Maternal Chapter 17
A new mother asks if it is possible to have rooming-in with the newborn. How should the nurse respond to this patient's request?
Rooming-in allows increased maternal-newborn contact.
When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartum day and how should it feel?
1 cm below the umbilicus
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?
Bleeding
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
Cannot be palpated
A nurse is observing a new mother interacting with her newborn. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?
Mother making eye-to-eye contact with the newborn
Healthy bonding behaviors are important to note when the nurse is assessing the new family. What statement or action would the nurse consider a warning sign that the mother and infant were not attaching as they should?
Mother states she wanted a boy this time, not another girl.
Which assessment finding 1 hour after birth should be reported to the health care provider?
Foul smelling lochia.
The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus?
Fundus two fingerbreadths below umbilicus and firm
When assessing a client's uterine fundus during the fourth stage of labor, the nurse palpates a soft, uncontracted fundus. Which of the following would the nurse do next?
Gently massage the boggy fundus
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
I can't wait for these stretch marks to disappear after delivery."
When palpating for fundal height on a postpartum woman, which technique is preferable?
Placing one hand at the base of the uterus, one on the fundus
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best?
The stitches do not need to be removed.
Which reason explains why women should be encouraged to perform Kegel exercises after birth?
They promote blood flow, enabling healing and muscle strengthening.
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?
Two fingerbreadths below the umbilicus
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?
Uterine atony
When developing a plan of care for a postpartum client, the nurse would identify which of the following as an expected outcome?
Vital signs within acceptable limits
A nurse is providing care to a postpartum woman who is breastfeeding her 1-day old neonate. While observing the interaction, the woman says to the nurse, "I have noticed some tingling in both of my breasts just before my baby starts to feed and then for a bit during the feeding. What is happening?" Which response by the nurse would be appropriate?
What you are feeling is the normal let-down reflex when milk is released."
A client who is breastfeeding 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?
Your uterus is still shrinking in size; that's why you're feeling this pain.
The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply.
a) Return of blood volume to prepregnancy level b) Contraction of the cervix c) Decrease of pregnancy hormones f) Involution of the uterus
The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective?
"I should plan to return to my full-time job after 6 weeks."
A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?
Administer pain medications
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
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?
Ice is applied to perineal edema within 24 hours after delivery.
A nurse is assessing a breastfeeding client in the third week postpartum. During the physical examination, the nurse observes that the rugae in the vagina have not reappeared. Which factor would the nurse identify as the possible cause of delayed return of rugae?
high circulating estrogen level
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
The nurse assesses a postpartum patient's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia?
lochia rubra
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