Maternity and Peds Exam 3

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. heavy B. light C. scant D. moderate

D. 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 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. Have your 2 year old stay at home while your in the hospital B. Talk to your 2 year old about the baby when your driving him to daycare C. Ask your 2 year to pick out a special toy for his sister D. Expect to see your 2 year old become more indepenent when baby comes home

C.

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? A. Telling the mother to feed the baby when it cries B. Changing the infant's diapers for the mother C. Correcting the mother when she holds the newborn incorrectly D. Demonstrating how to do cord care on the newborn

D. 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.

Many clients experience a slight fever after birth especially during the first 24 hours. This is attributed to dehydration. True or False.

True

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A. A client who had an 8 hour labor B. A client who had a nonelective cesarean birth C. A primaparous client who had a vaginal birth D. A client who conceived following fertility treatments

B.

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. 750 addtl cal per day B. 1,000 addtl cal per day C. 250 addtl cal per day D. 500 addtl cal per day

D.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond? A. Use of breast pumps B. frequent feedings C. complete emptying of the breast D. pierced nipple

D.

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication A. Her BP is below 140/90 B. she can walk without experiencing dizziness C. Her hematocrit level is over 45% D. her urine output is over 50 ml/h

A. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

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 fngerbreadth below the umbilicus B. one fingerbreadth above the umbilicus C. below the symphysis pubis D. at the level of the umbilicus

A. 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.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? A. increased heart rate B. increased cardiac output C. increased hematocrit level D. increased blood pressure

A. Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the puerperium, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? A. uterine subinvolution B. uterine atony C. uterine prolapse D. uterine contraction

B. Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? A. on her left side B. Flat in bed C. semi-fowler D. Trendelenburg

C. A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would not accomplish this goal and could result in the infection spreading to other parts of the body.

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? A. Bladder distention B. Poor bladder tone C. Full bowel D. Uterine atony

A.

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? A. a scant amount of lochia alba B. a scant amount of lochia serosa C. a moderate amount of lochia rubra D. a moderate amount of lochia alba

C. 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 woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? A. Risk for impaired BF r/t development of mastitis B. Risk for fatigue r/t chronic bleeding due to subinvolution C. Ineffective peripheral tissue perfusion r/t interference with circulation secondary to development of thrombophlebitis D. Risk for infection r/t microorganism invasion of episiotomy

B. Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? A. Administer RH immunoglobulins IM B. Determine the newborns blood type and rhesus C. Determine if this is the clients first baby D. Ask if the client received rH immunoglobulins during the pregnancy

B. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? A. Hypertension B. Hypothyroidism C. Hypovolemia D. Hyperglycemia

C. The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? A. nifedipine B. oxytocin agent C. indomethacin D. magnesium sulfate

B. The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.

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? A.Trauma to pelvic muscles B. Postpartum diuresis C. UTI D. urinary overflow

B.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.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? A. SOB is common adverse effect of the medication B. Wear knee high stockings when possible C. Avoid OTC salicylates D. Avoid iron replacement therapy

C. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue? A. yellowish-white lochia B. easy to seperate clots C. Difficult to seperate clotes D. Foul smelling lochia

C. If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? A. consistency, shape, and location B. location, shape, and content C. consistency, location, and place D. content, lochia, place

A.

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination? A. The client has a history of epidural anesthesia B. The client is receiving oral pain meds C. The client has a distended bladder D. The client had an episiotomy

A. If a client has an epidural, her sensation of pain is decreased, so nurses cannot rely on client reports of pain as a symptom of a perineal hematoma. The nurse should always inspect the perineum to determine if there is a hematoma present. Having an episiotomy, having a distended bladder, or taking oral pain medications would have no effect on a perineal hematoma.

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. A. women who had difficulties with BF in the past B.women on antineoplastic meds C. women with more than one infant D. women using street drugs E. women on antithyroid meds

B, D, E. 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 postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. A. Uterine infection B. Hydramnios C. Prolonged labor D. Early ambulation E. Breastfeeding F. Empty Bladder

A, B, C Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

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? A. Nausea B. Diuresis C. Blood loss D. Lactation

B. Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? A. uterine atony B. delayed hemorrhage C. extreme diaphoresis D. bladder distension

B. 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.

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. A. elevated oral temo B. moderate lochia rubra C. rounded mass over symphysis pubis D. dullness on percussion over symphysis pubis E. fundus boggy to the right of the umbilicus

C, D, E. If the bladder is distended, the nurse would most likely palpate a rounded mass at the 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 degrees F (38 degrees C), infection is suggested.

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? A. by assessing skin turgor B. by assessing BP C. by monitoring hCG titers D. by frequently assessing uterine involution

D.

Which factor might result in a decreased supply of breast milk in a postpartum client? A. Frequent feedings B. Maternal diet high in Vitamin C C. An alcoholic drink D. Supplemental feedings with formula

D.

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? A. blood loss of 250mL and WBC 25,000 cells/mL B. heart rate 70 bpm and excessive, soaking diaphoresis C. shaking chills with a fever of 99 F D. BP 90/50 mm HG, heart rate 120 bpm, respirations 24 breaths per min

D. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.