Chapter 16: Nursing Management During the Postpartum Period
A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior? A.) positive bonding B.) negative bonding C.) positive attachment D.) negative attachment
Answer: D.) negative attachment Rationale: Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.
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. - Low self-esteem - Feeling overwhelmed and out of control - Low socioeconomic status - Lack of social support - Involving family in infant care
Answer: - Low self-esteem - Feeling overwhelmed and out of control - Low socioeconomic status - Lack of social support
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
Answer: 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 nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A.) infection B.) hemorrhage C.) normal involution D.) atony
Answer: D.) atony Rationale; The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.
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. - commitment, attachment, and preparation for an infant - moving toward a new normal routine - acquaintance with and increasing attachment to the infant - achievement of the parental role
Answer: - commitment, attachment, and preparation for an infant - acquaintance with and increasing attachment to the infant - moving toward a new normal routine - achievement of the parental role Rationale: Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.
A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding? A.) Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. B.) Explain that breastfeeding comes naturally to all mothers. C.) Tell her that breastfeeding is a mechanical procedure that involves burping once in a while and that she should try finishing it quickly. D.) Ensure that the mother breastfeeds the newborn using the cradle method.
Answer: A.) Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. Rationale: The nurse should reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience; this information will help to reduce the feelings of frustration and uncertainty about their ability to breastfeed. The nurse should also explain that breastfeeding is a learned skill for both parties. It would not be correct to say that breastfeeding is a mechanical procedure. In fact, the nurse should encourage the mother to cuddle and caress the newborn while feeding. The nurse should allow sufficient time to the mother and child to enjoy each other in an unhurried atmosphere. The nurse should teach the mother to burp the newborn frequently. Different positions, such as cradle and football holds and side-lying positions, should be shown to the mother.
A nurse visiting a postpartum client at home is reviewing the need for the woman to meet her own nutritional needs. The woman is breastfeeding her newborn. The nurse determines that the client understands her nutritional needs based on which statements? Select all that apply. - "I need to drink about 2 to 3 quarts of fluid each day." - "I should have about 4 servings of fruits each day." - "I need to eat about 7 servings of vegetables daily." - "I will have at least 4 to 5 servings of milk each day." - "I need to cut way back on any fats and oils daily."
Answer: - "I need to drink about 2 to 3 quarts of fluid each day." - "I should have about 4 servings of fruits each day." - "I will have at least 4 to 5 servings of milk each day." Rationale: Daily nutritional recommendations for the lactating woman include: 2 to 3 quarts of fluids, 4 servings each of fruits and vegetables, 4 to 5 servings of milk, 7 servings of meat, poultry, fish and eggs, and 5 servings of fats, oils and sweets.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. - Give newborns water and other foods to balance nutritional needs. - Help the mother initiate breastfeeding within 30 minutes of birth. - Encourage breastfeeding of the newborn infant on demand. - Provide breastfeeding newborns with pacifiers. - Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Answer: - Help the mother initiate breastfeeding within 30 minutes of birth. - Encourage breastfeeding of the newborn infant on demand. - Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Rationale: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
A nursing student is studying postpartum complications. Thromboembolic conditions have which risk factors? Select all that apply. - anemia - diabetes - cigarette smoking - obesity - irritable bowel - multiparity
Answer: - anemia - diabetes - cigarette smoking - obesity - multiparity Rationale: Risk factors for developing thromboembolic conditions include anemia, diabetes, cigarette smoking, obesity, preeclampsia, hypertension, varicose veins, pregnancy, cesarean section, multiparity, inactivity, and advanced maternal age.
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. - performing Kegel exercises - avoiding smoking - losing weight if obese - increasing fluid intake - starting jogging
Answer: - performing Kegel exercises - avoiding smoking - losing weight if obese Rationale: Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoiding smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 ml to 2,000 ml.
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. - moderate lochia rubra - rounded mass over symphysis pubis - dullness on percussion over symphysis pubis - fundus boggy to the right of the umbilicus - elevated oral temperature
Answer: - rounded mass over symphysis pubis - dullness on percussion over symphysis pubis - fundus boggy to the right of the umbilicus Rationale: If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4°F (38°C), infection is suggested.
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 - women with more than one infant - women who had difficulties with breastfeeding in the past
Answer: - women on antithyroid medications - women on antineoplastic medications - women using street drugs Rationale: While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.
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? A.) "I only eat a low-fiber diet." B.) "I already have some pads with witch hazel at home." C.) "My mom always used dibucaine." D.) "Sitz baths worked the last time."
Answer: A.) "I only eat a low-fiber diet." Rationale: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
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? A.) "It might take up to a week for your bowels to return to their normal pattern." B.) "I'll get a laxative prescribed so that you can move your bowels." C.) "That's unusual. Are you making sure to eat enough?" D.) "Let me call your health care provider about this problem."
Answer: A.) "It might take up to a week for your bowels to return to their normal pattern." Rationale: Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.
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? A.) 500 additional calories per day B.) 1,000 additional calories per day C.) 250 additional calories per day D.) 750 additional calories per day
Answer: A.) 500 additional calories per day Rationale: The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.
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? A.) Schedule home visits for high-risk families. B.) Encourage frequent clinic visits for high-risk families. C.) Provide phone numbers for call centers for questions. D.) Ask family members to monitor the parents' progress.
Answer: A.) Schedule home visits for high-risk families. Rationale: To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? A.) delayed hemorrhage B.) bladder distention C.) extreme diaphoresis D.) uterine atony
Answer: A.) delayed hemorrhage Rationale: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.
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: A.) encouraging the client to wear a supportive bra. B.) having the client stand facing in a warm shower. C.) informing the primary care provider that the client is showing early signs of breast infection. D.) using a breast pump to facilitate removal of stagnant breast milk.
Answer: A.) encouraging the client to wear a supportive bra. Rationale: These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.
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? A.) generally within 3 to 6 weeks B.) whenever the couple wishes C.) generally after 12 weeks D.) usually within a couple weeks
Answer: A.) generally within 3 to 6 weeks Rationale; There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.
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
Answer: A.) one fingerbreadth above the umbilicus Rationale: After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.
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
Answer: A.) placing one hand at the base of the uterus, one on the fundus
A nurse is describing a technique developed in the 1940s by Dr. Arnold Kegel to assist postpartum women with a common issue. The nurse explains that the purpose of this technique is to: A.) strengthen the pelvic floor muscles to reduce urinary incontinence. B.) strengthen the uterine muscle fibers to return to their prepregnancy condition. C.) strengthen the joints and return them to their normal state. D.) strengthen the abdominal muscles to lessen the size of stretch marks.
Answer: A.) strengthen the pelvic floor muscles to reduce urinary incontinence.
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.
Answer: 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.
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? A.) thromboembolic disorder of the lower extremities B.) hormonal shifting of relaxin and estrogen C.) infection D.) normal response to the body converting back to prepregnancy state
Answer: A.) thromboembolic disorder of the lower extremities Rationale: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A.) touching B.) talking C.) looking D.) feeding
Answer: A.) touching Rationale: Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.
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? A.) venous duplex ultrasound of the right leg B.) transthoracic echocardiogram C.) venogram of the right leg D.) noninvasive arterial studies of the right leg
Answer: A.) venous duplex ultrasound of the right leg Rationale: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? A.) "If the symptoms last more than a few days, I need to call my doctor." B.) "I might feel like laughing one minute and crying the next." C.) "I'll need to take medication to treat the anxiety and sadness." D.) "I should call this support line only if I hear voices."
Answer: B.) "I might feel like laughing one minute and crying the next." Rationale: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down. Nurses can ease a mother's distress by encouraging her to vent her feelings and by demonstrating patience and understanding with her and her family. Suggest that getting outside help with housework and infant care might help her to feel less overwhelmed until the blues ease. Provide telephone numbers she can call when she feels down during the day. Making women aware of this disorder while they are pregnant will increase their knowledge about this mood disturbance, which may lessen their embarrassment and increase their willingness to ask for and accept help if it does
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? A.) "Breastfeeding takes time and practice." B.) "Some women just can't breastfeed. Maybe I'm one of these women." C.) "Some babies latch on and catch on quickly; others take a little more time." D.) "Maybe a lactation specialist can help me work through this."
Answer: B.) "Some women just can't breastfeed. Maybe I'm one of these women." Rationale: The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? A.) "If you do not get up to walk you will not recover." B.) "Walking is the best way to prevent complications such as blood clots." C.) "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." D.) "Maybe you will feel better after you take pain medication."
Answer: B.) "Walking is the best way to prevent complications such as blood clots." Rationale: The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.
Which finding would the nurse describe as "light" or "small" lochia? A.) 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss B.) 4-inch stain or a 10 to 25 ml loss C.) 4- to 6-inch stain with an estimated loss of 25 to 50 ml D.) pad is saturated within 1 hour after changing it
Answer: B.) 4-inch stain or a 10 to 25 ml loss Rationale: Typically the amount of lochia is described as follows: scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; light or small: 4-inch stain or a 10 to 25 ml loss; moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; large or heavy: a pad is saturated within 1 hour after changing it.
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? A.) Reassess the client in 1 hour. B.) Document the lochia as scant. C.) Stop using a peri-pad. D.) Massage the client's fundus.
Answer: B.) Document the lochia as scant. Rationale: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.
A nurse is assessing a postpartum client. Which measure is appropriate? A.) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. B.) Instruct the client to empty her bladder before the examination. C.) Wear sterile gloves when assessing the pad and perineum. D.) Perform the examination as quickly as possible.
Answer: B.) Instruct the client to empty her bladder before the examination. Rationale: An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.
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? A.) Avoid use of water-based gel lubricants. B.) Resume intercourse if bright red bleeding stops. C.) Avoid performing pelvic floor exercises. D.) Use oral contraceptive pills (OCPs) for contraception.
Answer: B.) Resume intercourse if bright red bleeding stops. Rationale: The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs).
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.
Answer: B.) Uterus is boggy. Rationale: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.
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.
Answer: B.) Wash her perineum with her daily shower. Rationale: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
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
Answer: 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 Rationale; A major complication in women who have lost an appreciable amount of blood with birth is orthostatic hypotension, or dizziness that occurs on standing because of the lack of adequate blood volume to maintain nourishment of brain cells. If blood pressure is 15 to 20 mm Hg lower after raising the head of the bed upright compared with the supine reading, the woman might be susceptible to dizziness and fainting when she ambulates. Developmentally, 18-year-old teenagers may stay up late and sleep late as a normal sleep cycle. The young 22-year-old packing for discharge is not the priority. A client who had a cesarean birth with minimal blood loss should be allowed to sleep after receiving pain medication and is not the priority.
It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine 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.
Answer: B.) between the umbilicus and symphysis pubis. Rationale: The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. 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.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A.) infection B.) dehydration C.) change in the temperature from the birth room D.) fluid volume overload
Answer: B.) dehydration Rationale: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? A.) nothing—it is normal B.) hematoma C.) infection D.) DVT
Answer: B.) hematoma Rationale: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.
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? A.) hemorrhage B.) infection C.) depression D.) pulmonary emboli
Answer: B.) infection Rationale; There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? A.) "Expect to see your 2-year-old become more independent when the baby gets home." B.) "Talk to your 2-year-old about the baby when you're driving him to day care." C.) "Ask your 2-year-old to pick out a special toy for his sister." D.) "Have your 2-year-old stay at home while you're here in the hospital."
Answer: C.) "Ask your 2-year-old to pick out a special toy for his sister." Rationale: The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.
A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? A.) Under 10 ml B.) 10 to 25 ml C.) 25 to 50 ml D.) Over 50 ml
Answer: C.) 25 to 50 ml Rationale: Typically, the amount of lochia is described as follows: scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-ml loss light or small: an approximately 4-in (10-cm) stain or a 10- to 25-ml loss moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 ml large or heavy: a pad saturated within 1 hour after changing it or over 50-ml loss.
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? A.) Apply ice packs directly to the perineal area. B.) Apply ice packs for 40 minutes continuously. C.) Ensure ice pack is changed frequently. D.) Use ice packs for a week after birth.
Answer: C.) Ensure ice pack is changed frequently. Rationale: The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths? A.) Sitz baths cause perineal vasoconstriction and decreased bleeding. B.) The longer a sitz bath is continued, the more therapeutic it becomes. C.) Sitz baths increase the blood supply to the perineal area. D.) Sitz baths may lead to increased postpartum infection.
Answer: C.) Sitz baths increase the blood supply to the perineal area. Rationale: Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? A.) The client is having a moderate amount of rubra lochia. B.) The client requires assistance to ambulate in the hallway. C.) The fundus is located 2 fingerbreadths above the umbilicus. D.) The client is afebrile. E.) Bowel sounds are active.
Answer: C.) The fundus is located 2 fingerbreadths above the umbilicus. Rationale: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? A.) The urinary output is inadequate and the mother needs to drinks more fluids. B.) The urinary output is inadequate suggestive of urinary retention. C.) The urinary output is normal. D.) The urinary output is above expected levels.
Answer: C.) The urinary output is normal. Rationale: Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void.
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: A.) inspect the perineum for lacerations. B.) increase the flow of an IV. C.) assess and massage the fundus. D.) call the primary care provider or the nurse-midwife.
Answer: C.) assess and massage the fundus. Rationale: This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
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: A.) scant. B.) light. C.) moderate. D.) heavy.
Answer: C.) moderate. Rationale; Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: A.) mitral valve collapse. B.) thrombophlebitis. C.) pulmonary embolism. D.) upper respiratory infection.
Answer: C.) pulmonary embolism. Rationale: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.
The nurse is caring for a woman who gave birth 4 hours prior. The woman had planned to pursue adoption through an agency she was working with during her pregnancy. The woman now expresses a desire to end the adoption process. How should the nurse respond to the woman? A.) "I adopted my child and he has had a good life. His birth mother is a part of his life and she is happy." B.) "You will want to really think on this...the adoptive family may allow you to be part of his life as he grows up." C.) "I would encourage you to move forward with the adoption since the adoptive parents will be disappointed." D.) "Ending the adoption process is a big decision and there are many factors to consider as you decide."
Answer: D.) "Ending the adoption process is a big decision and there are many factors to consider as you decide."
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? A.) Uterus is firm. B.) Lochia is less than usual. C.) Bladder is nonpalpable. D.) Percussion reveals dullness.
Answer: D.) Percussion reveals dullness.
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? A.) The flow contains large clots. B.) The flow is over 500 mL. C.) Her uterus is soft to your touch. D.) The color of the flow is red.
Answer: D.) The color of the flow is red. Rationale: A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.
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? A.) talking about how the nurse held her own newborn while on the birthing table B.) showing a video of parents feeding their babies C.) allowing the mother to pick the best time to hold her newborn D.) bringing the newborn into the room
Answer: D.) bringing the newborn into the room Rationale: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
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? A.) first degree B.) second degree C.) third degree D.) fourth degree
Answer: D.) fourth degree Rationale; The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: A.) the client will show no signs of infection. B.) discussing methods that the woman will use to prevent infection. C.) listing signs of infection that she will report to her health care provider. D.) maintaining previous household routines to prevent infection.
Answer: D.) maintaining previous household routines to prevent infection. Rationale: The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.
A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. Use all options. - Assess blood pressure. - Palpate the fundus. - Massage the fundus if boggy. - Determine the site of bleeding. - Increase IV oxytocin or breastfeed the newborn. - Notify the primary care provider.
Answer: Determine the site of bleeding. Palpate the fundus. Massage the fundus if boggy. Increase IV oxytocin or breastfeed the newborn. Assess blood pressure. Notify the primary care provider. Rationale: Determining the site of bleeding is the first assessment. Palpate the fundus. If the fundus is boggy, take steps to stimulate contractions by massaging. Stimulate contractions by oxytocin or breastfeeding. Assess blood pressure, and assess for safety to ambulate. Notify the health care provider and continue to monitor the client.
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? A.) first 30 to 60 minutes B.) first 3 to 5 days C.) first month D.) first 6 months
Answer: A.) first 30 to 60 minutes Rationale; Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.
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? A.) 97.5°F (36.9°C) B.) 99.2°F (37.3°C) C.) 100.1°F (37.8°C) D.) 100.8°F (38.2°C)
Answer: D.) 100.8°F (38.2°C) Rationale: Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.
