Chapter 15 Prep U

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?

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

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?

Bladder distention

The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?

Engorgement

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?

Feed the baby at least every two or three hours. -The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.

The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

Place an ice pack.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?

Showing increased confidence when caring for the newborn -Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

applying ice -Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change?

decreased intra-abdominal pressure -The nurse should identify decreased intra-abdominal pressure as the cause of the respiratory system functioning normally. Progesterone levels do not influence the respiratory system. Decreased bladder pressure does not affect breathing. Anesthesia used during birth causes the respiratory system to take a longer time to return to normal.

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

When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?

hemorrhage

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

oxytocin -Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?

postpartum diuresis -The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?

redness in lower legs -The nurse should identify redness, swelling, or warmth in the lower legs as early signs of thrombophlebitis. Edema in the perineal area usually accompanies an episiotomy. Diaphoresis is a normal finding in the immediate postpartum period. Increased lochia could be due to uterine atony.

Which factor might result in a decreased supply of breast milk in a postpartum client?

supplemental feedings with formula

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?

the taking-hold phase

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony -Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.

Eight hours after delivery, the client is found to have a perineal hematoma. The health care provider prescribes insertion of a Foley catheter. The client does not understand why she needs a catheter, because she has voided twice since giving birth. Which responses by the nurse explain the need for a Foley catheter? Select all that apply.

"If you are bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for you to void." "As the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later."

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?

"It sounded like you had quite a time getting here. Would you like to continue your story?" -The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?

"Ovulation may return as soon as 3 weeks after birth." -Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:

"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

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?

"You might try using a water-soluble lubricant to ease the discomfort." -Coital discomfort 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 client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

Apply ice. -Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?

Demonstrating how to do cord care on the newborn -When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.

A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?

Ensure the baby empties the breasts at each feeding

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize?

Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean -First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 ml of blood lost during the delivery process, the hemoglobin should decrease by 1 g/dl (10 g/L) and the hematocrit by 2%. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 ml to 500 m and for a cesarean delivery approximately 500 mL to 1000 ml. The loss of hemoglobin from 14 gm/dl (140 g/L) to 9 gm/dl (90 g/L) is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 ml of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?

Hold the baby frequently. - The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.

The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

Involution -Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take?

Let the health care provider know the condition of the incision.

When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action?

The fundus is firm and deviated sharply to the right side of the abdomen. -In the immediate postpartum period, the fundus is regularly assessed. The fundus must be firm. A boggy fundus indicates uterine atony and will result in blood loss. The fundus is to be midline in the abdomen. A deviation to the side may indicate a full bladder. In the immediate hours after birth, the fundus may be found at one fingerbreadth above or below the umbilicus.

The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive?

The mother is reluctant to touch the newborn for fear of hurting her.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?

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.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:

acutely decreased. -Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.

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?

increased coagulation factors -The woman is showing signs of thromboembolism or deep vein thrombosis, which is a risk for the postpartum client due to the increased hypercoagulable state that occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors that the body uses as a protective device; however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, the client should be evaluated for anemia. The stirrups should not cause an injury.

While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?

taking-in

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?

taking-in phase -During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in?

taking-in phase -The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period.

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition?

thromboembolism -An increase in blood coagulability places the client at risk for thromboembolism. Hyperglycemia is found in cases with diabetes. Varicose veins are due to engorgement of the veins in the lower extremities. Calcium depletion is not affected by increased blood coagulability.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?

touching

A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply.

trace WBCs moderate glycosuria mild ketonuria Occasional RBCs -Urine in a client in the early postpartum period may display ketonuria secondary to dehydration or prolonged labor, glycosuria from the inability of the kidneys to filter properly immediately following delivery, and RBC's from lochia contamination. Gross proteinuria is an abnormal finding for a urinalysis of this client.

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?

yellowish white -The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" -Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?

1 cm below the umbilicus -The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

"Be sure to change your pajamas to prevent you from chilling."

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?

Assist the woman in placing ice packs on her breasts.

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client?

Body secreting the excess fluids from pregnancy

The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?

Risk for injury: postpartum hemorrhage related to uterine atony

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?

Wear a tight, supportive bra.

A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra.

An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as:

attachment.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 -moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:

taking-in, taking-hold, letting-go. -The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child.