Ch 16: Nursing Management During the Postpartum Period

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.assess and massage the fundus. b.inspect the perineum for lacerations. c.increase the flow of an IV. d.call the primary care provider or the nurse-midwife.

assess and massage the fundus. Rationale: 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 finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a.infection b.normal involution c.atony d.hemorrhage

atony Rationale: The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? a.showing a video of parents feeding their babies b.allowing the mother to pick the best time to hold her newborn c.bringing the newborn into the room d.talking about how the nurse held her own newborn while on the birthing table

bringing the newborn into the room Rationale: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication? a.fluid volume overload b.permanent urinary incontinence c.increased lochia drainage d.ruptured bladder

increased lochia drainage Rationale: If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: a.maintaining previous household routines to prevent infection. b.listing signs of infection that she will report to her health care provider. c.the client will show no signs of infection. d.discussing methods that the woman will use to prevent infection.

maintaining previous household routines to prevent infection. Rationale: The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? a.positive bonding b.negative bonding c.positive attachment d.negative attachment

negative attachment Rationale: Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? a.policies that discourage unwrapping and exploring the infant b.policies that allow flexibility for cultural differences c.policies that allow rooming the infant and mother together d.policies that allow visitors

policies that discourage unwrapping and exploring the infant Rationale: Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? a.talking b.looking c.feeding d.touching

touching Rationale: Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

Which factor puts a client on her first postpartum day at risk for hemorrhage? a.hemoglobin level of 12 g/dl (120 g/L) b.uterine atony c.thrombophlebitis d.moderate amount of lochia rubra

uterine atony Rationale: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

Which factor puts a client on her first postpartum day at risk for hemorrhage? a.uterine atony b.hemoglobin level of 12 g/dl (120 g/L) c.moderate amount of lochia rubra d.thrombophlebitis

uterine atony Rationale: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? a.A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? b.hemoglobin of 11.5 mg/dl (115 g/L) c.placenta removed via manual extraction d.labor less than 3 hours

placenta removed via manual extraction Rationale: Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage.

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

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

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? a.lochia that is the color of menstrual blood b.lochia appearing pinkish-brown on the fourth day c.an absence of lochia d.red-colored lochia for the first 24 hours

an absence of lochia Rationale: Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a.edema b. drainage c.temperature d.redness

temperature Rationale: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum? a.Take her temperature every 4 hours. b.Palpate her feet for tingling or numbness. c.Assess for calf redness and edema. d.Ask her if she feels any warmth in her legs.

Assess for calf redness and edema. Rationale: Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? a.The fundus is located 2 fingerbreadths above the umbilicus. b.Bowel sounds are active. c.The client requires assistance to ambulate in the hallway. d.The client is having a moderate amount of rubra lochia. e.The client is afebrile.

The fundus is located 2 fingerbreadths above the umbilicus. Rationale: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? a.Obtain a urine culture; the woman most likely has a urinary tract infection. b.Inspect the perineum for hematoma formation. c.Continue to monitor the woman's temperature every 4 hours; this finding is normal. d.Notify the health care provider about this elevation; this finding reflects infection.

Continue to monitor the woman's temperature every 4 hours; this finding is normal. Rationale: A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. a.Low socioeconomic status b.Feeling overwhelmed and out of control c.Involving family in infant care d.Lack of social support e.Low self-esteem

Low socioeconomic status Feeling overwhelmed and out of control Lack of social support Low self-esteem Rationale: Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? a.100.1°F (37.8°C) b.100.8°F (38.2°C) c.97.5°F (36.9°C) d.99.2°F (37.3°C)

100.8°F (38.2°C) Rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? Rationale: a. 3 weeks b.1 week c.2 weeks d.4 weeks

2 weeks Rationale: Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? a."I might feel like laughing one minute and crying the next." b."If the symptoms last more than a few days, I need to call my doctor." c."I should call this support line only if I hear voices." d."I'll need to take medication to treat the anxiety and sadness."

"I might feel like laughing one minute and crying the next." Rationale: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does occur.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? a."Sitz baths worked the last time." b."I only eat a low-fiber diet." c."My mom always used dibucaine." d."I already have some pads with witch hazel at home."

"I only eat a low-fiber diet." Rationale: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

A postpartum client has decided to bottle feed her newborn. After teaching the woman about it, the nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. a."I will get my newborn to suck by touching the nipple to the lips." b."I will use warm water to mix the powdered formula." c."I will be sure not to use the microwave to warm the formula." d."I will store any formula left over from a feeding in the refrigerator." e."I will make sure the nipple and neck of the bottle are filled with formula during a feeding."

"I will be sure not to use the microwave to warm the formula." "I will make sure the nipple and neck of the bottle are filled with formula during a feeding." ."I will get my newborn to suck by touching the nipple to the lips." Rationale: Teaching about bottle feeding should include the following: mixing powdered formula with room temperature water to allow better mixing and quicker dissolution of lumps; storing any formula prepared in advance in the refrigerator to keep bacteria from growing but discarding any formula not taken during a feeding; making sure that the nipple and neck of the bottle are always filled with formula to prevent the newborn from taking in too much air; and stimulating the sucking reflex by placing the nipple to the newborn's lips.

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."Let me call your health care provider about this problem." 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"It might take up to a week for your bowels to return to their normal pattern."

"It might take up to a week for your bowels to return to their normal pattern." Rationale: 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.

A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? a."Breastfeeding takes time and practice." b."Some women just can't breastfeed. Maybe I'm one of these women." c."Maybe a lactation specialist can help me work through this." d."Some babies latch on and catch on quickly; others take a little more time."

"Some women just can't breastfeed. Maybe I'm one of these women." Rationale: The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? a.Call your health care provider if you saturate a peri-pad in less than 4 hours." b."Follow up with your health care provider within 3 weeks of being discharged." c.Notify the health care provider if your temperature is greater than 99° F (37.2° C)." d."You should be seen by your health care provider if you have blurred vision."

"You should be seen by your health care provider if you have blurred vision." Rationale: The client needs to notify the health care provider for blurred vision, as this can indicate preeclampsia in the postpartum period. The client should also notify the health care provider if she has a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is within 2 weeks after hospital discharge.

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time? a.Encourage use of a sitz bath. b.Apply an ice pack to the perineal area. c.Instruct in the use of witch hazel compresses. d.Apply a glycerin-based ointment to the area.

Apply an ice pack to the perineal area. Rationale: Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a.Vigorously massage the fundus. b.Immediately call the primary care provider. c.Have the charge nurse review the assessment. d.Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad. Rationale: If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? a.Administer Rh immunoglobulins intramuscularly. b.Determine if this is the client's first baby. c.Determine the newborn's blood type and rhesus. d.Ask if the client received rH immunoglobulins during the pregnancy.

Determine the newborn's blood type and rhesus. Rationale: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

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.Stop using a peri-pad. b.Massage the client's fundus. c.Document the lochia as scant. d.Reassess the client in 1 hour.

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

Educate the client on how to perform Kegel exercises. Rationale: 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.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. a.Encourage breastfeeding of the newborn infant on demand. b.Give newborns water and other foods to balance nutritional needs. c.Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. d.Help the mother initiate breastfeeding within 30 minutes of birth. e.Provide breastfeeding newborns with pacifiers.

Encourage breastfeeding of the newborn infant on demand. Help the mother initiate breastfeeding within 30 minutes of birth. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Rationale: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that apply. a.Labor of 1 1/2 hours b. Labor induction with oxytocin c.Third stage of labor of 10 minutes d.Forceps birth e.Hemoglobin 8.0 g/dL (80.0 g/L)

Labor of 1 1/2 hours Labor induction with oxytocin Forceps birth Rationale: Factors that increase a postpartum woman's risk for postpartum hemorrhage include: precipitous labor of less than 3 hours, labor induction, use of operative procedures such as forceps, and prolonged third stage of labor (greater than 30 minutes). A hemoglobin level less than 10.5 g/dL (105.0 g/L) increases the woman's risk for postpartum infection.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? a.Lochia is less than usual. b.Uterus is firm. c.Bladder is nonpalpable. d.Percussion reveals dullness.

Percussion reveals dullness. Rationale: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? a.Use oral contraceptive pills (OCPs) for contraception. b.Resume intercourse if bright red bleeding stops. c.Avoid use of water-based gel lubricants. d.Avoid performing pelvic floor exercises.

Resume intercourse if bright red bleeding stops Rationale: The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs).

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 is over 500 mL. b.The color of the flow is red. c.Her uterus is soft to your touch. d.The flow contains large clots.

The color of the flow is red. Rationale: 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.

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 normal. b. The urinary output is inadequate and the mother needs to drinks more fluids. c.The urinary output is above expected levels. d.The urinary output is inadequate suggestive of urinary retention.

The urinary output is normal. Rationale: 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.

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

between the umbilicus and symphysis pubis. Rationale: The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. 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.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? a.Schedule home visits for high-risk families b.Encourage frequent clinic visits for high-risk families. c.Ask family members to monitor the parents' progress. d.Provide phone numbers for call centers for questions.

Schedule home visits for high-risk families Rationale: To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

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.pulse rate 75 beats per minute b.oral temperature 100.8° F (38.2° C) c.respiratory rate 16 breaths/minute d.uterine fundus 1 cm below umbilicus

.oral temperature 100.8° F (38.2° C) Rationale: 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.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? a.normal response to the body converting back to prepregnancy state b.thromboembolic disorder of the lower extremities c.hormonal shifting of relaxin and estrogen d.infection

.thromboembolic disorder of the lower extremities Rationale: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? a.Under 10 ml b.25 to 50 ml c.10 to 25 ml d.Over 50 ml

25 to 50 ml Rationale: Typically, the amount of lochia is described as follows: -scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-ml loss -light or small: an approximately 4-in (10-cm) stain or a 10- to 25-ml loss -moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 ml -large or heavy: a pad saturated within 1 hour after changing it or over 50-ml loss.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time? a.9:00 a.m. b.3:30 a.m. c.5:15 a.m. d.7:45 a.m.

9:00 a.m. Rationale: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

A nurse is providing education to a client experiencing postpartum blues. The nurse determines client understanding when the client makes which of statements regarding factors that contribute to postpartum blues, signs and symptoms associated with postpartum blues, and collaborative care to treat symptoms?' Contributing Factors: "Postpartum blues are due to fatigue." "Postpartum blues are due to being overweight." "Postpartum blues are due to changes in hormones." "Postpartum blues are due to dehydration." Signs and Symptoms "A symptom of postpartum blues is being unable to care for self or the infant weeks after giving birth." "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." "Postpartum blues can occur up to 1 year after giving birth." "A sign of postpartum blues is persistent depression beyond 10 days." Collaborative Care "Sleep hygiene can help with postpartum blues." "Ensuring adequate support for newborn care can help with postpartum blues." "Adequate nutrition can help with postpartum blues." "Antidepressant medications can help with postpartum blues." "Regular physical exercise can help with postpartum blues."

Contributing Factors: "Postpartum blues are due to changes in hormones." Postpartum blues are due to fatigue." Signs and Symptoms: "A symptom of postpartum blues is being emotionally labile up to 10 days postpartum." Collaborative: "Sleep hygiene can help with postpartum blues." "Adequate nutrition can help with postpartum blues." "Regular physical exercise can help with postpartum blues." "Ensuring adequate support for newborn care can help with postpartum blues."

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? a.Encourage use of breast pads with plastic liners. b.Recommend a moisturizing soap to clean the nipples. c.Offer suggestions based on observation to correct positioning or latching. d.Fasten nursing bra flaps immediately after feeding.

Offer suggestions based on observation to correct positioning or latching. Rationale: The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? a.Lochia is less than usual. b.Uterus is boggy. c.Percussion reveals tympany. d.Bladder is nonpalpable.

Uterus is boggy. Rationale: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? a.a sitz bath b.opioid pain medication c.an ice pack applied to the perineum d.a heating pad applied to the perineum

an ice pack applied to the perineum Rationale: Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Opioid pain medication would not be the first choice.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color? a.milky white b.gray liquid c.bluish white d. creamy yellow

creamy yellow Rationale: If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

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

dehydration Rationale: 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.

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? a.delayed hemorrhage b.extreme diaphoresis c.bladder distention d.uterine atony

delayed hemorrhage Rationale: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a.after any period of decreased intake b.when the elevated temperature exceeds 100.4°F (38°C) c.when the white blood cell count is less than 10,000/mm³ d.during the first 24 hours after birth owing to dehydration from exertion

during the first 24 hours after birth owing to dehydration from exertion Rationale: Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.

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

encouraging the woman to empty her bladder completely every 2 to 4 hours Rationale: 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.

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a postpartum woman of Japanese descent, which action would be a priority? a.assigning a female nurse to care for her b.providing time for prayers to be performed at the bedside c.allowing time for the numerous visitors who come to see the woman and newborn d.ensuring that the newborn receives a daily bath

ensuring that the newborn receives a daily bath Rationale: In the Japanese American culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino American culture because families are very close-knit. Bedside prayer is common due to the strong religious beliefs of the Filipino American culture.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? a.first 6 months b.first 3 to 5 days c.first month d.first 30 to 60 minutes

first 30 to 60 minutes Rationale: Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel? a.fundus two fingerbreadths above symphysis pubis and hard b.fundus height 4 cm below umbilicus and midline c.fundus 4 cm above symphysis pubis and firm d.fundus two fingerbreadths below umbilicus and firm

fundus two fingerbreadths below umbilicus and firm Rationale: A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? a.hemorrhage b.pulmonary emboli c.infection d.depression

infection Rationale: There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means? Select all that apply. a.localized vascular damage b.decline in WBCs c.decline in HGB d.altered coagulation e.stasis

localized vascular damage altered coagulation stasis Rationale: Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during birthing process). All these increase the risk of clot formation.

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.light. b.moderate. c.heavy. d.scant.

moderate. Rationale: 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.

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.at the level of the umbilicus b.one fingerbreadth above the umbilicus c. below the symphysis pubis d. one fingerbreadth below the umbilicus

one fingerbreadth below the umbilicus Rationale: 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.

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus? a.places index and middle fingers across the muscle b.massages the fundus carefully to expel any blood clots c.places a gloved hand just above the symphysis pubis d.palpates the abdomen while feeling the uterine fundus

places a gloved hand just above the symphysis pubis Rationale: The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: a.thrombophlebitis. b.upper respiratory infection. c.pulmonary embolism. d.mitral valve collapse.

pulmonary embolism. Raionale: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? a.proximity b.reciprocity c.commitment d.all of the above

reciprocity Rationale: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. a.fundus boggy to the right of the umbilicus b.moderate lochia rubra c.rounded mass over symphysis pubis d. dullness on percussion over symphysis pubis e.elevated oral temperature

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus Rationale: If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4°F (38°C), infection is suggested.

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs the client to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" a.saturating 1 pad in 3 hours b.saturating 1 pad in 6 hours c.saturating 1 pad in 1 hour d.saturating 1 pad in 8 hours

saturating 1 pad in 1 hour Rationale: Bleeding is considered heavy when a client saturates 1 perineal pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 5- to 6 inches of a pad in 1 hour.

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply. a.first pregnancy b.severe varicose veins c.previous oral contraceptive use d.age 30 years e.preeclampsia

severe varicose veins previous oral contraceptive use preeclampsia Rationale: Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.

A nurse is describing a technique developed Dr. Kegel to assist postpartum clients a common issue. The nurse explains that the purpose of the Kegel technique is to: a.strengthen the joints and return them to their normal state. b.strengthen the abdominal muscles to lessen the size of stretch marks. c.strengthen the uterine muscle fibers to return to their prepregnancy condition. d.strengthen the pelvic floor muscles to reduce urinary incontinence.

strengthen the pelvic floor muscles to reduce urinary incontinence. Rationale: Dr. Arnold Kegel developed the Kegel exercises as a method of controlling incontinence in clients after childbirth. If done properly and regularly, they will help to strengthen the pelvic floor muscles. These exercises do not strengthen the uterine muscle, joints, or abdominal muscles.

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.2 cm below the umbilicus. b. the level of the umbilicus. c.1 cm below the umbilicus. d. between the umbilicus and symphysis pubis.

the level of the umbilicus. Rationale: 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.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a.transthoracic echocardiogram b.venous duplex ultrasound of the right leg c.venogram of the right leg d.noninvasive arterial studies of the right leg

venous duplex ultrasound of the right leg Rationale: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. a.women using street drugs b.women with more than one infant c.women who had difficulties with breastfeeding in the past d.women on antithyroid medications e.women on antineoplastic medications

women using street drugs women on antithyroid medications women on antineoplastic medications Rationale: While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.