NUAS240T - Chapter 16 - Nursing Management During Labor and Birth

Hypertension

Elevations in blood pressure from woman's baseline may suggest pregnancy-induced

Fundus

Top portion of the uterus; routinely assessed to determine uterine involution

colostrum

also called fore-milk.

Peribottle

A plastic squeeze bottle filled with warm tap water that is sprayed over the perineal area after each voiding and before applying a new perineal pad.

pain

Fifth vital sign

b. Active bowel sounds d. Passing gas e. Nondistended abdomen

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? (Select all that apply.) a. Abdominal pain b. Active bowel sounds c. Tender abdomen d. Passing gas e. Nondistended abdomen

d. postpartum depression.

At the 6-week visit following delivery of her infant, a postpartum client reports extreme​ fatigue, feelings of​ sadness and anxiety, and insomnia. Based on these assessment​ findings, the nurse documents that the client is exhibiting characteristics of: a. postpartum psychosis. b. postpartum adjustment. c. postpartum blues. d. postpartum depression.

d. Boggy or relaxed uterus

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? a. Fundus feels firm b. Foul-smelling urine c. Purulent vaginal drainage d. Boggy or relaxed uterus

c. Schedule home visits for high-risk families.

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. Ask family members to monitor the parents' progress. b. Provide phone numbers for call centers for questions. c. Schedule home visits for high-risk families. d. Encourage frequent clinic visits for high-risk families.

c. 500 additional calories per day

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. 250 additional calories per day b. 750 additional calories per day c. 500 additional calories per day d. 1,000 additional calories per day

proximity

Physical and psychological experience of the parents being close to their infant

b. indirect Coombs' test

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? a. ANA b. indirect Coombs' test c. titer screen d. CBC with differential

commitment

Refers to the enduring nature of the attachment relationship.

c. assess and massage the fundus.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. 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. increase the flow of an IV. b. inspect the perineum for lacerations. c. assess and massage the fundus. d. call the primary care provider or the nurse-midwife.

A. Home visits are usually made within the first week of discharge to assess the mother and newborn. This visit is made primarily to provide the nurse with the opportunity to recognize common biomedical and psychosocial problems or complications.

The major purpose of the first postpartum home care visit is to: a. Identify complications that require interventions b. Obtain a blood specimen for PKU testing c. Complete the official birth certificate d. Support the new parents in their parenting roles

b. Document the lochia as scant

The nurse observes a 2in (5cm) lochia stain on the perineal pad of a 1 day postpartum client. Which of the following should the nurse do next? a. Reassess the client in 1 hour b. Document the lochia as scant c. Ask when the peripad was changed d. Massage the client's fundus

b. hematoma

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. DVT b. hematoma c. infection d. nothing—it is normal

Reciprocity

This is the process by which the infant's capabilities and behavioral characteristics elicit parental response.

mastitis

Untreated nodules, masses, or areas of warmth on the breast

C. Periodic crying and insomnia are characteristics of postpartum blues, in addition to mood changes, irritability, and increased sensitivity.

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations

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

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? (Select all that apply.) a. Give newborns water and other foods to balance nutritional needs. b. Help the mother initiate breastfeeding within 30 minutes of birth. c. Encourage breastfeeding of the newborn infant on demand. d. Provide breastfeeding newborns with pacifiers. e. Place baby in uninterrupted skin-to-skin contact with the mother.

Cesearean

Women who experience this type of birth will have less lochia discharge than those having vaginal birth.

contact

sensory experiences such as touching, holding, and gazing at the newborn

postpartum blues

transient emotional disturbances

d. infection

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. depression b. hemorrhage c. pulmonary emboli d. infection

a. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.

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.

b. Increased intake will re-hydrate the client and decrease her skin temperature.

A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client? a. The client will have to call for the nurse's help more often. b. Increased intake will re-hydrate the client and decrease her skin temperature. c. Increased intake will increase the client's output and therefore will provide an opportunity for more frequent perineal self-care. d. The client needs to walk to the bathroom more often.

C. Lactating mothers need an extra 500 calories to sustain breast-feeding. An additional 20 g of protein is also needed to help build and regenerate body cells for the lactating woman.

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals

d. places a gloved hand just above the symphysis pubis

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? a. places index and middle fingers across the muscle b. massages the fundus carefully to expel any blood clots c. palpates the abdomen while feeling the uterine fundus d. places a gloved hand just above the symphysis pubis

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

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? a. after any period of decreased intake b. when the white blood cell count is less than 10,000/mm³ c. when the elevated temperature exceeds 100.4° F (38° C) d. during the first 24 hours after birth owing to dehydration from exertion

a. dehydration

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a. dehydration b. infection c. change in the temperature from the birth room d. fluid volume overload

c. fever more than 100.4° F (38° C)

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? a. presence of lochia rubra b. fundus is above the umbilicus c. fever more than 100.4° F (38° C) d. fundus is firm

d. fever more than 100.4° F (38° C)

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? a. presence of lochia rubra b. fundus is above the umbilicus c. fundus is firm d. fever more than 100.4° F (38° C)

c. "Walking is the best way to prevent complications such as blood clots."

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. "Maybe you will feel better after you take pain medication." b. "If you do not get up to walk you will not recover." c. "Walking is the best way to prevent complications such as blood clots." d. "As long as you walk more tomorrow to make up for the delay in walking today you should be fine."

a. head-to-toe assessment c. pain level e. vital signs of mother

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.) a. head-to-toe assessment b. newborn's vital signs c. pain level d. head-to-toe assessment of newborn e. vital signs of mother

b.maintain previous household routines to prevent infection.

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. list signs of infection that she will report to her health care provider. b.maintain previous household routines to prevent infection. c. the client will show no signs of infection. d. discuss methods that the woman will use to prevent infection.

d. Massage the client's fundus

Upon assessment, a nurse notes the client has a pulse of 90 beats per minute, moderate lochia, and a boggy uterus. What should the nurse do next? a. Notify the health care provider b. Assess the client's blood pressure c. Change the client's peripad d. Massage the client's fundus

A. Desiring to be in close proximity to another human being is all part of the bonding process.

Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant

Bonding

development of a close emotional attachment to a newborn by the parents during the first 30-60 minutes after birth

Process of attachment

development of strong affectional ties between an infant and a significant other (e.g., mother, father, sibling, caretaker)

orthostatic hypotension

This can occur when woman changes position rapidly from lying or sitting position to standing.

c. 100.8°F (38.2°C)

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. 100.1°F (37.8°C) b. 97.5°F (36.9°C) c. 100.8°F (38.2°C) d. 99.2°F (37.3°C)

d. 25 to 50 mL

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. 10 to 25 mL b. Under 10 mL c. Over 50 mL d. 25 to 50 mL

d. pulmonary embolism.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm 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. upper respiratory infection. b. thrombophlebitis. c. mitral valve collapse. d. pulmonary embolism.

b. Determine the newborn's blood type and rhesus.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? a. Determine if this is the client's first baby. b. Determine the newborn's blood type and rhesus. c. Ask if the client received rH immunoglobulins during the pregnancy. d. Administer Rh immunoglobulins intramuscularly.

c. one finger breadth below the umbilicus

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 finger breadth above the umbilicus b. below the symphysis pubis c. one finger breadth below the umbilicus d. at the level of the umbilicus

a. Low socioeconomic status c. Lack of social support d. Low self-esteem e. Feeling overwhelmed and out of control

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.) a. Low socioeconomic status b. Involving family in infant care c. Lack of social support d. Low self-esteem e. Feeling overwhelmed and out of control

b. odor.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: a. pH. b. odor. c. consistency. d. specific gravity.

d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

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: a. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." b. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." c. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

D. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention.

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on breast

c. The color of the flow is red.

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. The color of the flow is red. d. Her uterus is soft to your touch.

b. policies that discourage unwrapping and exploring the infant

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? a. policies that allow rooming the infant and mother together b. policies that discourage unwrapping and exploring the infant c. policies that allow visitors d. policies that allow flexibility for cultural differences

d. Fourth degree

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

a. Breasts are hard. b. Breasts are tender.

A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? (Select all that apply.) a. Breasts are hard. b. Breasts are tender. c. Nipples are fissured. d. Nipples are cracked. e. Breasts are soft.

d. Educate the client on how to perform Kegel exercises

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? a. Determine if the client is emptying her bladder b. Ask the client when she last urinated c. Perform an in and out catheter on the client d. Educate the client on how to perform Kegel exercises

a. Instruct the client to empty her bladder before the examination.

A nurse is assessing a postpartum client. Which measure is appropriate? a. Instruct the client to empty her bladder before the examination. b. Wear sterile gloves when assessing the pad and perineum. c. Perform the examination as quickly as possible. d. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus.

a. oral temperature 100.8° F (38.2° C)

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? a. oral temperature 100.8° F (38.2° C) b. respiratory rate 16 breaths/minute c. pulse rate 75 beats per minute d. uterine fundus 1 cm below umbilicus

c. "You should be seen by your health care provider if you have blurred vision."

A client has been discharged from the hospital after a cesarean birth. Which should the nurse include in the discharge teaching? a. "Follow-up with your health care provider within 3 weeks of being discharged." b. "Notify the health care provider if your temperature is greater than 99F (37.2C)." c. "You should be seen by your health care provider if you have blurred vision." d. "Call your health care provider if you saturate a peripad in less than 4 hours."

B. since wearing a supportive bra will decrease the discomfort and provide support for the heavy breasts.

The nurse is instructing the postpartum client who plans to bottle-feed her newborn about measures to prevent breast engorgement when she is discharged. Which of the following measures should the nurse include in the teaching plan? a. Decreasing her fluid intake for the first week at home b. Wearing a tight-fitting supportive bra 24 hours daily c. Take a diuretic to release the extra fluid in the breasts d. Manually express the milk that is accumulating

D. Nurses need first to become educated about various cultural practices to incorporate them into their care delivery. By gaining an understanding of diverse cultures different from their own, nurses can become sensitive to these different practices and not violate them.

Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? a. Taking a trans-cultural course b. Caring for only families of his or her cultural origin c. Teaching Western beliefs to culturally diverse families d. Educating himself or herself about diverse cultural practices

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

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? a. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." b. "I'll contact your primary care provider." c. "If you don't attempt to void, I'll need to catheterize you." d. "I'll check on you in a few hours."

c. Resume intercourse if bright red bleeding stops.

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. Use oral contraceptives for contraception. b. Avoid use of water-based gel lubricants. c. Resume intercourse if bright red bleeding stops. d. Avoid performing pelvic floor exercises.

a. atony

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a. atony b. normal involution c. infection d. hemorrhage

b. Every 15 minutes

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after birth? a. Every 30 minutes b. Every 15 minutes c. After 60 minutes d. After 45 minutes

D. because both parents will need education about the newborn, how to care for it, and how to care for themselves. Education is essential to help both parents in their transition and adaptation to parenthood.

A new mother was brought to the postpartum unit who gave birth 12 hours ago. Because this is her first child, which of the following goals by the nurse is most appropriate? a. Early discharge for the mother and newborn b. Rapid transition into her role of being a parent/caretaker c. Minimal need for expression of her feelings now d. Effective education of both parents before discharge

c. Ensure ice pack is changed frequently

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

c. postpartum depression.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of her baby and her husband. She is tired but cannot sleep and has isolated herself from her family and friends. The nurse recognizes that this client is exhibiting signs of: a. postpartum blues. b. maladjustment to parenting. c. postpartum depression. d. lack of partner support.

C. An older sibling needs to feel he or she is still loved and not upstaged by the newest family member. Allowing special time for that sibling reinforces the parent's love for him or her also.

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. Punishing the older child for bed-wetting behavior b. Sending the sibling to the grandparents' house c. Planning a daily "special time" for the older sibling d. Allowing the sibling to share a room with the infant

B. Because weight loss is based on the principle of intake of calories and output of energy, instructing this woman to avoid high-calorie foods that yield no nutritive value and expending more energy through active exercise would result in weight loss for her. Acid-producing foods (plums, cranberries, and prunes) are typically recommended for women to prevent urinary tract infections to acidify the urine, not for weight-loss purposes.

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods, breast-feed, increase exercise. c. Start a high-protein, low carbohydrate diet and restrict fluids. d. Eat no snacks or carbohydrates after dinner.

d. Walk with the nurse the length of her room.

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. Walk the length of the hallway to regain her strength. b. Avoid elevating her feet when she rests in a chair. c. Avoid getting out of bed for another 2 days. d. Walk with the nurse the length of her room.

a. "I might feel like laughing one minute and crying the next."

After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement? a. "I might feel like laughing one minute and crying the next." b. "If the symptoms last more than a few days, I need to call my doctor." 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."