Passpoint - Postpartum Period

One week after giving birth, a client comes to the clinic for a check up. The client tearfully tells the nurse, "I should feel happy, but I don't. What's wrong with me?" Which response by the nurse would be best?

"It's not unusual to have these feelings after giving birth."

A client is 2 days postpartum and is experiencing bleeding. She asks the nurse, "Will it always be like this?" Which statement by the nurse would be the most accurate?

"This is lochia rubra and will last 3 to 4 days."

What is the most likely reason for a temperature of 99.8° F (37.7° C) during the first 24 hours postpartum?

Dehydration

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 client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate?

Performing fundal massage

While preparing a client for a postpartum tubal ligation, a nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse would be best?

Review the client's understanding of the procedure in private.

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom?

Sudden onset of shortness of breath

A postpartum client has continuous seepage of blood from the vagina. Her fundus is firm and 1 cm below the umbilicus. A nurse would monitor this client closely for which condition?

cervical laceration

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 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

A postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. After assisting with the discharge teaching plan, the nurse determines that the client has understood the information when what statement is made?

"I should not take any over-the-counter (OTC) salicylates."

A postpartum client has been ordered 500 mg of ampicillin oral suspension. The label reads ampicillin 125 mg/5 mL. How many milliliters should the client receive? Record your answer using a whole number.

20

A nurse caring for a client during the first 24 hours following delivery notes normal lochia. Which of the following should the nurse include in the care of this client?

Encourage the client to increase fluid intake.

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client?

Height of fundus

A postpartal client reports that her afterpains have increased in severity. When reviewing the client's history, which condition would the nurse most likely find to support the client's statement?

Multiple gestation

A licensed practical nurse (LPN) who typically works in the nursery is being cross-trained to work with postpartum clients. The charge nurse is busy with a delivery and assigns her to complete hourly rounds on the unit. As she enters a client's room, the LPN notices that a client looks pale and shaky. Which action should she take?

Obtain a set of vital signs, check the client's fundus and flow, and compare the findings to baseline data.

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."

After a vaginal delivery, a postpartum client reports perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction?

"Contract your buttocks before sitting or rising."

A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse?

"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience."

The nurse is teaching a client about oral contraceptive therapy. The client reports missing three doses of the scheduled medication. Which statement made by the client indicates understanding of the teaching regarding oral contraceptives?

"I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."

The nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?

"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."

On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which response by the nurse would be appropriate?

"It isn't unusual to have those feelings after delivery."

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

"It's common for you to have a full bladder even though you can't sense it."

The nurse is teaching a client how to use a diaphragm. Which instruction should the nurse provide?

"Leave the diaphragm in place for at least 6 hours after intercourse."

A 15-year-old primigravida client gave birth 2 days ago. She tells the nurse that having her own little baby will be wonderful. The nurse gathers additional information from the client to determine the accuracy of the client's expectations. Which statement would be most appropriate?

"Tell me what your day will be like after you take your baby home."

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."

A nurse is reinforcing discharge education with a postpartum client who isn't immune to rubella. Which statement by the client indicates the need for further education?

"The immunization will be given at my 6-week postpartum examination."

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 client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:

3 days of elevated basal body temperature and clear, thin cervical mucus.

The nurse is observing a new mother interact with her baby for the first time approximately 1 hour after the baby's birth. Upon receiving the baby, the mother begins to undress her baby. Which of the following should the nurse do?

Anticipate and support the behavior as a normal part of bonding.

The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do?

Apply an ice pack to her perineum.

A nurse checks the fundus of a postpartum client and notes that the fundus is situated in the client's left abdomen. What is the priority action by the nurse?

Ask the client to empty her bladder.

The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. Order the sequence of events for performing this procedure. Use all of the options.

Ask the client to void. Place the client in supine position. Place one hand on the abdomen just above the symphysis pubis. Place one hand around the top of the fundus. Rotate the upper hand to massage the uterus until firm. Gently press the fundus between the hands using slight downward pressure.

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.

After receiving the shift report, the nurse realizes that she should monitor her postpartum client closely for puerperal infection. Which factor alerted the nurse to the client's risk for this complication?

Cesarean birth

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.

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is appropriate?

Encouraging increased fluid intake

A nurse is preparing to evaluate a client who gave birth 6 hours ago. Which statement best explains the use of gloves during the postpartum evaluation?

Gloves are an essential part of standard precautions.

In the fourth stage of labor, a full bladder increases the risk of which postpartum complication?

Hemorrhage

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.

The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. Which nursing intervention takes priority?

Locating a staff member who can interpret the discharge instructions.

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which terms best identifies the discharge?

Lochia rubra.

When caring for a client who has had a cesarean section, which of the following actions is appropriate?

Monitoring pain status and providing necessary relief

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.

A nurse is helping to prepare a client for discharge following the vaginal birth of a healthy neonate. As part of the discharge plan, the nurse is reviewing how to perform Kegel exercises. The nurse determines that the client understand the reason for these exercises when she states they accomplish which goal?

Strengthen the perineal muscles.

Which of the following correctly defines puerperium?

The 6 weeks following birth

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention?

The baby's lips smack.

The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day?

The client asks many questions about the baby's care.

A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior?

The client is showing expected behaviors for the taking-in period.

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 "normal" 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 new mother is discharged 16 hours after a vaginal birth. After reviewing the client's discharge instructions, the nurse determines that the teaching was successful when the client states that she will contact her health care provider if she develops which symptom?

increased flow of bright red lochia

A postpartum client is experiencing breast engorgement. When providing care to the client, which action would the nurse anticipate as being most helpful?

informing the client on how to express her breasts while in a warm shower

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

A nurse observes a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown). Which term best identifies the discharge?

lochia rubra

A nurse is collecting data on a client who gave birth yesterday. Where would 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 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 clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?

Client will demonstrate ability to bottle-feed the neonate.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which of the following actions by the nurse is the most appropriate?

Massage the uterine fundus gently.

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

A nurse is caring for a client who gave birth yesterday and had a right mediolateral episotomy 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."

The nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

"Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative."

The nurse is caring for a postpartum client with symptoms of swelling and tenderness in the left leg. The nurse suspects a developing DVT. When assessing for a DVT, identify the area on the body below, where the nurse would obtain data.

*** Note that an X is placed on the calf. To assess for the presence of a DVT, the nurse performs a Homans' sign. To elicit Homans' sign, the client dorsiflexes her ankle, and then the nurse assesses for pain in the calf during that motion. If a positive Homans' sign is noted, the health care provider may order an ultrasound or venography for a definitive diagnosis.

A nurse is about to give a client with type 1 diabetes insulin before breakfast on her first day postpartum. Which statement by the client indicates an understanding of insulin requirements immediately postpartum?

"I will need less insulin now than before I was pregnant."

After delivering her second baby, the client tells the nurse that she wants to breast-feed this baby. She indicates that she was unsuccessful at breast-feeding her first child and that she began bottle-feeding after 3 days of trying to nurse. Which of the following responses would best support this client's breast-feeding efforts?

"It's important to room-in with your newborn so that you can respond to her nursing cues."

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."

A client who is 9 days postpartum and breastfeeding her baby reports pain, redness, swelling of her left breast and is diagnosed with mastitis. The nurse is reviewing information with the client about how to care for her infected breast. Which information should the nurse most likely reinforce?

"Use a warm, moist compress over the painful area."

Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)?

A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void

A nurse is caring for a client with a warm, reddened, painful area in the breast as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding. Which instructions should the nurse include to prevent a recurrence of this condition? Select all that apply.

Change the breast pads frequently. Expose the nipples to air for part of each day. Wash hands before handling the breast and breast-feeding. Release the baby's grasp on the nipple before removing the baby from the breast.

One day after having a cesarean birth, a client reports incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?

Administer the drug with meals or milk.

A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her?

Advising her to massage the affected area gently while breast-feeding

A client delivers a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's husband seems withdrawn and barely speaks to the staff when visiting his child in the NICU. Which of the following nursing action should the nurse take?

Ask the father if he would want to talk about his feelings regarding the newborn and being in the intensive care.

A client and her neonate have a blood incompatibility. The neonate has had a positive direct Coombs' test. Which nursing intervention is appropriate?

Because the client has been sensitized, don't give Rho(D) immune globulin

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary health care provider?

Blurred vision and headache

A postpartum client who has developed mastitis is being discharged. What recommendation would be most appropriate when the client voices concern about breast-feeding her neonate with this condition?

Continue to breast-feed; mastitis won't infect the neonate.

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

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take?

Encourage the client to breast feed the baby more frequently and regularly.

A client who gave birth by cesarean 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, small amount of lochia rubra, and the client reports discomfort in her breasts, which are hard and warm to touch. Which action would be most appropriate?

Encourage the client to wear a supportive bra.

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

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

The nurse is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?

Risk for deficient fluid volume related to hemorrhage

Lochia normally progresses in which of the following patterns?

Rubra, serosa, alba

A nurse is caring for a postpartum client suspected of developing postpartum psychosis. Which statements accurately characterize this disorder? Select all that apply.

Symptoms include delusions and hallucinations. The disorder rarely occurs without a psychiatric history.

The nurse is providing care to a postpartum client with mastitis. As part of the client's teaching plan, the nurse is reinforcing information about the condition. Which information should the nurse emphasize?

Symptoms include fever, chills, malaise, and localized breast tenderness.

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

A postpartum client recovering from spinal anesthesia with morphine reports that her nose itches. Which would the nurse suspect as the cause?

The client is experiencing a common effect due to a morphine-based anesthetic.

The nurse is caring for a postpartum client had an uncomplicated vaginal birth of an 8-lb, 2-oz (3.7-kg) neonate 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. The nurse implements the plan of care, focusing on achievement of which outcome within the next 8 hours?

The client will demonstrate the ability to bottle-feed the neonate appropriately.

The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. Which client outcome takes priority for this client?

The client will verbalize the importance of reporting changes in lochia flow.

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.

The nurse is teaching a client how to perform perineal care to reduce the risk of puerperal infection. Which activity indicates that the client understands proper perineal care?

Using a peri bottle to clean the perineum after each voiding or bowel movement

The nurse is preparing to change the perineal pad on a postpartum client. Which actions taken by nurse prevents postpartum infection? Select all that apply.

Wash hands before touching the client. Use gloves while changing pad.

The nurse is collecting data on a neonate. Which findings should the nurse report to the health care provider? Select all that apply.

a positive Ortolani sign negative Babinski reflex head circumference of 42 cm and chest circumference of 35 cm

The nurse visits a client at home on the tenth postpartum day. When assessing the client's uterus, the nurse expects to find:

a nonpalpable fundus in the abdomen.

Following a precipitous birth, examination of the client's vagina reveals a fourth-degree laceration. Which of the following nursing interventions should the nurse implement to promote healing? Select all that apply.

applying cold to limit edema during the first 12 to 24 hours instructing the client on the use of sitz baths instructing the client about the importance of perineal (Kegel) exercises increasing fiber in the diet to prevent constipation

A nurse obtains the vital signs of a client who is 2 days postpartum and finds her temperature is 100.8°F (38.2oC). Additional data indicates that infection is not present. The nurse interprets the findings suspecting that the fever may be the result of which condition?

breast engorgement

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 primigravida client experiences a normal vaginal birth. The next day, the nurse monitors the client's lochia for color, amount, and the presence of clots. Which finding best describes lochia on the first postpartum day?

dark red, moderate amount, with a few small clots

A client experienced a perinatal loss 3 days ago. The nurse is concerned that the client may be experiencing dysfunctional grieving based on which finding?

denial of the death

A client asks the nurse about the rhythm (calendar-basal body temperature) method of family planning. The nurse explains that this method involves:

determination of the fertile period to identify safe times for sexual intercourse.

A 28-year-old client gave birth 1 hour ago to a full-term neonate. While collecting data on the client, the nurse checks the client's fundus. Which finding would the nurse interpret as within acceptable parameters for this client?

firm, at the level of the umbilicus

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

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition?

orthostatic hypotension

A postpartum client experiences postpartal 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.

oxytocin carboprost methylergonovine

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?

postpartum hemorrhage

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 reviewing a postpartum client's medical record and plan of care before discharge. Which factor if noted in the client's history would the nurse identify as most likely to interfere with this client's parental attachment?

recent loss of a parent

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 client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication?

severe pre-eclampsia

A client says she wants to practice natural family planning. The nurse teaches her how to use the calendar method to determine when she's fertile and advises her to avoid unprotected intercourse. When teaching her how to determine her fertile period, the nurse should instruct her to:

subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle.

A mother with a history of varicose veins has just given birth to her first baby. The nurse suspects that the mother has developed a pulmonary embolus. Which data below would lead to this nursing judgment? Select all that apply.

sudden dyspnea diaphoresis cough confusion Chest pain.

A nurse is assisting a postpartum woman with breast-feeding her newborn. Which action would the nurse recommend to help the new mother breast-feed? Select all that apply.

suggesting the mother cuddle and caress the infant while feeding him encouraging her to breast-feed when the infant is alert and hungry showing her the different positions for holding the infant for feeding

A nurse is assisting a postpartum client to breast-feed her newborn. The client is having difficulty in establishing an adequate supply of breast milk. The nurse understands that which factor might play a role?

supplemental formula feedings

A nurse is caring for a 1-day postpartum client. The progress note above informs the nurse that the client is in which phase of the postpartum period?

taking in

The nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply:

talks and coos to her son cuddles her son close to her

A nurse is reviewing instructions for perineal care with a client. Which action by the client indicates that she understands proper perineal care?

uses a peri-bottle to cleanse the perineum after each voiding or bowel movement

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

A postpartum client decides to bottle-feed her neonate. To prevent breast engorgement, the nurse should recommend that she:

wear a supportive, well-fitting brassiere.

A client has just given birth to her first child. The client is Rho(D)-negative and her baby is Rh-positive. At which time would the nurse most likely expect Rho(D) immune globulin IM to be given to the mother to reduce the risk of Rh incompatibility?

within 72 hours