approximation of edges of lacerations/episiotomy
8. The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus? 1.Scant amount of odorless lochia 2.Presence of headache, malaise, and chills 3.Pain or discomfort in the midline lower abdomen 4.Elevated temperature greater than 100.4°F (38°C)
1
A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient's medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply. 1. Neonatal macrosomia 2. Use of a vacuum extractor 3. Poor oral fluid intake 4. Urinary catheter during labor 5. Low-grade fever (101.3°F [38.5°C])
1 2 3 4
The nurse is aware of concern about the increasing numbers of severe maternal morbidity (SMM). It is believed to be related to changes in the overall health of the population of women giving birth. Which reasons does the nurse identify as causes of SMM? Select all that apply. 1. Increases in maternal age 2. Prepregnancy obesity 3. Cesarean deliveries 4. Inability to pay for health care 5. Preexisting chronic medical conditions
1 2 3 5
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be: Soft, non-tender; colostrum is present Leakage of milk at let down Swollen, warm, and tender upon palpation A few blisters and a bruise on each areola
1. Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.
Which of the following behaviors characterizes the PP mother in the taking in phase? Passive and dependant Striving for independence and autonomy Curious and interested in care of the baby Exhibiting maximum readiness for new learning
1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.
Which of the following factors might result in a decreased supply of breast milk in a PP mother? Supplemental feedings with formula Maternal diet high in vitamin C An alcoholic drink Frequent feedings
1. Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother's nipples affects hormonal levels and milk production.
When performing a postpartum check, the nurse should: Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation Wash hands and put on sterile gloves before beginning the check
1. While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus. The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate. Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.
A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A) A temperature of 100.4*F B) An increase in the pulse from 88 to 102 BPM C) An increase in the respiratory rate from 18 to 22 breaths per minute D) A blood pressure change from 130/88 to 124/80 mm Hg
B
The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: Place her on a bedpan to empty her bladder Massage her fundus Call the physician Administer Methergine 0.2 mg IM which has been ordered prn
2. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by 3 and 4, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder since the fundus is midline and below the umbilicus.
54) A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: Foster an active role in the baby's care Provide time for the mother to reflect on the events of and her behavior during childbirth Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now Promote maternal independence by encouraging her to meet her own hygiene and comfort needs
2. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.
A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains? Bottle-feeding Diabetes Multiple gestation Primiparity
3. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains. Bottle-feeding and diabetes aren't directly associated with increasing severity of afterpains unless the client has delivered a macrosomic infant.
The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? Lower than during her pregnancy Higher than during her pregnancy Lower than before she became pregnant Higher than before she became pregnant
3. PP insulin requirements are usually significantly lower than prepregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum.
Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that: Return to prepregnant weight is usually achieved by the end of the postpartum period Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss The expected weight loss immediately after birth averages about 11 to 13 pounds Lactation will inhibit weight loss since caloric intake must increase to support milk production
3. Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? Assess vital signs every 4 hours Inform health care provider of assessment findings Measure fundal height every 4 hours Prepare an ice pack for application to the area.
4. Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.
After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: She had a precipitate birth This was an extramural birth Retained placental fragments must be expelled Multigravida's are at increased risk for uterine atony.
4. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? Postural hypotension Temperature of 100.4°F Bradycardia — pulse rate of 55 BPM Pain in left calf with dorsiflexion of left foot
4. Responses 1 and 3 are expected related to circulatory changes after birth. A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.
Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: Uses soap and warm water to wash the vulva and perineum Washes from symphysis pubis back to episiotomy Changes her perineal pad every 2 - 3 hours Uses the peribottle to rinse upward into her vagina
4. Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
8. A pregnant woman is being discharged from the hospital after placement of a cerclage because of a history of recurrent pregnancy loss secondary to an incompetent cervix. Discharge teaching should emphasize that a. Any vaginal discharge should be reported immediately to her care provider. b. The presence of any contractions, rupture of membranes, or severe perineal pressure should be reported. c. She will need to make arrangements for care at home, because her activity level will be restricted. d. She will be scheduled for a cesarean birth.
ANS: B Feedback A Vaginal bleeding needs to be reported to her primary care provider. B Nursing care should stress the importance of monitoring signs and symptoms of preterm labor. C Bed rest is an element of care. However, the woman may stand for periods of up to 90 minutes, which allows her the freedom to see her physician. Home uterine activity monitoring may be used to limit the woman's need for visits and to safely monitor her status at home. D The cerclage can be removed at 37 weeks of gestation (to prepare for a vaginal birth), or a cesarean birth can be planned.
1. The perinatal nurse is giving discharge instructions to a woman, status post suction and curettage secondary to a hydatidiform mole. The woman asks why she must take oral contraceptives for the next 12 months. The best response from the nurse is a. "If you get pregnant within 1 year, the chance of a successful pregnancy is very small. Therefore, if you desire a future pregnancy, it would be better for you to use the most reliable method of contraception available." b. "The major risk to you after a molar pregnancy is a type of cancer that can be diagnosed only by measuring the same hormone that your body produces during pregnancy. If you were to get pregnant, it would make the diagnosis of this cancer more difficult." c. "If you can avoid a pregnancy for the next year, the chance of developing a second molar pregnancy is rare. Therefore, to improve your chance of a successful pregnancy, it is better not to get pregnant at this time." d. "Oral contraceptives are the only form of birth control that will prevent a recurrence of a molar pregnancy."
ANS: B Feedback A Women should be instructed to use birth control for 1 year after treatment for a hydatidiform mole. Pregnancy raises hCG levels which increases the risk for choriocarcinoma. B This is an accurate statement. Beta-hCG levels will be drawn for 1 year to ensure that the mole is completely gone. There is an increased chance of developing choriocarcinoma after the development of a hydatidiform mole. The goal is to achieve a "zero" hCG level. If the woman were to become pregnant, it may obscure the presence of the potentially carcinogenic cells. C The rationale for avoiding pregnancy for 1 year is to ensure that carcinogenic cells are not present. D Any contraceptive method except an IUD is acceptable.
25. A woman taking magnesium sulfate has respiratory rate of 10 breaths/min. In addition to discontinuing the medication, the nurse should a. Vigorously stimulate the woman. b. Instruct her to take deep breaths. c. Administer calcium gluconate. d. Increase her IV fluids.
ANS: C Feedback A Stimulation will not increase the respirations. B This will not be successful in reversing the effects of the magnesium sulfate. C Calcium gluconate reverses the effects of magnesium sulfate. D Increasing her IV fluids will not reverse the effects of the medication.
A woman is undergoing induction of labor for an intrauterine fetal death. The nurse considers that which plans should be made for the woman's partner? 1. Should be included for support and to facilitate the partner's acceptance of the fetal death as real 2. Should be included to decrease misunderstanding of medical procedures by the mother 3. Should be excluded to prevent the additional emotional strain of the birth on the partner 4. Should be excluded because another child can be conceived soon and help to forget this death
Answer: 1 Rationale: Involvement in the labor and birth process will help facilitate moving out of the denial stage, and help facilitate that the death of their child was real. The partner is often a good source of support for the mother during the pain of labor. Cognitive Level: Applying Client Need: Psychosocial Integrity Integrated Process: Nursing Process: Planning Content Area: Maternal-Newborn Strategy: The focus of the question is the needs of the family experiencing a childbearing loss. Eliminate incorrect options because they do not facilitate validation of the death or provide support to the grieving family. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 528-529.
the nurse caring for the after birth woman understands that breast engorgement is caused by: a. over production of colostrum b. accumulation of milk in the lactiferous ducts c. hyperplasia of mammory tissue d. congestion of veins and lymphatics.
D
A mother is exhibiting signs of Postpartum psychosis. She is delusional and has bizarre behaviors. She thinks her infant is the devil and must be killed. She will be fine with the intervention of psychotherapy.
False
The mother who receives Duramorph post c-section. Her vital signs are BP 120/76 P-88 RR-10 Temp.-97.2. You do not need to intervene.
False
maternal mortality
age obeisty c-section
what is the self destruction of excess hypertrophied tissue in the uterus?
autolysis
after birth a crying infant may be soothed by being held in a position in which the newborn can hear the mother's heartbeat
birhythmicity
