Passpoint maternity

A nurse is caring for a client who gave birth yesterday and had a right mediolateral episiotomy performed. The client asks the nurse, "What can I do to get pain relief from my episiotomy?" Which response by the nurse would be most appropriate?

"Apply a cold pack to your perineum."

A new mother who's breast-feeding asks how she can quickly lose the 40 lb she gained during pregnancy. Which response by the nurse is best?

"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."

The night nurse reports that a postpartum client is homeless, has poor hygiene, and has tested positive for the human immunodeficiency virus (HIV). The nurse assigned to care for the client requests that the assignment be changed because she's pregnant and doesn't want to risk exposure. Which response by the charge nurse indicates an understanding of the ethical responsibilities of a professional nurse?

"It's inappropriate to refuse this assignment; all clients should be treated equally."

The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment."

When reviewing self-care instructions with a postpartum client, the nurse emphasizes the need for the client to report heavy or excessive bleeding. The nurse would describe "heavy bleeding saturating one sanitary pad" within which time span?

1 hour

The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as:

100 ml

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority?

Ask the client when she last changed her perineal pad.

The nurse is caring for a client who just delivered triplets. Which intervention by the nurse is most important?

Assessing fundal tone and lochia flow

Lochia rubra

Bright red, clots, 1-3 days after delivery

One day after a client gives birth, the nurse performs a postpartum assessment. The nurse finds a moderate amount of lochia rubra on the client's perineal pad. Which action should the nurse?

Document this as a normal finding

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby?

Encourage the client to see, touch, and hold the dead neonate.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse?

Encourage the family to identify their frustrations and fears.

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution?

Encourage the mother to breast feed.

The nurse is performing a postpartum check on a client. Which nursing action is appropriate?

Instruct the client to empty her bladder before the examination.

The nurse explains to new parents the importance of maintaining their infant's safety during hospitalization. Which action best ensures the infant's safety?

Instructing the mother to notify staff when she showers to avoid leaving the infant unattended

During an annual checkup, a client tells the nurse that she and her husband have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after delivery.

Which of the following options best describes the anticipated actions in the taking-hold phase of the maternal attachment process?

Kissing, embracing, and caring for the infant

When monitoring a postpartum client 2 hours after birth of her newborn, the nurse notices heavy bleeding with large clots. Which action would the nurse perform first?

Massage the fundus firmly.

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding?

Massage the fundus.

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate?

Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

Lochia serosa

Pinkish/brown, serosanguineous. Lasts day 4-10 postpartum

Lochia normally progresses in which of the following patterns?

Rubra, serosa, alba

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts?

Share the feedback with the nursing colleague directly.

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple?

Stroke the neonate's lips gently with the nipple.

A nurse is caring for a client who delivered a healthy full-term baby 2 hours ago by cesarean section. When assessing this client, which finding requires immediate nursing action?

Tachycardia and hypotension

Which of the following correctly defines puerperium?

The 6 weeks following birth

A client had an emergency cesarean birth. Afterward, the client expresses disappointment about not being able to give birth vaginally. The nurse understands that this feeling may be based on which concept?

The client may feel a loss for not having experienced a vaginal birth.

The nurse is checking for rooting reflex in a newborn. Which response should the nurse expect to see?

The neonate will turn the head to the side of the stroked cheek.

A client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?

Use the football hold to avoid incisional discomfort.

Breast engorgement occurs on the second or third postpartum day. Which of the following processes causes engorgement?

Vasodilation, which causes the breast to feel full

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor?

allowing volunteers to return neonates to the nursery

A postpartum client requires teaching about breast-feeding. To prevent breast engorgement, the nurse should instruct her to:

breast-feed every 1½ to 3 hours.

A postpartum client experiences postpartum hemorrhage. Fundal massage has failed to maintain uterine contraction, and the client continues to experience hemorrhage. The nurse would anticipate which medications to be prescribed? Select all that apply.

carboprost methylergonovine

A postpartum client has given birth to a healthy newborn by cesarean. Which information would the nurse most likely reinforce?

coughing and deep-breathing exercises

The nurse is caring for a postpartum client after giving birth to a healthy neonate. When checking the client's fundus, which finding would the nurse most likely note?

fundus 1 cm above the umbilicus 1 hour postpartum

The nurse receives a report on a client who gave birth to a healthy neonate 1 hour ago. What is the priority for the nurse to monitor during the immediate postpartum period?

fundus level related to umbilicus

The nurse is caring for a postpartum client with diabetes who has developed an infection. The nurse would monitor this client for which complication?

ketoacidosis

Two days after a cesarean birth, a client is diagnosed with deep vein thrombosis. Which complication is this client at greatest risk for?

pulmonary embolism

A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day?

red with moderate flow

A postpartum client is scheduled for discharge tomorrow. The nurse is reinforcing discharge instructions with the client. The nurse determines that the client understands the information when stating that she will report which finding to her health care provider?

redness, warmth, and pain in a breast

A nurse is providing care to a postpartum client. As part of the client's plan of care, the nurse reinforces the need to perform Kegel exercises based on which reason?

to promote blood flow, enabling healing and muscle strengthening

A multiparous client has given birth vaginally to a healthy neonate. It is now her first postpartum day. Which factor would the nurse identify as putting this client at risk for developing hemorrhage?

uterine atony

The nurse is reviewing the medical record of a client who is 6 weeks postpartum and came for a follow up appointment with her health care provider. The client's uterus is enlarged and soft, and she is experiencing vaginal bleeding. Based on the findings, which condition would the nurse most likely suspect?

uterine subinvolution

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. Based on this finding, the nurse would anticipate which test as the priority?

venous duplex ultrasound of the right leg