Maternity: Chpt. 16

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

atony

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:

between the umbilicus and symphysis pubis

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony?

boggy or relaxed uterus

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 nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day

650 calories

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

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."

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?

"Some women just can't breastfeed. Maybe I'm one of these women."

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks

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

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Apply an ice pack to the perineal area

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply.

Edema and slight bruising

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

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination.

Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means? Select all that apply.

Stasis; altered coagulation; and localized vascular damage

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?

The color of the flow is red

A postpartal woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

Wash her perineum with her daily shower

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

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.

head-to-toe assessment; pain level; and vital signs of mother

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 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?

negative attachment

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

non-distended abdomen; passing gas; and active bowel sounds

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

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:

strengthen the pelvic floor muscles to reduce urinary incontinence

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

temperature

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:

the level of the umbilicus

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

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

touching

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?

uterus is boggy

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 may discuss 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 using street drugs; women on antineoplastic medications; and women on antithyroid medications

Not all mothers express joy at seeing their newborn upon birth and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is:

referring to a facial feature as "ugly"

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

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth; Place baby in uninterrupted skin-to-skin contact with the mother; and Encourage breastfeeding of the newborn infant on demand

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 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?

first 30 to 60 minutes

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor

placenta removed via manual extraction

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

A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply

walk alongside the client to the bathroom; elevate the head of the bed for several minutes before getting her up; and frequently ask the client how her head feels

Prior to discharge is an appropriate time to evaluate the client's status for preventative measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh negative mother?

indirect Coombs' test

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. All options must be used.

Assist the client to empty her bladder in the bathroom; palpate the fundus; massage the fundus if boggy; increase IV oxytocin or breastfeed the newborn; assess bp; notify the primary care provider

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 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

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 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."

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever more than 100.4° F (38° C)

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant

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 postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercises

During a routine assessment the nurse notes the client is tachycardic. Which possible cause should be ruled out?

delayed hemorrhage

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?

during the first 24 hours after birth owing to dehydration from exertion

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

"You should be seen by your healthcare provider if you have blurred vision."

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; acquaintance with an increasing attachment to the infant; moving toward a new normal routine; achievement of the parental role

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?

Percussion reveals dullness

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."

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

dehydration

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm?

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply

Preeclamsia; previous oral contraceptive use; and severe varicose veins

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:

maintain previous household routines to prevent infection

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis

A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?

pulmonary embolism

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.

Fundus boggy to the right of the umbilicus; rounded mass over symphysis pubis; and dullness on percussion over symphysis pubis