Ch 16 Postpartum Nursing Management

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?

bringing the newborn into the room

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?

"I only eat a low-fiber diet."

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

nondistended abdomen active bowel sounds passing gas

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?

"Walking is the best way to prevent complications such as blood clots."

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 10 to 25 ml loss

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

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 with the mother.

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

Inspecting posture, color, and respiratory effort

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?

Resume intercourse if bright red bleeding stops.

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?

The color of the flow is red

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

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

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.

pain level vital signs of mother head-to-toe assessment

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?

placenta removed via manual extraction

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

postpartum depression

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm 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:

pulmonary embolism.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

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?

venous duplex ultrasound of the right leg

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony

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?

mastitis

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?

thromboembolic disorder of the lower extremities

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action?

Walk with the nurse the length of her room.

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?

an ice pack applied to the perineum

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree