Chapter 15: Postpartum Adaptations
The nurse interprets which of the following as evidence that a client is in the taking-in phase? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newborn.
A) Client states, "He has my eyes and nose." During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.
A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which of the following would the nurse identify as being least significant to this condition? A) Early ambulation B) Prolonged labor C) Large fetus D) Use of anesthetics
A) Early ambulation Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breast-feeding, and early ambulation.
A woman who delivered 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 father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) Expectations B) Transition to mastery C) Reality D) Taking-in
B) Transition to mastery The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which of the following would the nurse expect to find when assessing the client's fundus? A) Cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus
A) Cannot be palpated By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A) "You'll notice that this will fade to silvery lines." B) "Exercise will help to improve the muscles." C) "Expect the color to lighten somewhat." D) "You'll notice that your shoe size will increase."
B) "Exercise will help to improve the muscles." Separation of the rectus abdominis muscles, called diastasis recti, is more common in women who have poor abdominal muscle tone before pregnancy. After birth, muscle tone is diminished and the abdominal muscles are soft and flabby. Specific exercises are necessary to help the woman regain muscle tone. Fortunately, diastasis responds well to exercise, and abdominal muscle tone can be improved. Stretch marks (striae gravidarum) fade to silvery lines. The darkened pigmentation of the abdomen (linea nigra), face (melasma), and nipples gradually fades. Parous women will note a permanent increase in shoe size.
A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."
B) "It varies, but you can estimate it returning in about 7 to 9 weeks." For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after childbirth.
A group of nursing students are reviewing respiratory system adaptations that occur during the postpartum period. The students demonstrate understanding of the information when they identify which of the following as a postpartum adaptation? A) Continued shortness of breath B) Relief of rib aching C) Diaphragmatic elevation D) Decrease in respiratory rate
B) Relief of rib aching Respirations usually remain within the normal adult range of 16 to 24 breaths per minute. As the abdominal organs resume their nonpregnant position, the diaphragm returns to its usual position. Anatomic changes in the thoracic cavity and rib cage caused by increasing uterine growth resolve quickly. As a result, discomforts such as shortness of breath and rib aches are relieved.
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." Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum. Rapid bladder filling, possible infection, or effects of anesthesia are not involved.
Which of the following would lead the nurse to suspect that a postpartum woman is experiencing a problem? A) Elevated white blood cell count B) Acute decrease in hematocrit C) Increased levels of clotting factors D) Pulse rate of 60 beats/minute
B) Acute decrease in hematocrit Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output.
A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as which of the following? A) Involution B) Engorgement C) Mastitis D) Engrossment
B) Engorgement Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.
A nursing student is preparing a class presentation about changes in the various body systems during the postpartum period and their effects. Which of the following would the student include as influencing a postpartum woman's ability to void? (Select all that apply.) A) Use of an opioid anesthetic during labor B) Generalized swelling of the perineum C) Decreased bladder tone from regional anesthesia D) Use of oxytocin to augment labor E) Need for an episiotomy
B) Generalized swelling of the perineum C) Decreased bladder tone from regional anesthesia D) Use of oxytocin to augment labor Many women have difficulty feeling the sensation to void after giving birth if they received an anesthetic block during labor (which inhibits neural functioning of the bladder) or if they received oxytocin to induce or augment their labor (antidiuretic effect). These women will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. In addition, urination may be impeded by perineal lacerations; generalized swelling and bruising of the perineum and tissues surrounding the urinary meatus; hematomas; decreased bladder tone as a result of regional anesthesia; and diminished sensation of bladder pressure as a result of swelling, poor bladder tone, and numbing effects of regional anesthesia used during labor.
Which of the following would the nurse interpret as being least indicative of paternal engrossment? A) Demonstrating pleasure when touching or holding the newborn B) Identifying imperfections in the newborn's appearance C) Being able to distinguish his newborn from others in the nursery D) Showing feelings of pride with the birth of the newborn
B) Identifying imperfections in the newborn's appearance Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.
A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which of the following would the nurse expect to find? A) Bright red discharge B) Pinkish brown discharge C) Deep red mucus-like discharge D) Creamy white discharge
B) Pinkish brown discharge Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.
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 of the following stages? 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.
A nurse is assessing a postpartum woman's adjustment to her maternal role. Which of the following 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 her 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.
A group of nursing students are reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as which of the following? A) Puerperium B) Lactation C) Attachment D) Engrossment
C) Attachment Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.
When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) Deep red, fleshy-smelling lochia B) Voiding of 350 cc C) Heart rate of 120 beats/minute D) Profuse sweating
C) Heart rate of 120 beats/minute Tachycardia in the postpartum woman warrants further investigation. It may indicate hypovolemia, dehydration, or hemorrhage. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.
The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform Kegel exercises. The nurse includes this information for which reason? A) Reduce lochia B) Promote uterine involution C) Improve pelvic floor tone D) Alleviate perineal pain
C) Improve pelvic floor tone Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location? 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
C) Two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) Greater than after a vaginal delivery B) About the same as after a vaginal delivery C) Less than after a vaginal delivery D) Saturated with clots and mucus
C) less than after a vaginal delivery Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.
A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the uterus to contract."
D) "The baby's sucking releases a hormone that causes the uterus to contract." The woman is describing afterpains, which are usually stronger during breast-feeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breast-feeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
A nurse teaches a postpartum woman about her risk for thromboembolism. Which of the following would the nurse be least likely to include as a factor increasing her risk? A) Increased clotting factors B) Vessel damage C) Immobility D) Increased red blood cell production
D) Increased red blood cell production Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the puerperium, which causes mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks.
The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which of the following would the nurse include in the teaching plan to facilitate suppression of lactation? A) Encouraging the woman to manually express milk B) Suggesting that she take frequent warm showers to soothe her breasts C) Telling her to limit the amount of fluids that she drinks D) Instructing her to apply ice packs to both breasts every other hour
D) Instructing her to apply ice packs to both breasts every other hour If the woman is not breast-feeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breast-feeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.
A group of students are reviewing the process of breast milk production. The students demonstrate understanding when they identify which hormone as responsible for milk let-down? A) Prolactin B) Estrogen C) Progesterone D) Oxytocin
D) Oxytocin Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.
A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) Shapeless B) Circular C) Triangular D) Slit-like
D) Slit-like The external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."
After teaching a group of nursing students about the process of involution, the instructor determines that additional teaching is needed when the students identify which of the following as being involved? A) Catabolism B) Muscle fiber contraction C) Epithelial regeneration D) Vasodilation
D) Vasodilation Involution involves three retrogressive Process: contraction of muscle fibers to reduce those previously stretched during pregnancy; catabolism, which reduces enlarged myometrial cells; and regeneration of uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off and shed during lochial discharge. Vasodilation is not involved.
