CH 16- Nursing Management During the Postpartum Period

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. a. Active bowel sounds b. Abdominal pain c. Tender abdomen d. Passing gas e. Nondistended abdomen

a. Active bowel sounds b. Passing gas e. Nondistended abdomen

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

a. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother b. Encourage breastfeeding of the newborn on demand e. Help the mother initiate breastfeeding within mins after birth

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. Call the primary care provider or the nurse mid-wife b. Assess and massage the fundus c. Inspect the perineum for lacerations d. Increase the flow of an IV

b. Assess and massage the fundus

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a. Hemorrhage b. Atony c. Normal involution d. Infection

b. Atony

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount? a. Scant b. Moderate c. Heavy d. Light

b. Moderate

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: a. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." b. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." c. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood."

c. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? a. An improperly positioned baby during feedings b. Too much milk being retained c. Mastitis d. Normal findings in breastfeeding mothers

c. Mastitis

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

c. Placing one hand at the base of the uterus, one on the fundus

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? a. "I'll check on you in a few hours." b. "If you don't attempt to void, I'll need to catheterize you." c. "I'll contact your primary care provider." d. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

d. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

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. Notify the health care provider about this elevation; this finding reflects infection b. Inspect the perineum for hematoma formation c. Obtain a urine culture; the woman most likely has a urinary tract infection d. Continue to monitor the woman's temperature every 4 hours; this finding is normal

d. Continue to monitor the woman's temperature every 4 hours; this finding is normal

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

d. The color of the flow is red

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? a. Bonding b. Attachment c. Being spoiled d. None of the above

b. Attachment

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. Dehydration c. Infection d. Change in the temperature from the birth room

b. Dehydration

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? a. Apply ice packs directly to the perineal area b. Ensure ice pack is changed frequently c. Apply ice packs for 40 minutes continuously d. Use ice packs for a week after birth

b. Ensure ice pack is changed frequently

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. Multiparity b. Placenta removed via manual extraction c. Hemoglobin of 11.5 mg/dl (115g/L) d. Labor less than 3 hours

b. Placenta removed via manual extraction

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 WBC is less than 10,000/mm3 c. During the first 24 hours after birth owing to dehydration from exertion d. When the elevated temperature exceeds 100.4F

c. During the first 24 hours after birth owing to dehydration from exertion

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. Upper respiratory infection b. Pulmonary embolism c. Thrombophlebitis d. Mitral valve collapse

b. Pulmonary embolism

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority? a. Provide time for prayers to be performed at bedside b. Allow time for the numerous visitors who come to see the mother and her newborn c. Assign a female nurse to care for her d. Ensure that the newborn's daily bath is performed by the nurses

c. Assign a female nurse to care for her

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 anti-thyroid medications e. Women on antineoplastic medications

a. Women using street drugs d. Women on anti-thyroid medications e. Women on antineoplastic medications

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. Depression c. Infection d. Pulmonary emboli

c. Infection