CH 17: After Delivery
During a routine assessment the nurse notes the client is tachycardic. Which possible cause should be ruled out? A) delayed hemorrhage B) bladder distention C) extreme diaphoresis D) uterine atony
A) Delayed hemorrhage 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.
Involution of the uterus (CH17)
the uterus returns to its normal nonpregnant size
One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? A) Content, lochia, place B) Location, shape, and content C) Consistency, shape, and location D) Consistency, location, and place
C) Consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.
The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse interprets this finding as indicating which amount of blood loss? A) 10 mL B) 10 to 25 mL C) 25 to 50 mL D) over 50 mL
B) 10 to 25 mL The amount of lochia is described as light or small for an approximately 4-inch stain and indicates a blood loss of 10 to 25 mL. Scant refers to a 1- to 2-inch stain of lochia and approximately 10 mL of blood loss; moderate refers to a 4- to 6-inch stain, suggesting a 25 to 50 mL blood loss; and large or heavy refers to a pad that is saturated within 1 hour after changing, indicating over 50 mL blood loss.
The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? A) Notify a primary care provider. B) Apply a warm washcloth. C) Place an ice pack. D) Put on a witch hazel pad.
C) Place an ice pack. The labia and perineum may be edematous after birth and bruised; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the primary care provider. Notifying a care provider is not necessary at this time as this is considered a normal finding.
Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths? A) Sitz baths cause perineal vasoconstriction and decreased bleeding. B) The longer a sitz bath is continued, the more therapeutic it becomes. C) Sitz baths increase the blood supply to the perineal area. D) Sitz baths may lead to increased postpartal infection.
C) Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.
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) 3:30 a.m. B) 5:15 a.m. C) 7:45 a.m D) 9:00 a.m.
D) 9:00 a.m. 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 finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A) infection B) hemorrhage C) normal involution D) atony
D) atony 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.
Subinvolution of the uterus (Ch17)
Uterus remains enlarged with continued lochial discharge which may result in postpartum hemorrhage
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? A) 1 week B) 2 weeks C) 3 weeks D) 4 weeks.
B) 2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.
The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 2-inch lochia stain. This amount should be documented as which type? (Ch17) A) moderate B) scant C) light D) heavy
B) Scant Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.
When palpating for fundal height on a postpartal woman, which technique is preferable? (CH17) A) placing one hand at the base of the uterus, one on the fundus B) placing one hand on the fundus, one on the perineum C) resting both hands on the fundus D) palpating the fundus with only fingertip pressure
A) placing one hand at the base of the uterus, one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: (Ch17) A) taking, holding-on, letting-go. B) taking-in, holding-on, letting-go. C) taking-in, taking-hold, letting-go. D) taking-in, taking-on, letting-go.
C) taking-in, taking-hold, letting-go The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
On the first postpartum night, a client requests that her neonate be sent back to the nursery so she can get some sleep. The client is most likely in which phase? A) Depression phase B) Letting-go phase C) Taking-hold phase D) Taking-in phase
D) Taking-in phase The taking-in phase occurs in the first 24 hours after birth. The client is concerned with her own needs and requires support from staff and relatives. The taking-hold phase occurs when the client is ready to take responsibility for her care as well as her neonate's care. The letting-go phase begins several weeks later, when the client incorporates the new infant into the family unit. The depression phase isn't an appropriate answer.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? (CH17) A) infection B) hemorrhage C) normal involution D) atony
D) atony 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.
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: A) the level of the umbilicus. B) between the umbilicus and symphysis pubis. C) 1 cm below the umbilicus. D) 2 cm below the umbilicus.
A) The level of the umbilicus Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
A nurse is caring for a client who has had a cesarean birth. Which of the following interventions is most important for such a client? A) Discouraging early ambulation B) Providing the client only clear fluids C) Offering the client extra pillows D) Administering calcium supplements
B) Providing the client only clear fluids A client who has had a cesarean birth should be given only clear fluids until bowel sounds are present. Once present, intake can progress to solid foods. The client may be prescribed iron supplements if there has been an excess loss of blood; however, the client need not immediately be given calcium supplements. Early ambulation is encouraged to prevent DVT and to stimulate peristalsis. Although extra pillows may be comforting, they are not necessary.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? (Ch17) A) a scant amount of lochia alba B) a moderate amount of lochia alba C) a moderate amount of lochia rubra D) a scant amount of lochia serosa
C) A moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
You are the senior LVN/LPN on the unit and you are orienting a new graduate LVN/LPN. One of the subjects you want to cover today is a postpartum assessment for a vaginal delivery. What would you know to cover during this assessment? (Ch17) A) Nagal sign B) Hagar sign C) Chadwick sign D) Homans sign
D) Homans sign Inspect the extremities for edema, equality of pulses, and capillary refill. Check for Homans sign. Feel along the calf area for any warmth or redness. The calves should be of equal size and warmth bilaterally. There should be no reddened, painful areas, and there should be no pain in the calves when the feet are dorsiflexed (negative Homans sign), or when the woman is walking.
The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? A) presence of lochia rubra B) fever more than 100.4° F (38° C) C) fundus is above the umbilicus D) fundus is firm
B) fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.
The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus? A) Semi-Fowler's B) High Fowler's C) Supine D) Left-lateral side lying
C) Supine The best position for a complete assessment of the uterus is lying flat, supine. The other positions will not allow for a true assessment of the location of the uterus in relation to the umbilicus.
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? A) Complete blood count B) Vital signs C) Pad count D) Urine volume excreted
C) Pad count The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.
A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed? A) allowing unlimited visiting hours on maternity units B) offering round-the-clock nursery care for all infants C) promoting rooming-in D) encouraging infant contact immediately after birth
B) offering around the clock nursery care for all infants Factors that can affect attachment include separation of the infant and parents for long times during the day, such as if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant contact immediately after birth promote bonding and attachment.
A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: (CH17) A) "If you are breast-feeding, that will help make your uterus contract and get smaller." B) "I would recommend that you rest for a few days to allow your body to heal and get back to normal." C) "Eating a large amount of protein and carbohydrates will help make the uterus contract." D) "There is really nothing you can do to speed along the progress, so just be patient."
A) "If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? A) "It might take up to a week for your bowels return to their normal pattern." B) "I'll get a laxative prescribed so that you can move your bowels." C) "That's unusual. Are you making sure to eat enough?" D) "Let me call your healthcare provider about this problem."
A) "It might take up to a week for your bowels return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. 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 healthcare provider is not necessary, and this statement could add to the client's current concern.
The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient? A) Absence of lochia B) Red-colored lochia for the first 24 hours C) Lochia that is the color of menstrual blood D) Lochia appearing pinkish-brown on the fourth day
A) Absence of lochia Lochia should never be absent during the first 1 to 3 weeks because absence of lochia may indicate postpartal infection. Red-colored lochia for the first 24 hours is normal. Lochia that is the color of menstrual blood is normal. Lochia appearing pinkish-brown on the fourth postpartum day is normal.
The night shift LPN is checking on a woman who had a cesarean delivery with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first? (CH17) A) Administer naloxone per the preprinted orders. B) Awaken the woman and instruct her to breathe more rapidly. C) Call the anesthesiologist from the room for orders. D) Perform bag-to-mouth rescue breathing at a rate of 12 per minute.
A) Administer naloxone per the preprinted orders. Have naloxone readily available. The anesthesiologist orders naloxone administration if the respiratory rate falls below 10 to 12 per minute.
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 mostappropriate for the nurse to implement at this time? A) Apply an ice pack to the perineal area. B) Encourage use of a sitz bath. C) Instruct in the use of witch hazel compresses. D) Apply a glycerin-based ointment to the area.
A) Apply an ice pack to the perineal area. 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.
A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? A) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. B) Advise that the woman not get out of bed until the nurse returns with assistance. C) Do nothing, this is normal. D) Ask the woman what she has had to eat today.
A) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.
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? (CH17) A) Continue to monitor the woman's temperature every 4 hours; this finding is normal. B) Notify the health care provider about this elevation; this finding reflects infection. C) Obtain a urine culture; the woman most likely has a urinary tract infection. D) Inspect the perineum for hematoma formation.
A) Continue to monitor the woman's temperature every 4 hours; this finding is normal. 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.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next? A) Determine the newborn's blood type and rhesus. B) Determine if this is the client's first baby. C) Administer Rh immunoglobulins intramuscularly. D) Ask if the client received rH immunoglobulins during the pregnancy.
A) Determine the newborn's blood type and rhesus. 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
A nurse is providing discharge instructions to a postpartum client. Which symptom is a possible complication that the nurse should educate the client about? A) Notify the health care provider of increased lochia and bright red bleeding. B) Notify the health care provider of passing clots the size of golf balls. C) Notify the health care provider of a decrease in the amount of brown-red lochia. D) Palpate your fundus to make sure it is soft.
A) Notify the health care provider of increased lochia and bright red bleeding. Once the lochia has changed to pink, a change back to bright red may indicate a problem or complication. Palpating the funds to make it soft is not appropriate. The other occurrences are normal and would not need to be reported to the health care provider.
The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority? A) placing the call light within her reach B) teaching her how the sitz bath works C) telling her to use the sitz bath for 30 minutes D) cleaning the perineum with the peri-bottle
A) Placing the call light within her reach Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be done once the woman's safety needs are met.
A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? (CH17) A) Risk for fatigue related to chronic bleeding due to subinvolution B) Risk for infection related to microorganism invasion of episiotomy C) Risk for impaired breastfeeding related to development of mastitis D) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis
A) Risk for fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.
Which factor might result in a decreased supply of breast milk in a postpartum client? A) supplemental feedings with formula B) maternal diet high in vitamin C C) an alcoholic drink D) frequent feedings
A) Supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.
A nurse is describing the many changes that will occur during the early postpartum period with a group of young parents. The nurse reviews common reports experienced as the woman's body returns to her prepregnancy state. The nurse determines that the teaching was successful when the participants identify which report as being most common during the first week that will indicate their fluid volume is returning to normal? (Ch17) A) diaphoresis B ) nocturia C) urinary frequency D) urinary urgency
A) diaphoresis The profuse diaphoresis is common during the early postpartum period. Many women will wake up drenched with perspiration. This diaphoresis is a mechanism to reduce the amount of fluids retained during pregnancy and restore prepregnant body fluid levels. It is common, especially at night during the first week after birth. Nocturia, urinary frequency, or urinary urgency are not associated with this fluid shift.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely? A) diuresis B) lactation C) blood loss D) nausea
A) diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.
A woman who gave birth to a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A) estrogen B) hCG C) hPL D) progesterone
A) estrogen Although hCG, hPL, and progesterone decline rapidly after birth, decreased estrogen levels are associated with breast engorgement and with the diuresis of excess extracellular fluid accumulated during pregnancy.
A nurse is assessing a client's lochia every 15 minutes for the first hour during the fourth stage of labor. Which finding would the nurse expect to assess? A) moderate lochia rubra with a fleshy odor B) lochia alba saturating at least 3 pads C) lochia rubra with large clots D) lochia rubra saturating two pads
A) moderate lochia rubra with a fleshy odor During the first hour following birth, the nurse should find moderate lochia rubra with a fleshy odor. Lochia rubra with large clots is concerning and should be reported to the RN or health care provider. Saturation of two or more pads within this first hour are not an abnormal finding that require further investigation. Lochia alba appears around the 10th day postpartum which is white or pale yellow because the bleeding has stopped.
During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition? (CH17) A) uterine atony B) urinary retention C) postpartum diaphoresis D) urinary tract infection
A) uterine atony Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.
During a home visit with new parents, the nurse also assesses the new father's adaptation to his new role. Which statement would indicate that he is in the expectation stage? A) "I didn't realize all that went into being a dad. I wasn't prepared for this." B) "It'll be fun to have a baby in the house, but things shouldn't change too much." C) "I've learned how to diaper and bathe the baby so I can be a really involved dad." D) "I may not be a pro at helping out with the baby, but I enjoy being involved."
B) "It'll be fun to have a baby in the house, but things shouldn't change too much." The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? (CH17) A) shaking chills with a fever of 100.4° F (38° C) B) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. C) heart rate 70 bpm and excessive, soaking diaphoresis D) blood loss of 250 mL and WBC 25,000 cells/mL
B) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3° F (37.9° C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? (CH17) A) presence of lochia serosa B) frequent scant voidings C) fundus firm, below umbilicus D) milk filling in both breasts
B) Frequent scant voidings Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.
A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first? A) Call the Medical Response Team to her room. B) Notify the doctor of your findings. C) Have another nurse come listen to the client's respirations and count the rate. D) Ask the charge nurse to look in on the client before the end of the shift.
B) Notify the doctor of your findings If the nurse notes abnormal findings on her exam—such as depressed respiratory status like this client is presenting—the nurse will immediately notify the doctor. Having a peer come in to confirm your findings is always fine but this does not preclude notification of the doctor. Asking the charge nurse to look in on the client later indicates there is no urgency to the situation, which there is.
The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from: A) becoming Rh positive. B) developing Rh sensitivity. C) developing AB antigens in her blood. D) becoming pregnant with an Rh-positive fetus.
B) developing Rh sensitivity. The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization
The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which stage? A) expectations B) reality C) transition to mastery D) taking-hold
B) reality The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation.
When assessing a woman with pelvic organ prolapse, which of the following would the nurse be least likely to find? A) Feeling of dragging in the vagina B) Stress incontinence C) Diarrhea D) Dyspareunia
C) Diarrhea Constipation and difficulty passing stool is a typical complaint associated with pelvic organ prolapse. A feeling of dragging in the vagina or "something coming down" is a common complaint of women with pelvic organ prolapse, as are stress incontinence and pain with sexual intercourse (dyspareunia).
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? (Ch17) A) ferrous sulfate B) methylergonovine C) docusate D) bromocriptine
C) Docusate A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
While caring for a new mother on her second day postpartum, the nurse notes the new mother handles her newborn tentatively, not kissing her child but appears afraid to interact with her baby. Which situation would the nurse suspect as the probable reason for this? A) Disappointment in the child's sex. B) Waiting for instruction from the nurse. C) Normal reaction to accepting a new child. D) Responding with cultural customs of avoiding interaction.
C) Normal reaction to accepting a new child. Many new mothers approach a newborn tentatively as part of the bonding process, so this is typical behavior for a second postpartum day. It is unlikely this would be an indication of disappointment in the sex of the child. It is also not an indication of her waiting for the nurse to provide instruction. The nurse should be observant and offer advice and instruction as it is deemed appropriate. There are many cultural practices but avoiding the child is not one of them.
A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event would the nurse expect to occur first? A) reestablishing relationships with others B) demonstrating increasing confidence in care of the newborn C) assuming a passive role in meeting her own needs D) becoming preoccupied with the present
C) assuming a passive role in meeting her own needs The first task of adjusting to the maternal role is the taking-in phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting own basic needs. During the taking-hold phase, the mother becomes preoccupied with the present. During the letting-go phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.
The nurse encourages the mother of a healthy newborn to put the newborn to the breast immediately after birth for which reason? (CH17) A) to aid in maturing the newborn's sucking reflex B) to encourage the development of maternal antibodies C) to facilitate maternal-infant bonding D) to enhance the clearing of the newborn's respiratory passages
C) to facilitate maternal-infant bonding Breastfeeding can be initiated immediately after birth. This immediate mother-newborn contact takes advantage of the newborn's natural alertness and fosters bonding. This contact also reduces maternal bleeding and stabilizes the newborn's temperature, blood glucose level, and respiratory rate. It is not associated with maturing the sucking reflex, encouraging the development of maternal antibodies, or aiding in clearing of the newborn's respiratory passages.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? A) lochia serosa B) edematous vagina C) uterus 1 cm below umbilicus D) diaphoresis
C) uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate? A) "You should notice a change in your respiratory status within the next 24 hours." B) "Everyone is different, so it is difficult to say when your respirations will be back to normal." C) "It usually takes about 3 months before all of your abdominal organs return to normal, allowing you to breathe normally." D) "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy."
D) "Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." The abdominal organs, including the diaphragm, typically return to prepregnancy state within 1 to 3 weeks after birth. Discomforts such as shortness of breath and rib aches lessen, and tidal volume and vital capacity return to normal values.
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) palpates the abdomen while feeling the uterine fundus C) massages the fundus carefully to expel any blood clots D) places a gloved hand just above the symphysis pubis
D) places a gloved hand just above the symphysis pubis 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.
