Postpartum 5.1
Develop a discharge teaching plan for postpartum patient: After instruction about episiotomy care, which primiparous client statement indicates successful teaching? "Before bedtime, I'll use a cold water sitz bath." "I'll use hot, sudsy water to clean the episiotomy area." "I'll wipe the area from front to back using a blotting motion." "I can use ice packs for 3 to 4 days after delivery."
"I'll wipe the area from front to back using a blotting motion" Rationale The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. Twenty-four hours after delivery warm sitz baths taken 3 to 4 times per day for 20 minutes can help increase circulation to the area. Ice packs are only helpful for the first 24 hours after delivery.
Explain the purpose and components of the postpartum home visit: A student nurse is shadowing a home health care nurse who is making postpartum visits. The student asks the nurse what is the average length of stay in the hospital for a cesarean-section client. What is the correct response? 3-4 days 5-6 days 8-10 days 2 days
3-4 days Rationale The Length of stay in the hospital for an uncomplicated cesarean-section delivery is usually 3dash-4 days. Vaginal deliveries without complications have a 2-day length of stay.
Contrast newborn attachment and bonding behaviors and their effect on familial adaptation: A new father shares his concern regarding how the baby will bond with him. He states, "I read in the baby book that feeding time is the best time to bond with your baby. My wife is breastfeeding our baby, so how can I bond with our son?" What other ways of connecting and strengthening the father's relationship with his son can the nurse teach the father? Select all that apply. Watching over him as he sleeps in the crib Bathing the baby Holding and talking to his son Changing the baby's diaper Talking to his wife while she is breastfeeding the baby
Bathing the baby Holding and talking to his son Changing the baby's diaper Rationale Fathers have feelings of attachment to their newborn just like the mothers do. If the mother is breastfeeding the baby, fathers need to be shown other ways they can bond with the baby. By bathing the baby, changing the diaper, and holding and talking to the baby the father can strengthen his relationship with the baby. Watching over the baby in the crib and talking to his wife while she is feeding the baby help with the father feeling secure and strengthening the relationship between the mother and father.
Recognize the assessment, care, and teaching required for the postpartum woman during a home visit: The home care nurse is assessing a new mother who delivered 5 days ago. The mother has a temperature of 100.9°F. What condition in a postpartum mother may cause a fever not caused by infection? Mastitis Breast engorgement Endometritis Uterine involution
Breast engorgement Rationale Breast engorgement and dehydration are noninfectious causes of postpartum fevers. Endometritis and mastitis are both postpartum infections. Involution of the uterus will not cause elevations in temperature.
Apply strategies to promote maternal well-being after birth including nutrition, rest, and activity: The nurse reviews a postpartum client's chart and notes the client may have Percocet for pain. The nurse will monitor for which complication of the medicine? Dry mouth Frequent urination Decreased respirations Constipation
Constipation Rationale Nurses should be aware of the complications of narcotic analgesic medications. The nurse should monitor clients taking this type of medication for constipation. This medication does not lead to the side effect of decreased respirations. Narcotic analgesics do not cause frequent urination as a side effect. Dry mouth is not an anticipated side effect of taking narcotic analgesics.
The student nurse is shadowing a home health care nurse for the day. The nurse talks to the student about ways to establish a therapeutic relationship with the families she visits. What should the nurse include in her discussion with the student? Select all that apply. Convey regard and respect for the family by asking to be introduced to other family members who may be present at the time of the visit. Honestly answer their questions; if the answer is not known, give them your opinion. Since you are the professional they will not question the response. Review the mother's and infant's history including any problems during pregnancy, type of birth, problems during birth or postpartum, and infant feeding choices. Show up unannounced so that you can get a more realistic evaluation of the family relationships. Verbal and nonverbal communication should be congruent.
Convey regard and respect for the family by asking to be introduced to other family members who may be present at the time of the visit. Review the mother's and infant's history including any problems during pregnancy, type of birth, problems during birth or postpartum, and infant feeding choices. Verbal and nonverbal communication should be congruent.
Examine the normal physiologic changes expected in the postpartum client: Four hours after a vaginal deliver, the nurse is assisting primiparous client, who had an epidural anesthesia, to the bathroom to void. The client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following? Effects of analgesics used during labor Decreased blood volume in the vascular system Effects of the anesthetic during labor Hemorrhage during the delivery process
Decreased blood volume in the vascular system Rationale The client's dizziness is most likely due to orthostatic hypotension secondary to decreased blood volume in the cardiovascular system resulting from the physiologic changes occurring in the mother after delivery. The effects of the epidural wear off 1dash-2 hours postpartum, and the effects of analgesia used during labor should be worn off.
Examine the components of a postpartum assessment: The nurse is performing a thorough fundal check during a postpartum assessment on a newly delivered mother. What components are included in a fundal assessment? Fundal location and height Fundal consistency and height Fundal consistency, location, and height Fundal location and potential fundal distention
Fundal consistency, location, and height Rationale A thorough fundal check includes assessment of fundal consistency, height, and location. Normal results are a firm fundus that is at the correct height for the postpartum day and located in the center of the pelvis. Options 2, 3, and 4 are not thorough fundal assessments.
Compare various etiologies and management of woman with postpartum hemorrhage: A mother who gave birth to a baby boy vaginally after Pitocin augmentation 2 weeks ago returns to the office concerned because her flow has increased and is red but not foul smelling. The nurse suspects subinvolution. Which of the following can the nurse identify as a risk factor for this complication? Select all that apply. History of leiomyomas Vaginal delivery Abnormally adherent placenta Manual removal of the placenta Placenta previa
History of leiomyomas Abnormally adherent placenta Manual removal of the placenta Rationale Risk factors for subinvolution include manual removal of the placenta, leiomyomas, and abnormally adherent placenta.
Recognize the assessment, care, and parental teaching required for the newborn during a home visit: While making a home visit to a primiparous client and her 4-day-old daughter, the nurse observes the mother changing the infant's diaper. Before putting the new diaper on, the mother begins to apply baby powder to the infant's buttocks. Which statement about baby powder would the nurse make to the mother? It can result in allergies later in life. It helps prevent diaper rash. It keeps the diaper from adhering to the infant's skin. It may cause pneumonia to develop.
It may cause pneumonia to develop Rationale Baby powder can enter the infant's lungs and result in pneumonia secondary to aspiration of the particles. The best prevention for diaper rash is frequent diaper changes and keeping the infant's skin dry. The disposable diapers on the market today have moisture-collecting materials and generally do not adhere to the infant's skin. Allergies are not typically associated with the use of baby powder.
Examine the normal physiologic changes expected in the postpartum client. The nurse is assessing the lochia on the client's perineal pad. Which finding should the nurse report to the health care provider? mucous tissue debris blood large clots
Large clots Rationale Normal lochia rubra contains mucous, tissue debris, and blood. Small stringy clots are normal, but larger clots need to be reported to the health care provider.
Examine the normal physiologic changes expected in the postpartum client: A patient reports painful contractions, or afterpains, on her second postpartum day. The nurse knows that which condition could increase the severity of afterpains? Diabetes Mellitus Multiparity Primiparity Bottle feeding
Multiparity Rationale Multiparity, breastfeeding, and multiple gestation are conditions that cause overdistention of the uterus and can increase the intensity of afterpains.
Explore maternal postpartum psychological adaptation: On the first postpartum night a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which phase of psychological adaptation? Taking in phase Taking hold phase Letting go phase Depression phase
Taking in phase Rationale The taking in phase occurs during the first 24 hours after delivery. The mother is concerned with her own needs and requires support from the nursing staff and relatives. The taking hold phase is when the mother is ready to take responsibility for her care and the newborn's care. The letting go phase occurs several weeks after birth when the mother and her partner incorporate the infant into the family unit. The depressive phase is not a phase in psychological adaptation.
Examine the components of a postpartum assessment: What intervention should the nurse teach the breastfeeding mother who reports engorged breasts? Apply ice Administer bromocriptine (Parlodel) Teach how to express her breasts in a warm shower Apply a breast binder
Teach how to express her breasts in a warm shower Rationale Teaching the client how to express her breasts in a warm shower aids with letdown and will give the client temporary relief. Applying ice can promote comfort by decreasing blood flow, numbing, and discouraging further letdown of milk. Breast binders are not effective in relieving discomforts of engorgement. Bromocriptine (Parlodel) is no longer indicated for lactation suppression.
Explore maternal postpartum psychological adaptation: Which percentage of postpartum clients experiences "postpartum blues"? 70 to 80% 100% 40 to 45% 20 to 25%
70-80% Rationale Feelings of sadness and insecurities about a woman's ability to care for a newborn are not uncommon in the early weeks after birth. Postpartum blues, sometimes called the "baby blues," is a transient depressive condition that can affect 70-80% of mothers after birth. It is characterized by mood swings, weepiness, anorexia, insomnia, irritability, and feeling "let down."
Which safety device is most appropriate for the nurse making home visits? Pepper spray/mace Small pistol State map Cell phone
Cell phone Rationale A cell phone is the most appropriate safety device for the home care nurse to carry. The nurse is not permitted to carry a small pistol or pepper spray/mace. A local map would be a better choice than a state map.
A new mother asks the nurse about starting postpartum exercises. What exercise would be most appropriate to include in the nurse's instructions? Flex the knees while supine, then bring the chin to chest while exhaling and reach for the knees by lifting the head and shoulders while inhaling. Assume a prone position, and then do push-ups by using the arms to lift the upper body. Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles. Start in a sitting position, then lie back, and return to a sitting position, repeating this 5 times.
Flex the knees while supine, then inhale deeply and exhale while contracting the abdominal muscles. Rationale After an uncomplicated delivery, the client can begin postpartum exercises to strengthen the abdominal muscles. These are done in a supine position with the knees flexed, inhaling deeply while allowing the abdomen to expand, and then exhaling while contracting the abdominal muscles. Sit-ups and push-ups or exercises involving reaching for the knees are too strenuous right after delivery. They may be done later, around 3-6 weeks postpartum.
Contrast newborn attachment and bonding behaviors and their effect on familial adaptation. A mother of three children confides in the nurse that she is concerned about how her two children ages 1 and 3 will react to their new sister when she goes home. What would be the best suggestion the nurse can make for the mother to do when she goes home from the hospital? For the mother to carry the newborn into the home and settle the newborn into her crib before greeting the other children For the father to carry the newborn into the home and then give the baby to the mother to rock For the mother to carry the newborn into the home and sit in a rocker with the newborn Have the father carry the newborn into the home so that the mother's arms are free to hug the other children
Have the father carry the newborn into the home so that the mother's arms are free to hug the other children Rationale When a new baby comes home from the hospital the toddlers may feel that they are competing for their mother's attention. It is important for the mother to pay attention to the toddlers since they do not understand that they are still loved and depending on their age do not understand about the new baby.
Recognize the assessment, care, and teaching required for the postpartum woman during a home visit: A breastfeeding mother is visited by the home care nurse 2 weeks after delivery. The woman is febrile with flulike symptoms. Which statement regarding mastitis is correct? Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness. The most common pathogen is group A beta-hemolytic streptococci. A breast abscess is a common complication.
Symptoms include fever, chills, malaise and localized breast tenderness. Rationale Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common agent is Staphylococcus aureus. A breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.
Determine nursing interventions that promote health maintenance in the postpartum client: The nurse is caring for four postpartum clients. The nurse would question a provider's order for administering the rubella vaccine to which client? Cesarean section delivery, received 1 unit of blood Caucasian with negative rubella titer Breastfeeding mother of twins Vaginal delivery, HIV positive
Vaginal delivery, HIV positive Rationale The nurse administers rubella vaccine to clients who are nonimmune to rubella. This live vaccine is harmful to clients who have a compromised immune system. The nurse should question the provider's order to administer the rubella vaccine to a client who is HIV positive. The rubella vaccine does not pass through breast milk to the fetus. The nurse may administer this vaccination to a breastfeeding mother. Receiving blood products after a cesarean section delivery is not a contraindication to rubella vaccination. The nurse would administer the rubella vaccine to a client who has a negative rubella titer.
A mother who is bottle feeding her newborn asks to be discharged 24 hours postdelivery because she has no insurance and has a 3-year-old at home. The hospital provides a complementary visit from the home care nurse for the newborn. When should the nurse schedule this visit to occur? Within 3 weeks of discharge Within 7 days of discharge Within 2 weeks of discharge Within 36-48 hours of discharge
Within 36-48 hours of discharge Rationale Newborns discharged before 48 hours of age should be seen within 48 hours of discharge. Waiting any longer for the home care nurse to see the newborn could increase the possibility that common newborn conditions could go undiagnosed.
Relate assessment findings to the management of a woman diagnosed with a postpartum infection: A postpartum client who delivered 2 days ago has developed endometritis. Which charting entry would the nurse expect to find in this client's chart? "Client has history of pregnancy-induced hypertension." "Cesarean birth performed secondary to arrest of dilation." "Rupture of membranes occurred 2 hours prior to delivery." "Vaginal delivery with epidural anesthesia."
"Cesarean birth performed secondary to arrest of dilation." Rationale Risk factors associated with endometritis include a cesarean or operative vaginal birth, prolonged labor, prolonged rupture of membranes, chorioamnionitis, and postpartum hemorrhage.
Determine nursing interventions that promote maternal comfort during postpartum period: A client who had a cesarean section asks the nurse why she needs to ambulate. Which of the following is an appropriate response by the nurse? "The doctor wrote orders for you to walk 3 times a day." "It will help you feel better to get out of your room." "You can ask the doctor when he comes." "Walking will help prevent blood clots in your legs."
"Walking will help prevent blood clots in your legs." Rationale The nurse encourages ambulation in the postpartum client to prevent deep vein thrombosis. The nurse is avoiding answering the client's question by stating that the doctor ordered this. The client may benefit from walking. However, this answer is not the most appropriate and does not address the reason for ambulating. The nurse should answer the client's question. This is not an appropriate question to refer to the provider.
Apply strategies to promote maternal well-being after birth including nutrition, rest, and activity: The nurse is caring for a client who had a cesarean section delivery. Which assessment finding will indicate to the nurse that the client may be ready to tolerate clear liquids? Voiding Absence of pain Ambulation Active bowel sounds
Active bowel sounds Rationale The diet for postpartum clients recovering from a cesarean section delivery is progressive. Initially, the client remains NPO. The nurse assesses for the presence of bowel sounds as an indicator that the client is ready to advance to clear liquids. Pain is a subjective assessment finding. Some clients may report mild pain after a cesarean section, while others may have moderate-to-severe pain for a longer period of time. The ability to take clear liquids is not directly related to the level of pain in the client. The client in pain may consume clear liquids if desired. The client may consume clear liquids when bowel sounds are audible. Early ambulation is encouraged but is not an indicator for nutritional intake. The client may consume clear liquids prior to the first void, as long as bowels are active.
Examine the components of a postpartum assessment: The nurse is doing a postpartum assessment on a client who delivered 8 hours ago. On completing the fundal assessment, the nurse notes the fundus is situated in the left side of the abdomen. Which nursing action is most appropriate? Call the client's primary health care provider for direction. Straight catheterize the client immediately. Anchor a Foley catheter. Ask the client to empty her bladder.
Ask the client to empty her bladder Rationale A full bladder may displace the uterus to the right or left side of the abdomen. Straight catheterization is unnecessary if the woman can urinate on her own. The nurse should refrain from doing invasive procedures to decrease the possible introduction of bacteria into the bladder and uterus. Notifying the health care provider is not needed for direction. This is a nonemergency situation and nursing measures to help the woman urinate should be tried prior to notifying the health care provider. It is not uncommon for a woman to have difficulty voiding after delivery due to the edema caused by the delivery. Insertion of a Foley catheter is an invasive procedure. This procedure is unnecessary for a newly delivered woman.
Determine the nursing care specific to a woman who has undergone a cesarean birth: The nurse is preparing to administer RhoGam to a postpartum client. Which of the following nursing interventions are appropriate when giving this medication? Select all that apply. Reminding the mother to avoid caffeine for 12 hours Checking the lot number and expiration date of the medication Monitoring for adverse effects of medication Verifying Rh status of the mother and newborn Verifying the client's identity
Checking the lot number and exp date of med Monitoring for adverse effects of med on patient Verifying Rh status of mother and newborn Verifying client's identity Rationale The nurse prepares to administer RhoGam by verifying the Rh-negative status of the mother and the Rh-positive status of the newborn. The nurse should always check the lot number and expiration date of medication prior to giving it for safe medication administration. Safe medication administration requires that the nurse verify the client's identity. The nurse will assess the client for adverse reactions after medication administration. These include hypotension, chills, fever, headache, and pruritus. The client does not have to avoid caffeine after receiving a vaccination of RhoGam.
Determine nursing interventions that promote maternal comfort during postpartum period: The nurse is assisting a postpartum client in the bathroom. What teaching would the nurse use to help promote hygiene and comfort? Cleansing the vulva and perineum with a spray bottle of warm water after voiding Wiping with toilet paper instead of patting to ensure cleanliness Wiping from back to front to prevent urinary tract infections (UTIs) Explaining to only do a sitz bath once home to ensure privacy
Cleansing the vulva and perineum with spray bottle or warm water after voiding Rationale It is very important to cleanse the vulva and perineum with a spray bottle after voiding or a bowel movement to promote hygiene and comfort. The nurse may teach the mother to use a peri bottle for cleansing. The client should pat, not wipe, which will also aid in comforting and promote healing. The client should always pat from front to back to prevent UTIs. A sitz bath can and should be done as soon as the client wants to relieve discomfort. This can be done while in the hospital.
A client who delivered by cesarean section is having difficulty holding her infant comfortably in order to breastfeed. She asks for assistance from the home care nurse. What position for the infant would the nurse suggest to provide maximum comfort for the mother? Football hold Scissors hold Cradle hold Cross-cradle hold
Football hold Rationale The football hold is the most comfortable position for a mother who is breastfeeding after a cesarean delivery. In this position the mother is in semi-Fowler's position, supporting the infant's head in her hand and resting the infant's body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the infant easy access to the mother's breast. The scissors hold, cross-cradle hold, and cradle hold would all put pressure on the incision and be uncomfortable for the mother.
Apply nursing process to the care of women with postpartum complications: What should the nurse include in the plan of care for a client with postpartum depression? Select all that apply. Help facilitate bonding with the infant. Provide resources and referrals as needed. Schedule an appointment with a therapist. Use a depression scale to assess the client's status. Educate the client and family about signs of postpartum depression.
Help facilitate bonding with the infant Provide resources and referrals as needed Use depression scale to assess client's status Educate the client and family about signs of postpartum depression Rationale The nurse caring for a client with postpartum depression should assess the client's emotional state using the Edinburgh Postnatal Depression Scale (EPDS). The nurse should discuss options and resources available to the mother and provide referrals as needed. The nurse should educate the mother on the signs/symptoms of postpartum blues vs. PPD or psychosis as well as when she should seek help. The nurse should assist the mother to positively interact with her newborn by explaining infant cues and their meanings. The nurse should assist family members in understanding what the mother is going through and provide opportunities for family to express their feelings/concerns, while assisting and encouraging the mother to care for the infant.
Apply the nursing process to the care of a woman with postpartum complications: A postpartal client recovering from a deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Select all that apply. Increase activity gradually. Apply ice to the affected area. Apply moist heat to the affected area. Elevate the affected limb. Massage the affected area.
Increase activity gradually Apply moist heat to the affected area Elevate affected limb Rationale Supportive therapy for a client recovering from a deep vein thrombosis includes elevating the affected limb, applying moist heat to the affected area, and gradual ambulation once symptoms have disappeared. The nurse and client should refrain from massaging the affected area because this could dislodge the clot.
Recognize mood disorders associated with the postpartum client: A postpartum client states that she can't understand why she doesn't enjoy being with her baby.What should the nurse be most concerned about? Postpartum infection Postpartum depression Postpartum blues Postpartum psychosis
Postpartum depression Rationale Postpartum depression is characterized by feelings of shame and guilt, among others. Postpartum psychosis is more severe and includes hallucinations and confusion, which are not represented in this situation. Postpartum blues is characterized by mild depression interspersed with happier feelings and is self-limiting. Postpartum infection is not related to this situation.
Determine nursing interventions that promote maternal comfort during postpartum period: The nurse is caring for a postpartum client who had a cesarean section 1 day ago. Which nursing interventions will help prevent stasis of lung fluids and respiratory infection? Select all that apply. Providing education about the use of an incentive spirometer Encouraging healthy meals and fluid intake Teaching the client to cough correctly Monitoring the client's urinary output Encouraging the client to breathe deeply
Providing education about the use of IS Teaching the client to cough correctly Encourage the client to breathe deeply Rationale The nurse should encourage proper coughing in the postoperative client. This will prevent the stasis of lung fluids and decrease the chances of lung infection. The nurse can encourage the client to breathe deeply to prevent lung infection. The nurse encourages deep breathing through the use of incentive spriometry. This helps prevent stasis of lung fluids and infection. The nurse will encourage good nutrition. However, this does not promote healthy lung function. The client's urinary output is not an indicator of lung functioning. This nursing intervention is not related to promoting lung health.
Determine nursing interventions that promote health maintenance in the postpartum client: A postpartum client, who is Rh negative, delivers a newborn who is Rh positive. The nurse anticipates a provider's order for which of the following? Send placenta to pathology Infuse two units of packed red blood cells STAT RhoGam 300 mcg IM Administer rubella vaccine on postpartum day 2
RhoGam 300 mcg IM Rationale The nurse administers RhoGam to the Rh-negative postpartum client if she delivers a baby who is Rh positive. This is given to prevent Rh sensitization in the mother. It is not reasonable for the nurse to anticipate administering blood products to the Rh-negative mother, unless there has been significant blood loss during delivery. The nurse would not anticipate the need to prepare and send the placenta for pathological examination. The nurse does not anticipate the need to administer rubella based on the client's Rh status.
Apply strategies to promote maternal well-being after birth including nutrition, rest, and activity: A postpartum client with an episiotomy reports perineal pain. Which of the following nursing interventions would be helpful for this client? Select all that apply. Warm compresses Sitz baths Topical anesthetic spray Intermittent ice packs Frozen cabbage leaves
Sitz baths Topical anesthetic spray Intermittent ice packs Rationale The nurse may administer topical anesthetic spray to the perineal area for comfort. Intermittent ice packs are often used in the early postpartum period to relieve perineal edema and promote comfort. Sitz baths are another effective method of relieving perineal pain and discomfort. The nurse would not apply warm compresses to the perineal area. This would lead to vasodilation and increased blood flow to the area. This may increase pain in the perineum. Frozen cabbage leaves may be used for discomfort in breastfeeding mothers but are not recommended for perineal discomfort.
Determine the nursing care specific to a woman who has undergone a cesarean birth: A postpartum client tells the nurse that she would like to know about a birth control method she can start prior to discharge. What is an appropriate response from the nurse? "You should discuss different types of birth control with your health care provider." "You may be able to have a birth control injection before discharge." "You should take the pills; they work the best." "You will need to wait 6 weeks before starting any method."
"You should discuss different types of birth control with your health care provider." Rationale Since the client just delivered a baby, the nurse should tell the client that birth control methods should be discussed with the health care provider prior to discharge. The client may be able to have a birth control injection prior to discharge, but this needs to be discussed with the health care provider first. The client should not wait 6 weeks to start any birth control. The client should begin it's use before the health care provider clears the client to have sexual intercourse again. The nurse should not give their opinion as to what works best.
A postpartum primiparous client is having difficulty breastfeeding her infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. Which statement by the mother indicates the need for FURTHER INSTRUCTION from the home care nurse? "I can put breast milk on my nipples to heal the sore areas." "The baby needs to have as much of the nipple and areola in his mouth as possible to prevent sore and cracked nipples." "The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth." "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."
"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." Rationale As much of the mother's nipple and areola as possible needs to be in the infant's mouth in order to establish a latch that does not cause nipple cracks or fissures. Having the nipple and areola deep in the infant's mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking, and fissures. Breast milk has been found to heal nipples when placed on the nipples at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth.
Apply strategies to promote maternal well-being after birth, including nutrition, rest, and activity: The nurse is teaching a postpartum client about her nutritional needs. What statement is appropriate to include? "You should continue to take your prenatal vitamins." "Because you are breastfeeding, you will need fewer calories." "Drinking cold water is what will help hydrate you." "Limit fluid intake so you won't have problems with swelling."
"You should continue to take your prenatal vitamins" Rationale Mothers should be advised to continue their prenatal vitamins and iron as prescribed as part of discharge teaching about nutrition. Postpartum clients need to stay well hydrated, especially those who are breastfeeding. The nurse will encourage the mother to drink around 2000 mL of fluid per day. The nurse should ask the client if she prefers to drink hot or cold beverages. Some cultures prefer warm fluids due to cultural beliefs. The nurse would not recommend drinking only cold water. Breastfeeding mothers need, on average, 500 extra kilocalories per day.
Explain the purpose and components of the postpartum home visit: A primiparous client has been discharged from the hospital after delivering a 5lb baby girl. How many days postpartum should she expect the home care nurse to visit? 2 weeks after discharge The next day after discharge 3-6 days after discharge 8-10 days after discharge
3-6 days after discharge Rationale The postpartum home visit will usually occur between the third and sixth day postpartum depending on when the mother was discharged from the hospital. This time frame allows the home care nurse to assess the newborn for problems related to weight loss, feeding, and jaundice. It also allows for reinforcement of maternal teaching on self-care and newborn care. The next day is too soon if there are not any urgent problems to be assessed, as the mother has not had time to get settled and adjusted to the newborn. A period of 8dash-10 days can be too long, as the newborn needs to be assessed by the home care nurse 3dash-6 days after discharge.
Determine the nursing care specific to a woman who has undergone a cesarean birth: A postpartum client reports having difficulty voiding. Which strategies would the nurse suggest to promote urine elimination? Select all that apply. Administering pain medication Ensuring privacy when voiding Running water in the sink Administering Colace as ordered Encouraging voiding in the shower or during a sitz bath
Administering pain medication Ensure privacy when voiding Running water in the bathroom Encourage voiding in the shower or sitz bath Rationale The nurse should ensure the client has privacy when voiding. The client may take extra time to void due to fear of pain. Privacy allows the client to take extra time when attempting to void. The nurse may administer pain medication for comfort. The postpartum client may have a fear of voiding due to lacerations, episiotomies, and hemorrhoids. The nurse may run water in the sink to promote elimination. The nurse may also run water over the mother's hands. The nurse may encourage voiding in the shower, which may feel more natural to the client. Administration of Colace may help with fecal elimination. The question asks for measures to promote urine elimination.
In preparation for discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. What would the nurse include as the most appropriate time for resuming sexual intercourse? After the postpartum follow-up visit with the health care provider In 3 weeks, when the episiotomy is completely healed When the lochia flow and episiotomy pain have stopped Whenever the client is feeling amorous and desirable
After the postpartum follow-up visit with the health care provider Rationale Counsel women on "pelvic rest," which refers to refraining from sexual activity, until they are seen at their 4- to 6-week follow-up visit. This allows the complete healing of the cervix, uterus, and episiotomy. Lochia flow can stop as early as 3 weeks, and although the pain from the episiotomy may have stopped, the episiotomy may not have completely healed, so sexual intercourse may be painful. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while.
Determine nursing interventions that promote maternal comfort during postpartum period: The nurse is providing discharge teaching for a formula feeding mother. Which of the following will promote comfort for breast engorgement? Using medication to suppress lactation Applying ice bags Applying warm compresses Pumping the breasts
Applying ice bags Rationale Applying ice bags will assist in decreasing discomfort. The ice packs would be applied to the axillary area of each breast for 20 minutes, 4 times daily. Pumping the breast will encourage the breasts to refill. Applying warm compresses will promote vasodilation and venous congestion. This may lead to further engorgement and discomfort. A warm compress may be applied just before feeding to soften the breast. However, this should not be recommended for comfort measures. Medications to suppress lactation are not used.
Explore maternal postpartum psychological adaptation: The nurse observes several interactions between a mother and her newborn daughter. Which maternal behaviors should the nurse identify as evidence of mother-infant attachment? Select all that apply. Cuddles her daughter close to her Requests the nurse take the baby to the nursery for her feedings Takes a nap when the baby is sleeping Talks and coos to her daughter Encourages the father to hold the baby
Cuddles her daughter close to her Talks and coos to her daughter Rationale The maternal behaviors that indicate mother-infant attachment include cuddling, talking, and cooing with her daughter. Requesting that the nurse take the baby to the nursery does not indicate mother-infant attachment. Encouraging the father to hold the infant indicates the mother is encouraging father-infant attachment. Taking a nap when the baby naps is important to conserve energy and is recommended, but this does not indicate mother-infant attachment.
Examine the components of a postpartum assessment: The nurse is explaining the stages of lochia to a mother who just delivered a baby. Which statement best describes lochia rubra to the mother? It contains bacteria, erythrocytes, and blood. It contains a mixture of mucus, tissue debris, and blood. It contains placental fragments and blood. It contains mucus, placental fragments, and blood.
It contains a mixture of mucus, tissue debris and blood. Rationale Lochia rubra contains a mixture of mucus, tissue debris, and blood. Normal lochia rubra does not contain placental fragments.
Compare various etiologies and management of postpartum hemorrhage: The nurse is caring for a woman 8 hours after a vaginal delivery. On assessment, the nurse finds the woman's fundus to be firm but she continues to have heavy vaginal bleeding. Which of the following would the nurse suspect? Uterine atony Endometritis A hematoma A laceration
Laceration Rationale Lacerations should be suspected when vaginal bleeding persists in the presence of a firmly contracted uterus. The nurse should suspect a hematoma if there is no excessive vaginal bleeding, but the woman exhibits signs of excessive blood loss such as tachycardia and decreased blood pressure. Uterine atony manifests as a soft or open double quote"boggy,close double quote" difficult-to-locate fundus. Endometritis would result in an elevated temperature, not in persistent vaginal bleeding.
At a home visit, the nurse assesses a neonate delivered vaginally at 42 weeks gestation 6 days ago, noting the following findings: frequent hiccups; loose, watery stool in diaper; red rash on face; and dry, peeling skin. Which of these findings warrants further assessment? Loose, watery stool in diaper Dry, peeling skin Pink papular vesicles on the face Frequent hiccups
Loose watery stool in diaper Rationale A loose, watery stool in the diaper is indicative of diarrhea and needs immediate attention. The infant may become severely dehydrated quickly because of the higher percentage of water content per body weight in the newborn compared with an adult. Hiccups, pink papular vesicles on the face, and dry, peeling skin are normal findings in a post-term newborn.
Determine the nursing care specific to a woman who has undergone a C-section birth: A nurse is assessing a postpartum client's response to morphine administered through an epidural. The nurse collects the following vital signs: 98.6°F temperature, 80 pulse, and 11 respirations. What actions should the nurse take? Select all that apply. Notify the health care provider. Begin CPR. Administer Narcan according to policy. Document the vital signs as normal. Administer oxygen.
Notify the provider Administer oxygen Administer Narcan according to policy Rationale The nurse must assess the client's respiratory status closely when administering narcotics. If a client's respiratory rate falls below 12, the nurse should notify the health care provider. The nurse should administer oxygen for the client whose respiratory rate falls below 12. This indicates the client may not be receiving adequate oxygenation. The nurse should administer Narcan to reverse the noted effects on respirations. The nurse would not document a respiratory rate of 11 as normal. The client has a pulse and spontaneous respirations. The nurse would not start CPR for this client.
Examine the normal physiologic changes expected in the postpartum client: The nurse knows that which of the following physiologic responses is considered normal in the early postpartum period? Rapid diuresis Decrease in blood pressure Increased motility of the GI system Urinary urgency and dysuria
Rapid diuresis Rationale In the early postpartum period there is an increase in the glomerular filtration rate and a drop in progesterone levels, which results in rapid diuresis. Urinary retention and bladder distention can occur due to the effects of childbirth. The tissue around the urethra, urethral meatus, and bladder becomes edematous. There is a minimal change in blood pressure following childbirth. Constipation can result from peristalsis being sluggish for several days after delivery.
Explore maternal postpartum psychological adaptation: The nurse is assessing the client and asks how they are feeling. In response to the nurse's question, the postpartum client states, "I am fine." The client then begins talking to the baby, changing the diaper, and asking infant care questions. The nurse determines that the client is in which postpartum phase of psychological adaptation? Taking In Taking Hold Taking On Letting go
Taking Hold Rationale During the taking hold phase the mother becomes more independent, taking more responsibility for her self-care. Since she is starting to feel more comfortable taking care of herself, her focus will start to shift to her newborn, exhibiting interest in how to properly care for her newborn. Taking in is the first period after delivery when the new mother is focused on her own need for food, rest, and fluids and can be dependent on others. Letting go allows the woman to let go of her former self. Taking on is not a period of postpartum psychological adaptation.
Recognize mood disorders associated with the postpartum client: The nurse is making follow-up calls to several postpartum clients. Which client should the nurse schedule to be seen immediately? The client reports hearing voices talking about the baby. The client describes feeling sad all the time. The client says she needs a refill on her sertraline (Zoloft) next week. The client states she has no appetite and wants to sleep all day.
The client reports hearing voices talking about the baby. Rationale Hearing voices is an indication that the client is experiencing postpartum psychosis and is the highest priority; hallucinations and delusions may lead to her harming her baby. Feeling sad is an indication that the client is experiencing postpartum blues and is not the highest priority. Fatigue and loss of interest in activities indicate that the client is experiencing postpartum depression, but this is not the highest priority. A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority.
Relate assessment findings to the management of a woman diagnosed with a postpartum infection: During a home visit a client reports of a reddened, swollen, and tender breast 10 days after delivery. Once this is confirmed on assessment, which of the following would the nurse advise? She should mention it to her health care provider at her 2-week checkup. She has to stop breastfeeding immediately. This is normal breast engorgement. These symptoms are suggestive of an inflammatory or infectious process and need immediate attention; the nurse should notify her health care provider.
These symptoms are suggestive of an inflammatory or infectious process and need immediate attention; the nurse should notify her health care provider. Rationale Erythema, swelling, and localized tenderness are symptomatic of mastitis. Since these are signs and symptoms outside of the expected normal range, the health care provider should be notified. Without intervention, it is likely the condition will worsen, so waiting 4 more days until the checkup is not the best response. There is no need to stop breastfeeding; the client will be encouraged to empty her breasts, beginning on the unaffected side, enabling her to capitalize on the let-down reflex.
Contrast newborn attachment and bonding behaviors and their effect on familial adaptation: The nurse is observing a new mother with her newborn. Which nursing interventions allow a new mother acquaint herself with her newborn? SELECT ALL THAT APPLY Unwrapping the newborn and exploring the baby's extremities with her fingertips Holding the newborn in her arms and states, "He has his daddy's nose" Places the newborn in the crib next ot her bed Holds the newborn so that she has direct face-to-face and eye-to-eye contact Lays the newborn on the bed next to her and watches TV
Unwrapping the newborn and exploring the baby's extremities with her fingertips Holding the newborn in her arms and states, "He has his daddy's nose" Holds the newborn so that she has direct face-to-face and eye-to-eye contact Rationale Attachment behavior includes finger tipping the newborn, face-to-face and eye-to-eye contact, and holding and talking to the newborn. Placing the newborn in the crib or on the bed is not considered bonding with the newborn.
Determine nursing interventions that promote health maintenance in the postpartum client: The night shift nurse gets report on four clients who delivered between 7:00 a.m. and 8:00 a.m. that morning. Which of the following clients would the nurse assess first? Cesarean section, pain medication 30 minutes ago, tolerated clear liquids Vaginal delivery, ambulating well, Colace due in 30 minutes Cesarean section, twins, breastfeeding, requests assistance with nursing Vaginal delivery, episiotomy, has not voided since delivery
Vaginal delivery, episiotomy, has not voided since delivery Rationale It is generally expected that a postpartum client will void within 6 hours of delivery. The risks of not voiding include hemorrhage and/or excessive vaginal bleeding. The client who has not voided is the priority for the nurse. A client who has had pain medication 30 minutes ago will need reassessment within an hour of medication administration. This is not the priority. A client who is ambulating well is not the priority for the nurse. The nurse should provide assistance with breastfeeding; however, this education is not the priority in this example.
The home care nurse is visiting a mother who is breastfeeding. The nurse is teaching the mother how to care for her breasts to prevent complications. What should the mother be taught to prevent cracked nipples while she is breastfeeding? Wash the nipples with water daily. Nurse at least 20 minutes on each breast each feeding. Apply a soothing cream prior to feeding. Use plastic bra liners.
What nipples with water daily Rationale Nipples should be washed with water only (no soap) to prevent drying. Soothing cream should be applied after feeding. Emptying the breast during feeding sessions can prevent engorgement. Plastic bra liners could lead to skin breakdown of the breast tissue since they would not absorb any milk leakage and moisture would accumulate on the skin.
A primiparous client who is bottle-feeding her infant asks the nurse, "When will my menstrual cycle return?" What response by the nurse would be most appropriate? "You can expect your menses to start in 12 to 14 weeks." "Your menstrual cycle will return in 3 to 4 weeks." "It will probably be 6 to 10 weeks before it starts again." "Your menses will return in 16 to 18 weeks."
"It will probably be 6 to 10 weeks before it starts again." Rationale For a client who is bottle-feeding, the menstrual cycle should return in 6 to 10 weeks, after the rise of follicle-stimulating hormone from the pituitary gland. For clients who are breastfeeding, the menstrual flow may not return for 3 to 4 months or, in some women, for the entire time of lactation, because ovulation is suppressed.
Determine the nursing care specific to a woman who has undergone a C-section birth: A postpartum client is recovering from a cesarean section and has taken Tylenol #3 for pain for 2 days. Which of the following client statements is concerning to the nurse? "I am crying for no reason; something is wrong with me." "My stomach feels funny; I may be constipated." "My breasts are really sore; I can't breastfeed." "I do not like the taste of my meals; my appetite is poor."
"My stomach feels funny; I may be constipated." Rationale The nurse should monitor for complications of oral analgesics such as Percocet and Tylenol #3. Constipation is a common side effect of these medications. The nurse would encourage good nutrition for the postpartum client. The client's expression of disliking her meals is not related to her medication. Narcotic analgesics do not lead to breast engorgement. This is an expected physiological response in the postpartum period. The nurse understands that most women experience the baby blues. This is an expected response in the first postpartum week and is not related to the administration of narcotic analgesics.
Contrast newborn attachment and bonding behaviors and their effect on familial adaptation: A multipara mother mentions to the nurse that she does not understand why her 3-year-old daughter is so aggressive toward her new baby brother. "All she talked about was having a baby brother before I delivered." The nurse reassures the mother by stating which of the following? "Just ignore your 3-year-old's behavior; she needs time to get used to the new baby." "You need to hold and reassure your 3-year-old that she is loved and has not been replaced by the new baby." "Have someone else hold the 3-year-old when she is visiting in the hospital so she does not harm the baby." "You need to discipline the 3-year-old now or the behavior will escalate."
"You need to hold and reassure your 3-year-old that she is loved and has not been replaced by the new baby." Rationale Toddlers see the new baby as competition for their parents' affection and attention. They can respond by regressing in behavior (if they were potty trained they begin wetting their pants) or by being aggressive. The child needs to be reassured that he/she is still loved and wanted. Recommendations to ignore the behavior and discipline the child do not address the mother's concerns with the child's behavior.
