Ch. 17 After Delivery PrepU

If a woman has not voided within ____ to ____ hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage.

4-6 hrs

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? 3:30 a.m. 5:15 a.m. 7:45 a.m. 9:00 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 mother's chart notes that she is non-immune on her rubella status. The nurse explains what this means to the client. Which statement by the mother indicates that more teaching is needed? a. "I need to have three shots to get my rubella levels up." b. "I may need to have a re-vaccination if I remain non-immune." c. "Rubella is bad disease that I need to immunized against." d. "I will get my rubella immunization before I leave the hospital."

a. "I need to have three shots to get my rubella levels up." Rationale: If a mother is non-immune to rubella, she will receive a rubella immunization prior to being discharged from the hospital. She will have titers drawn 6 to 8 weeks later to determine if she developed immunity to rubella. If she remains non-immune, she will receive a re-vaccination. There will only be two shots potentially, not three.

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who has started to breastfeed

a. Gravida 5, para 5

The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum client. Which outcome indicates that teaching has been effective? a. The client performs perineal care independently with every morning shower. b. The client explains the purpose of performing perineal care at least once a day. c. The client flushes the commode before standing when performing perineal care. d. The client washes the perineum from back to front when performing perineal care.

a. The client performs perineal care independently with every morning shower.

What contributes to the increased risk for venous thromboembolic disease increases during pregnancy? Select all that apply. a. stasis of blood in lower extremities b. decrease in blood glucose c. hypercoagulability d. placenta nourishing the fetus e. decrease in estrogen

a. stasis of blood in lower extremities c. hypercoagulability

Immediately after birth, the fundus may be...

above the umbilicus

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply. abdominal pain active bowel sounds tender abdomen passing gas nondistended abdomen

active bowel sounds passing gas nondistended abdomen

6 to 12 hours after birth, the fundus should be...

at the level of the umbilicus

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics? a. Have her fill out a questionnaire on the subject. b. Ask her questions and observe her caring for the baby. c. Since she has had a previous child, she should already know how to do most everything. d. Have her demonstrate how to do all the baby care tasks as well as her self-care tasks.

b. Ask her questions and observe her caring for the baby.

What two elements play the biggest role in becoming a mother after delivery of her newborn? a. Confidence and happiness with the pregnancy b. Love and attachment to the child and engagement with the child c. Planned and desired pregnancy and previous experience with infants d. Interactions with the child and support systems

b. Love and attachment to the child and engagement with the child

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action? a. Call the primary care provider. b. Massage the boggy fundus until it is firm. c. Document the findings. d. Nothing—excessive postpartum blood loss is normal.

b. Massage the boggy fundus until it is firm.

The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention? a. Hesitates to hold newborn, expressing disappointment with baby's appearance. b. Neglects to engage or provide care or show interest in infant. c. Tearful for several days, difficulty eating and sleeping. d. Express doubt in ability to care for newborn.

b. Neglects to engage or provide care or show interest in infant.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? a. To monitor the mother's blood pressure to note any elevations b. To check for postpartum hemorrhage c. To determine if the mother's milk is coming in d. To answer questions the new parents may have

b. To check for postpartum hemorrhage

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. Percussion reveals tympany. b. Uterus is boggy. c. Lochia is less than usual. d. Bladder is nonpalpable.

b. Uterus is boggy.

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give? a. Avoid using soap for any perineal care. b. Wash her perineum with her daily shower. c. Use an alcohol wipe to wash her episiotomy line. d. Refrain from washing lochia from the suture line.

b. Wash her perineum with her daily shower.

Which postpartum client will the nurse assess first? a. an 18-year-old who wants to sleep until 10:00 before the nurse brings the infant for a visit b. a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated c. a 22-year-old who has been up, showered, and packing for discharge later today d. a 30-year-old postpartum client who had a cesarean birth and is sleeping following pain medication administration

b. a 35-year-old who had estimated blood loss of 700 ml and has a supine BP of 130/80 mm Hg and BP of 100/65 mm Hg when head of the bed is elevated

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? a. two fingerbreadths above the umbilicus b. at the level of the umbilicus c. two fingerbreadths below the umbilicus d. four fingerbreadths below the umbilicus

b. at the level of the umbilicus

10 days after birth, the fundus should be...

below the symphysis pubis

Typically, the postpartum woman is (bradycardic or tachycardic) for the first two weeks.

bradycardic Rationale: Tachycardia in the postpartum woman warrants further investigation.

Which condition in a postpartum client may cause fever not caused by infection? breast engorgement endometritis mastitis uterine involution

breast engorgement

A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply. uterine infection prolonged labor hydramnios breastfeeding early ambulation

breastfeeding early ambulation

The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her? a. "I will avoid medications for constipation such as psyllium because it can upset the baby's stomach." b. "It is all right to suppress the urge to have a stool for a few days to allow my stitches to heal." c. "I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." d. "A good meal for me is cream of chicken soup, cheese toast, and ice cream for dessert."

c. "I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow."

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? a. A primiparous client who delivered 4 hours ago b. A multiparous client who delivered 6 hours ago c. A multiparous client who delivered a large baby after oxytocin induction A primiparous client who delivered 6 hours ago and had epidural anesthesia

c. A multiparous client who delivered a large baby after oxytocin induction

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? a. Her uterus is 2 cm above the symphysis pubis. b. Her uterus is three finger widths under the umbilicus. c. Her uterus is at the level of the umbilicus. d. She experiences "pulling" pain while breastfeeding.

c. Her uterus is at the level of the umbilicus.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values? a. The client will need a transfusion, so the RN needs to be notified. b. The client will be tired, so encourage her to sleep whenever the baby sleeps. c. The health care provider needs to be notified of the latest lab values. d. These values are expected for a 1-day postpartum mother.

c. The health care provider needs to be notified of the latest lab values. Rationale: If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation? a. deep red, fleshy-smelling lochia b. voiding of 350 cc c. blood pressure 90/50 mm Hg d. profuse sweating

c. blood pressure 90/50 mm Hg

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? a. by assessing skin turgor b. by assessing blood pressure c. by frequently assessing uterine involution d. by monitoring hCG titers

c. by frequently assessing uterine involution

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

The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness? a. increased white blood cell count b. stirrup injury during birth c. increased coagulation factors d. decreased red blood cell count

c. increased coagulation factors

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

When assessing a client who is 5 days postpartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage? a. oliguria b. fundal tenderness c. rubra colored lochia d. increased rectal pressure

c. rubra colored lochia

Which client should the postpartum nurse assess first after receiving shift report? a. the 3-day postpartum client who has a pulse of 50 bpm b. the 12-hour postpartum client who has a temperature of 100.4°F (38°C). c. the 2-day postpartum client who has a blood pressure of 138/90 mm Hg d. the 1-day postpartum client who has a respiratory rate of 20 breaths/minute.

c. the 2-day postpartum client who has a blood pressure of 138/90 mm Hg

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? a. "It'll be fun to have a baby in the house, but things shouldn't change too much." b. "I've learned how to diaper and bathe the baby so I can be a really involved dad." c. "I may not be a pro at helping out with the baby, but I enjoy being involved." d. "I didn't realize all that went into being a dad. I wasn't prepared for this."

d. "I didn't realize all that went into being a dad. I wasn't prepared for this."

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.

d. Ask the client when she last changed her perineal pad.

Which assessment finding 1 hour after birth should be reported to the health care provider? a. Fundus of uterus is palpable at the level of the umbilicus. b. Fundus is displaced to the right, and bladder is hard. c. Large, bruised hemorrhoids are protruding from the anal opening. d. Lochia rubra is saturating a pad every 45 to 60 minutes.

d. Lochia rubra is saturating a pad every 45 to 60 minutes.

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

A nurse is assessing uterine involution of a postpartum woman. When reviewing the woman's labor and birth record, which factor would the nurse identify as potentially delaying involution? Select all that apply. hydramnios birth of triplets labor of 4 hours grand multiparity limited use of analgesia

hydramnios birth of triplets grand multiparity

During the _______-____ phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.

letting-go

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 3-in (7.5-cm) lochia stain. This amount should be documented as which type? moderate scant light heavy

light

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 documents this finding as which description? scant light moderate large

light The amount of lochia is described as light or small for an approximately 4-inch stain. Scant refers to a 1- to 2-inch stain of lochia; moderate refers to a 4- to 6-inch stain; and large or heavy refers to a pad that is saturated within 1 hour after changing.

By the end of the first postpartum day, the fundus should be....

one fingerbreadth below the umbilicus

When assessing a postpartum woman, the nurse would find which factor to be most significant in identifying possible postpartum hemorrhage? pulse rate blood pressure cardiac output hematocrit

pulse rate

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? semi-Fowler high Fowler supine left-lateral side lying

supine

During the ______-___ phase, the mother becomes preoccupied with the present.

taking-hold

The first task of adjusting to the maternal role is the _______-___ phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting own basic needs.

taking-in

A client who received morphine during a cesarean birth is recovering satisfactorily from the spinal anesthesia. The nurse will ensure the client's pulse oximetry is monitor for what time period after the surgery? 24 hours 12 hours 4 hours 36 hours

24 hours

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status? 6 to 8 weeks after pregnancy 4 to 6 weeks after pregnancy 8 to 10 weeks after pregnancy 2 to 4 weeks after pregnancy

6 to 8 weeks after pregnancy

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. Breasts are hard. Breasts are tender. Nipples are fissured. Nipples are cracked. Breasts are soft.

Breasts are hard. Breasts are tender.

The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report? Length of labor Maternal blood type The newborn's weight Apgar scores

Maternal blood type Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh, and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.

A client diagnosed with pelvic organ prolapse is being taught how to perform pelvic floor muscle exercises. During the teaching session, the client asks the nurse, "How do these exercises help?" Which response by the nurse would be most appropriate? a. "They help to increase the volume of your muscles, which leads to stronger muscle contraction." b. "They help to move the pelvic floor upward so that your symptoms eventually decrease." c. "The exercises increase the amount of blood that your muscles receive, making them less relaxed." d. "The exercises help you to establish regular bowel elimination patterns so you don't strain so much."

a. "They help to increase the volume of your muscles, which leads to stronger muscle contraction." Rationale: The purpose of pelvic floor exercises is to increase the muscle volume, which will result in a stronger muscular contraction.

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? a. "You might try using a water-soluble lubricant to ease the discomfort." b. "It takes a while to get your body back to its normal function after having a baby." c. "This is entirely normal, and many women go through it. It just takes time." d. "Try doing Kegel exercises to get your pelvic muscles back in shape."

a. "You might try using a water-soluble lubricant to ease the discomfort." Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first? a. Administer pain medications. b. Assess client vital signs. c. Assist the client in emptying her bladder. d. Encourage the client to stop breastfeeding until the pains stop.

a. Administer pain medications.

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. a. Assess the client's uterine tone. b. Monitor the client's vital signs. c. Assess the client's skin turgor. d. Get a pad count. e. Assess deep tendon reflexes.

a. Assess the client's uterine tone. b. Monitor the client's vital signs. d. Get a pad count.

A gravida 2, para 2 recently gave birth to a healthy 3304 g (7 lb, 6 oz) female newborn. There were no complications during the birth, and the parent appears to be well. Which action will the nurse take to assess this client's psychologic state after the pregnancy? a. Encourage the client to talk about the birthing experience with the nurse and others. b. Ask if the client had any depressive symptoms after giving birth the first time. c. Explore potential strategies to minimize stress when returning home. d. Ask the client about family history related to mental illness.

a. Encourage the client to talk about the birthing experience with the nurse and others. Rationale: After the birth, the nurse will encourage the client to talk about and share the experience. This "debriefing time" can be an important way to help the client appreciate everything that happened and integrate the experience into their total life.

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? 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

A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. What should the nurse do next? a. Tell the client to take an NSAID orally. b. Have the client stop breastfeeding. c. Instruct the client to take a warm shower. d. Ask how often the client is breastfeeding.

a. Tell the client to take an NSAID orally.

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as a mother by going through a series of four developmental stages. What is one of them? a. achieving a maternal identity b. finding a way to get the new baby to conform to existing family interrelationships c. physical restoration and learning to get help in caring for the infant d. preparing for the infant before she conceives

a. achieving a maternal identity

The nurse is caring for a 28-year-old client after the delivery of a healthy neonate. What would the nurse expect to find when assessing this client's fundus? a. fundus 1 cm above the umbilicus 1 hour postpartum b. fundus 1 cm above the umbilicus on postpartum day 3 c. fundus palpable in the abdomen at 2 weeks' postpartum d. fundus slightly to right; 2 cm above umbilicus on postpartum day 2

a. fundus 1 cm above the umbilicus 1 hour postpartum

A nurse is assessing a breastfeeding client in the third week postpartum. During the physical examination, the nurse observes that the rugae in the vagina have not reappeared. Which factor would the nurse identify as the possible cause of delayed return of rugae? a. low circulating estrogen level b. low circulating progesterone level c. high circulating prolactin level d. low circulating oxytocin level

a. low circulating estrogen level

The nurse is appraising the post-birth laboratory results of a client and discovers the WBC is 22,000 cells/μL (22 x 109/L). Which action should be prioritized in response? a. none, a normal variation due to labor b. an abnormal finding, needs antibiotics c. occurs in clients after a cesarean birth d. further testing is required to determine source.

a. none, a normal variation due to labor Rationale: An elevation of WBC up to 30,000 cells/μL (30 x 109/L) can be a normal variation for any woman after birth. This is related to the stress on her body from labor and birth.

When palpating for fundal height on a postpartum woman, which technique is preferable? 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

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? a. "You must have an infection, so let me get a urine specimen." b. "Your body is undergoing many changes that cause your bladder to fill quickly." c. "Your uterus is not contracting as quickly as it should." d. "The anesthesia that you received is wearing off and your bladder is working again."

b. "Your body is undergoing many changes that cause your bladder to fill quickly."

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. 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 health care provider is discussing the results of a recent sonogram with the client. A new diagnosis of uterine displacement is made. Which statement indicates a need for further teaching? a. "My bladder can enter into my vagina if the muscles of the vagina are weak." b. "To eliminate the source of the problem, my uterus will have to be removed." c. "You thought that I had a problem when doing my pelvic examination." d. "Kegel exercises may help strengthen my perineal muscles and decrease stress incontinence."

b. "To eliminate the source of the problem, my uterus will have to be removed."

A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention? a. No action needed. b. Administer rubella vaccine before discharge. c. Assess the rubella titer of the baby. d. Notify the health care provider.

b. Administer rubella vaccine before discharge.

The nurse is admitting a postpartum client from five days ago with diagnosis of perineal infection. What nursing intervention is most helpful to decrease pain levels from an 8 out of 10 to a 3 out of 10? a. Administer topical or oral corticosteroids as prescribed. b. Assist the client with sitz baths. c. House the client in a negative-pressure isolation room. d. Provide the client with a high-calorie, high-fat diet.

b. Assist the client with sitz baths.

A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? a. Change in pregnancy hormone b. Body secreting the excess fluids from pregnancy c. The patient may be drinking too much fluid. d. The body is trying to get rid of the extra blood made during pregnancy.

b. Body secreting the excess fluids from pregnancy

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. a. Lochia rubra b. Fundal height level of one fingerbreadth above the umbilicus c. Episiotomy appears edematous d. Temperature of 101.8°F (38.8°C) e. White blood cell count of 28,000/mm3

b. Fundal height level of one fingerbreadth above the umbilicus d. Temperature of 101.8°F (38.8°C)

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do? a. Assist the client to the bathroom. b. Have the client sit dangling her legs off the side of the bed for 5 minutes. c. Ask the client to lie back down and get her a bedpan. d. Suggest catheterizing her this time to prevent the possibility of fainting.

b. Have the client sit dangling her legs off the side of the bed for 5 minutes.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? a. Assess her blood pressure. b. Palpate her fundus. c. Have her turn to her left side. d. Assess her perineum.

b. Palpate her fundus.

A client gave birth 90 minutes ago and has just arrived on the postpartum unit. The initial set of vital signs reveals a blood pressure of 138/86 mm Hg. The blood pressure during labor never rose above 128/74 mm Hg. Which best describes the rise in blood pressure? a. The client is having a side effect to the opioid pain medication given while in labor. b. The client's stroke volume has increased after birth of the placenta, causing a physiologic response in blood pressure. c. The client's stroke volume should decrease after birth; this reflects a pathologic adjustment of blood pressure. d. The client is experiencing pain after the childbirth, causing the rise in blood pressure.

b. The client's stroke volume has increased after birth of the placenta, causing a physiologic response in blood pressure. Rationale: Stroke volume increases, not decreases, after birth of the placenta. This increase in blood volume can cause increased blood pressure. Blood pressure will stabilize as diuresis reduces the circulating blood volume.

The nurse is checking the lochia of a new mother at her 2-week checkup. The mother reports that the lochia is a small amount, pale yellow with occasional tinges of brown. She also reports that it has fleshy odor to it. How would the nurse evaluate these findings? a. The lochia's odor indicates that an infection may be present and the doctor needs to be notified. b. The color and amount of the lochia is normal and there are no concerns. c. The brownish tinges indicate that the mother is regressing on the expected pattern of lochia and this is problematic. d. Lochia should have stopped by now, so this is definitely concerning for the nurse and should be reported.

b. The color and amount of the lochia is normal and there are no concerns.

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? a. cracking of the nipple b. improper positioning of infant c. inadequate secretion of prolactin d. inability of infant to empty breasts

d. inability of infant to empty breasts

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. permanent urinary incontinence b. increased lochia drainage c. fluid volume overload d. ruptured bladder

b. increased lochia drainage

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? a. uterus 5 cm below umbilicus b. lochia rubra c. edematous vagina d. diaphoresis

b. lochia rubra

A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which finding? a. nonpalpable fundus b. moderate lochia serosa c. bruising on arms and legs d. fever

b. moderate lochia serosa Rationale: Subinvolution is usually identified at the woman's postpartum examination 4 to 6 weeks after birth. The clinical picture includes a postpartum fundal height that is higher than expected, with a boggy uterus; the lochia fails to change colors from red to serosa to alba within a few weeks. Normally, at 4 to 6 weeks, lochia alba or no lochia would be present and the fundus would not be palpable. Thus evidence of lochia serosa suggests subinvolution.

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 round-the-clock nursery care for all infants Rationale: 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.

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

b. one fingerbreadth below the umbilicus

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

b. one fingerbreadth below the umbilicus

After teaching a group of nurses during an in-service program about risk factors associated with postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which risk factor(s)? Select all that apply. a. use of indwelling catheter b. placenta previa c. nulliparity d. hydramnios e. labor augmentation

b. placenta previa d. hydramnios e. labor augmentation

A nurse is developing a teaching plan about sexuality and contraception for a postpartum woman who is breastfeeding. Which information would the nurse most likely include? Select all that apply. a. resumption of sexual intercourse about two weeks after birth b. possible experience of fluctuations in sexual interest c. use of a water-based lubricant to ease vaginal discomfort d. use of combined hormonal contraceptives for the first three weeks e. possibility of increased breast sensitivity during sexual activity

b. possible experience of fluctuations in sexual interest c. use of a water-based lubricant to ease vaginal discomfort e. possibility of increased breast sensitivity during sexual activity

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

b. 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.

A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? a. "Express some milk from your breasts every so often to relieve the distention." b. "Remove your bra to relieve the pressure on your sensitive nipples and breasts." c. "Apply ice packs to your breasts to reduce the amount of milk being produced." d. "Take several warm showers daily to stimulate the milk let-down reflex."

c. "Apply ice packs to your breasts to reduce the amount of milk being produced."

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

c. "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.

After the birth of the newborn, the mother is ready to be discharged home. The client's mother is present and will remain with her for 1 month. The client's mother tells the nurse that her daughter will not be allowed to leave the house for the first month after the birth, based on the family's cultural customs. How should the nurse respond to this statement? a. Remind the client's mother that the woman needs to get out and get fresh air over the next month. b. Ask the client's mother why she is putting such restrictions on her daughter. c. Accept the mother's statement and perform discharge teaching accordingly. d. Explain to the client's mother that her daughter may have to go places in caring for the newborn.

c. Accept the mother's statement and perform discharge teaching accordingly.

The nurse is assisting in developing a care plan for a client who had an episiotomy. Which interventions would be included for the nursing diagnosis: Acute pain related to perineal sutures as manifested by client stating pain of 8 out of 10? Select all that apply. a. Apply an ice pack to the perineal area throughout the first week. b. Avoid the use of topical products to assist with pain. c. Administer sitz baths three to four times per day. d. Encourage Kegel exercises with each voiding. e. Change the perineal pad twice daily.

c. Administer sitz baths three to four times per day. d. Encourage Kegel exercises with each voiding. Explanation: Ice packs should be applied to the perineum for the first 24 hours only; after that time, heat should be used.

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 Rationale: Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? a. Acute pain related to afterpains or episiotomy discomfort b. Risk for infection related to multiple portals of entry for pathogens c. Risk for injury: postpartum hemorrhage related to uterine atony d. Risk for injury: falls related to postural hypotension and fainting

c. Risk for injury: postpartum hemorrhage related to uterine atony

A client with vaginitis reports itching and burning of the perineum. Which suggestion would be most appropriate to relieve the client's symptoms? a. Use a pure vinegar douche daily. b. Use skin protectants containing zinc oxide. c. Take sitz baths frequently. d. Avoid yogurt with active lactobacilli cultures.

c. Take sitz baths frequently.

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

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."

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

d. Educate the client on how to perform Kegel exercises.

A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period? a. She sits and rocks her infant for long intervals. b. She is eager to talk about her birth experience. c. She has not asked for anything for pain all day. d. She did her perineal care independently.

d. She did her perineal care independently.

The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction? a. Temp: 99.4° F (37.4° C), HR 90, RR 18, BP 112/67 b. Temp: 97.0° F (36.1° C), HR 80, RR 20, BP 120/72 c. Temp: 100.2° F (38° C), HR 65, RR 22, BP 130/78 d. Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85

d. Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Rationale: The elevated BP of 150/85 is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth.

The nurse is discharging a 34-year-old multiparous postpartum client 48 hours after a successful 16-hour vaginal delivery of a neonate weighing 4,036 g (8 lb, 14 oz). The nurse notes that the mother is rubella-immune with Rh-positive blood type. When formulating a discharge plan, the nurse should prioritize which objective first? a. The client will receive Rho(D) immune globulin IM before discharge. b. The client will understand the need for planned rest periods and identify a support system. c. The client will understand and consent to a rubella vaccine before discharge. d. The client will verbalize the importance of reporting any change in character of lochia.

d. The client will verbalize the importance of reporting any change in character of lochia. Explanation: A multiparous client who has a history of prolonged labor and delivery of a large infant is at a higher risk for developing late postpartum hemorrhage.

The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation? a. achieving a maternal identity b. physical restoration and learning to care for infant c. shift in normal life to "new normal" d. beginning attachment and preparation for family

d. beginning attachment and preparation for family

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used. a. moving toward a new normal routine in the first several months b. acquaintance with and increasing attachment to the infant c. achievement of the parental role/maternal identity around 4 months d. commitment, attachment, and preparation for an infant

d. commitment, attachment, and preparation for an infant b. acquaintance with and increasing attachment to the infant a. moving toward a new normal routine in the first several months c. achievement of the parental role/maternal identity around 4 months

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? a. yellowish-white lochia b. foul-smelling lochia c. easy to separate clots d. difficult to separate clots

d. difficult to separate clots Rationale: Easily separable lochia indicates the presence of clots only.

A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation? a. apply warm compresses b. apply moist heat c. massage the muscles d. suggest proper exercise

d. suggest proper exercise Rationale: This client developed diastasis recti, a condition in which the abdominal muscles separate during the pregnancy, leaving part of the abdominal wall without muscular support. Exercise can improve muscle tone when this condition occurs.

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? diuresis lactation blood loss nausea

diuresis

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? depression phase letting-go phase taking-hold phase taking-in phase

taking-in phase

A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis. The nurse would also expect to assess an elevation in which of the following? temperature blood pressure heart rate respiratory rate

temperature

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be? red pink yellowish white yellowish pink

yellowish white