Exam One

A woman who is two days postpartum has painful hemorrhoids postpartally. Which of the following positions would you suggest she use for resting? A) Spine with uterus pressed to the side B) Sims' position C) Knee-chest position D) Trendelenburg position

A Sims' position relieves pressure on rectal veins, thus reducing the size and pain of hemorrhoids. A knee-chest position is not recommended.

T/F: Post Delivery a woman's coagulation factors increase, increasing the risk of blood clots.

True: 2-3 days post partum a woman's coagulation factors increase. WBC cell count also increases (20,000 and 25,000).

Which action would most make the nurse believe that a postpartum woman is accepting a child well? A) She states she has named the child after a well-loved friend. B) She turns her face to meet the infant's eyes when she holds her. C) She comments that her baby has the most hair of any in the nursery. D) She asks the nurse to use her camera to take a photo of the child.

B: An "enface" position is a mark of a woman who is interacting warmly with a newborn.

A postpartal woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartally? A) Ask her if she feels any warmth in her legs. B) Assess for calf redness and edema. C) Take her temperature every 4 hours. D) Palpate her feet for tingling or numbness.

Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

A postpartal woman is concerned that her abdomen is extremely lax. Which exercise would the nurse suggest she start on the second day postpartum to tighten her abdominal muscles? A) Sit-ups B) Pelvic rocking C) Kegel exercises D) Chin-to-chest

Chin-to-chest exercises strengthen abdominal muscles yet are not exhausting and can be started on the second day. Sit-ups can be started after a few more days. Kegel exercises strengthen the perineal, not abdominal, muscles.

14. A nurse is assessing a postpartal woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartal period? A) She sits and rocks her infant for long intervals. B) She is eager to talk about her birth experience. C) She has not asked for anything for pain all day. D) She did her perineal care independently.

During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior? A) Disappointment with the child's sex B) Difficulty accepting the role changes C) Reacting normally to accepting a new child D) Cultural customs do not include kissing children

More often, a woman enters into a relationship with her newborn tentatively and with qualms and conflicts that must be addressed before the relationship can be meaningful. This is because parental love is only partly instinctive. The tentative behavior does not indicate disappointment with the child's sex, difficulty accepting role changes, or cultural customs that do not include kissing children.

A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action? A) Avoid getting out of bed for another 2 days. B) Walk with the nurse the length of her room. C) Walk the length of the hallway to regain her strength. D) Avoid elevating her feet when she rests in a chair.

Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

Amount of blood loss post delivery normal finding

Vaginal Birth: 500mL C-Section: 1000mL

A postpartal woman (gravida 1, para 1) asks immediately after delivery if she should request rooming-in with her infant. Your best response would be that:

Rooming-in (having the baby with her for the majority of the day) encourages bonding and is recommended whether a woman will breastfeed or not.

Which information would the nurse emphasize in the teaching plan for a postpartal 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 postpartal infection.

Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

8. When palpating for fundal height on a postpartal 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

Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

5. A postpartal 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.

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.

A nurse helps a postpartum woman out of bed for the first time postpartally 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.

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.

7. When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel? A) fundus height 4 cm below umbilicus and midline B) fundus two fingerbreadths above symphysis pubis and hard C) fundus 4 cm above symphysis pubis and firm D) fundus two fingerbreadths below umbilicus and firm

A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

2. The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? A) lochia rubra B) lochia serosa C) lochia normalia D) lochia alba

Lochia rubra is red; it lasts for the first few days of the postpartal period.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? A) an absence of lochia B) red-colored lochia for the first 24 hours C) lochia that is the color of menstrual blood D) lochia appearing pinkish-brown on the fourth day

Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.