Chapter 12: Postpartum Nursing Care

A woman reports that she has not urinated since delivering 8 hours ago and says she has no urge to void despite drinking adequate fluids postpartum. The nurse attributes this to what? A. The woman was dehydrated and has not fully hydrated yet to produce urine. B. The woman's bladder tone is reduced, and she does not feel the urge to urinate. C. The bladder has more room to expand and can hold more urine because of a smaller uterus. D. The woman is experiencing a release of epinephrine, causing absence of bladder sensation.

B. The woman's bladder tone is reduced, and she does not feel the urge to urinate. In the first days after delivery, the woman's bladder tone is reduced, resulting in the lack of an urge to void. She is not aware of the full bladder but should be encouraged to try to void.

The nurse enters a postpartum patient's room and finds the father staring at the newborn in the bassinet with a contemplative look on his face. How should the nurse interpret this behavior? A. The father may be a danger to the baby. B. The father feels resentful toward the baby. C. The father is uncertain about being a father. D. The father is bonding with the baby.

D. The father is bonding with the baby. Men can often be observed staring at the baby, which is a form of attachment and bonding with the newborn.

The nurse is assessing a postpartum woman's understanding of sitz baths. Which statement made by the patient indicates the need for further teaching? A. "I should add soap to warm water to prepare the sitz bath at home." B. "Sitz baths will provide pain relief for my episiotomy." C. "I can prepare a sitz bath in the tub or in a basin." D. "I can sit on a soft wet towel in the warm sitz bath water for 10 to 15 minutes three times a day."

A. "I should add soap to warm water to prepare the sitz bath at home." No soap, shower gels, or bubble bath should be added to sitz baths.

What does the nurse assess as part of the BUBBLE LE mnemonic? (Select all that apply.) A. Episiotomy or abdominal incision B. Bonding and attachment C. Pain D. Circulation in the legs mnemonic. E. Gait

A. Episiotomy or abdominal incision Assessing the episiotomy or cesarean section incision is part of the BUBBLE LE mnemonic. C. Pain Pain should be assessed as part of the BUBBLE LE mnemonic. D. Circulation in the legs Circulation in the legs should be assessed to rule out a potential deep vein thrombosis as part of the BUBBLE LE mnemonic.

A new mother asks the nurse what she can do to foster attachment between the newborn and her 8-year-old daughter. Which recommendations should the nurse make? (Select all that apply.) A. Have the child visit in the hospital. B. Let the child help care for the baby as he or she is able. C. Have Mom spend some time alone with the child. D. Keep the baby away from the child as much as possible. E. Anticipate unpredictable and uncomplimentary statements about the baby.

A. Have the child visit in the hospital. Having the child visit in the hospital can reduce separation anxiety and promote sibling attachment. B. Let the child help care for the baby as he or she is able. Allowing the child to help with baby care, such as running for a diaper or holding the baby, can promote attachment. C. Have Mom spend some time alone with the child. Spending some time alone with the older child can reduce jealousy and promote attachment. E. Anticipate unpredictable and uncomplimentary statements about the baby. Even though the child is older, the mother should expect that the child will occasionally make uncomplimentary or unpredictable statements about the baby.

The nurse is preparing a postpartum patient for discharge. The nurse educates the patient to call the provider if she experiences which symptom? A. Lochia rubra after transition to serosa or alba B. Breast tenderness C. Difficulty sleeping D. Vaginal soreness

A. Lochia rubra after transition to serosa or alba Lochia should transition from rubra (dark red) to lochia serosa (brownish red) and finally lochia alba (lighter red/ yellowish). The return to lochia rubra could indicate an increase in vaginal bleeding, so the patient should call the provider.

It is time for a newborn to have blood collected for the newborn screening. How does the nurse turn this into a bonding opportunity for the mother? A. Perform the test in the mother's room and encourage her to comfort the newborn afterward. B. Take the baby to the nursery for the test to avoid upsetting the mother. C. Explain the bandage on the baby's foot when returning the baby to the mother's room. D. Perform the test without mentioning it to the mother to reduce anxiety.

A. Perform the test in the mother's room and encourage her to comfort the newborn afterward. When the test is performed in the mother's room, the new mother can comfort the baby during and after the procedure.

Which action by a postpartum mother is a sign of bonding between her and her infant? A. Positioning the baby facing her so she can explore the baby's face B. Spontaneously erupting in tears for unexplained reasons C. Correctly positioning the baby for breastfeeding D. Asking the nurse to keep the baby in the nursery

A. Positioning the baby facing her so she can explore the baby's face The mother positioning the baby facing her is known as the en face position. This position encourages eye contact and is a positive bonding behavior.

Which events after delivery of the placenta cause the uterus to contract and begin shrinking to nonpregnant size? A. Reduced estrogen and progesterone levels B. Reduced estrogen and oxytocin levels C. Reduced progesterone and oxytocin levels D. Estrogen, progesterone, and oxytocin levels decline.

A. Reduced estrogen and progesterone levels After delivery, estrogen and progesterone levels drop quickly, which cause the uterus to contract and begin the process of shrinking to pre-pregnancy size.

The nursing instructor observes a student providing care to an adolescent postpartum patient. Which statement made by the student indicates the need for further teaching? A. "Let me show you a way to hold the baby when you're giving him a bath." B. "Do you want your little friend to stay while you breastfeed?" C. "You're going to be a great mother because you really want to learn." D. "Do you have any questions or need help with anything?"

B. "Do you want your little friend to stay while you breastfeed?" Although it is correct to ask the adolescent whether she prefers privacy while breastfeeding, the phrase "little friend" is talking down to the patient and should be avoided.

The nurse is assessing a student's knowledge of postpartum care. Which of the following statements regarding nursing care during the first hour after delivery is incorrect? A. "I should observe the patient's peripads for the amount of lochia, color, odor, and the presence of clots." B. "I should check vital signs, including pulse and blood pressure, every hour." C. "I should palpate the fundus of the uterus for firmness and location every 15 minutes." D. "The first hour after delivery is the most dangerous hour in childbearing because of the risk of hemorrhage after delivery."

B. "I should check vital signs, including pulse and blood pressure, every hour." This is incorrect and would require the nurse to correct the student. During the first hour after delivery, the nurse should check vital signs, including pulse and blood pressure, every 15 minutes.

Before massaging the fundus, the nurse should look for which of the following? A. Amount of lochia B. Bladder distention The nurse should check for bladder distention before massaging the fundus. If distention is noted, the nurse should assist the patient to the bathroom before continuing. The bladder can become distended and push the uterus upward and to the side. Displacing the uterus can interfere with involution and can lead to hemorrhage for the postpartum patient. C. Breast engorgement D. Hemorrhoids

B. Bladder distention The nurse should check for bladder distention before massaging the fundus. If distention is noted, the nurse should assist the patient to the bathroom before continuing. The bladder can become distended and push the uterus upward and to the side. Displacing the uterus can interfere with involution and can lead to hemorrhage for the postpartum patient.

The nurse is assessing a postpartum patient 1 hour after delivery. Where should the nurse expect to palpate the fundus? A. Between the umbilicus and the symphysis pubis B. Even with the umbilicus C. Even with the symphysis pubis D. 1 cm above the symphysis pubis

B. Even with the umbilicus One hour after delivery, the fundus of the uterus should be palpable at the umbilicus.

The nurse is caring for a woman who delivered her third child 2 days ago and who says, "I am having pain; it feels like labor pain. I never experienced this with my other children, and it is worse when I breastfeed." Which is the nurse's priority response? A. Further assess the pain's location, intensity, and frequency. B. Explain the purpose of afterpains and reassure the patient. C. Immediately obtain vital signs and monitor vital signs every 15 minutes. D. Administer a narcotic analgesic to control pain.

B. Explain the purpose of afterpains and reassure the patient. The nurse should explain that these are afterpains resulting from the involution of the uterus and that they are stronger in women who are multiparous.

Which actions performed by the nurse demonstrate appropriate uterine massage for the postpartum patient? (Select all that apply.) A. Positioning one hand at the fundus of the uterus B. Pressing down until the fundus is palpated as a firm, hard, globular mass C. Noting the position of the fundus D. Placing one hand at the base of the uterus E. Calling and informing the provider of the uterine location

B. Pressing down until the fundus is palpated as a firm, hard, globular mass The nurse presses down with the hand at the umbilicus until the fundus is palpated. C. Noting the position of the fundus The position of the uterus should be noted and documented. D. Placing one hand at the base of the uterus One hand—the nondominant hand—is placed at the base of the uterus, just above the symphysis pubis.

During which phase of postpartum adjustment to motherhood should the nurse provide praise and positive reinforcement to a mother who is learning to care for her infant? A. Taking-in phase B. Taking-hold phase C. Letting-go phase D. Transitioning from taking-in to taking-hold phase

B. Taking-hold phase During the taking-hold phase the mother initiates care of the baby. She wants to be more independent and to make her own decisions, but she is concerned and anxious about her own physical care, breastfeeding, and baby care. This would be an appropriate time to provide praise and positive reinforcement.

A patient who is 6 weeks postpartum asks the nurse when she will start her menstrual cycle. How should the nurse respond? A. "You should start your cycle in 2 weeks." B. "How much sleep are you getting?" C. "Are you breastfeeding?" D. "You should begin your period the month after delivery."

C. "Are you breastfeeding?" The first menstrual period for a postpartum woman can occur anytime from 6 to 12 weeks after childbirth or even longer if the patient is breastfeeding, so the nurse should ask the patient if she is breastfeeding.

The nurse is assessing a postpartum patient within the first hour after delivery and notes that her peripad is saturated. Which is the nurse's priority action? A. Call the provider immediately. B. Obtain consent for blood transfusion. C. Change the peripad and document findings. D. Put the patient in the Trendelenberg position.

C. Change the peripad and document findings. During the first hour after delivery, one saturated pad would be an expected finding. The nurse should change the peripad, document findings, and continue to monitor the lochia.

While reviewing laboratory values, the nurse sees a postpartum patient's white blood cell count is 26,699 mg/dL, and her neutrophil count is also elevated. Which is the nurse's priority action? A. Assessing the episiotomy for signs of infection B. Notifying the RN and/or provider C. Continuing to monitor laboratory findings D. Obtaining STAT vital signs

C. Continuing to monitor laboratory findings These are expected changes after childbirth, so the nurse should continue to monitor laboratory findings.

The nurse is making a home-care visit when the newborn starts to cry. The new mother smiles and says, "That's his hungry cry." The nurse interprets this as indicating the mother is in which phase of maternal role attainment? A. Taking-in phase B. Taking-hold phase C. Letting-go phase D. Transitioning from taking-in to taking-hold phase

C. Letting-go phase This mother is demonstrating confidence in her ability to interpret her baby's cry and indicates that she is in the letting-go phase.

The nurse is assessing a postpartum patient's peripad 6 hours after delivery. How should the nurse document lochia that is 5 inches in diameter? A. Scant B. Light C. Moderate D. Heavy

C. Moderate Moderate is less than 6 inches of lochia on the pad.

A postpartum patient who plans to relinquish her baby for adoption says, "I'm having second thoughts. Maybe I should keep the baby." Which is the nurse's best response? A. "If you aren't sure, you should keep the baby until you make up your mind." B. "You've made a promise to the adopting parents, and it's too late to change your mind." C. "It is such a difficult decision to make. You must feel pulled in two directions." D. "I can hear the indecision in your voice. Would you like to talk about it?"

D. "I can hear the indecision in your voice. Would you like to talk about it?" This response validates that the nurse is listening and offers the mother the option of discussing her feelings in more detail if she wishes.

The nurse is explaining afterpains to a postpartum patient. Which of the following statements is correct? A. Afterpains are more painful for women who have not given birth previously. B. Oxytocin may be administered to resolve afterpains. C. Afterpains usually last for 3 weeks. D. Afterpains can be noticed while breastfeeding as a result of nipple stimulation.

D. Afterpains can be noticed while breastfeeding as a result of nipple stimulation. Afterpains can be noticed while breastfeeding as a result of nipple stimulation, which causes the release of oxytocin.

A new adolescent mother asks the nurse how to bathe her baby. Which is the nurse's best approach to teach her this procedure? A. Have the new mother bathe the baby while the nurse talks her through the process. B. Explain the procedure using pictures and diagrams. C. Give the new mother a brochure and tell her to ask if she has any questions. D. Let the new mother watch the nurse bathe the baby and then give a return demonstration tomorrow.

D. Let the new mother watch the nurse bathe the baby and then give a return demonstration tomorrow. The nurse should bathe the baby, pointing out what is being done and how the baby's head is supported. The new mother should then bathe the baby the next day while the nurse observes and assists.

The nurse performs a focal postpartum assessment using the BUBBLE LE mnemonic. Which assessment finding is incorrect to document as part of this examination? A. Breasts firm and tender; patient reports sore nipples B. Fundus 2 cm below umbilicus, firm C. Lochia pink, small amount of drainage D. Pulse strong and regular at rate of 84 beats per minute

D. Pulse strong and regular at rate of 84 beats per minute Pulse rate is not a part of the BUBBLE LE mnemonic and should not be included in this assessment.