chapter 16 nurse management Postpartum

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet."

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:

moderate

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels return to their normal pattern."

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day

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?

Ask the client when she last changed her perineal pad.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus.

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?

Offer suggestions based on observation to correct positioning or latching.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops.

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color?

creamy yellow

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

encouraging the woman to empty her bladder completely every 2 to 4 hours

The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.

feeling overwhelmed ad out of control lack of support low self-esteem low socioeconomic status

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3 to 6 weeks

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

one fingerbreadth below the umbilicus

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C)

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?

places a gloved hand just above the symphysis pubis

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temp

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting:

centrality

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

Inspecting posture, color, and respiratory effort

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony

Which factor puts a client on her first postpartum day at risk for hemorrhage?

uterine atony

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply.

avoid smoking lose weight if obese perform kegal exercises

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

bringing the newborn into the room

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

dullness on percussion over symphysis pubis rounded mass over symphysis pubis fundus boggy to the right of the umbilicus

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently.

During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply.

To identify client at risk for perinatal depressions To identify clients at risk for suicide

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider?

100.8°F (38.2°C)

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long term obesity

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment?

reciprocity