postpartum period

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."

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 mother of a neonate expresses concern about how she will continue to breastfeed when she returns to work in 6 weeks. Which response by the nurse would be best?

"Tell me what you would like to do when you return to work."

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 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. Which statement by the client indicates that additional teaching is needed?

"The exercise strengthens the gluteal muscles."

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."

The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. In what order, from first to last, should the nurse perform the listed steps? All options must be used.

-Ask the client to void. -Place the client in a supine position. -Place one hand on the abdomen just above the symphysis pubis and the other on top of the fundus. -Rotate the upper hand to massage the uterus until firm. -Document the findings.

The nurse is caring for a postpartum client who gave birth five hours ago. Which action(s) taken by nurse prevents postpartum infection? Select all that apply.

-washing the hands and wearing gloves. -providing perineal care every shift and after every bowel movement. -encouraging the client to change the perineal pad every two hours.

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 One gram of weight is approximately equivalent to 1 ml of fluid. Therefore, the blood loss estimate for a perineal pad weighing 100 g would be approximately 100 ml.

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 To solve this problem, set up proportions as follows: 5 mL/125 mg = X mL/500 mg X X x 125 mg = 5 mL X 500 mg. Solve for X by dividing both sides of the equation by 125 mg: X X x 125 mg/125 mg = 5 mL X 500 mg/125 mg X = 2,500 mL/125 X = 20 mL.

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.

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.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation?

Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?

Discuss the unit's policy with the charge nurse.

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.

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.

A student nurse is accompanying a community health nurse for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The mother's partner declines this opportunity. What is the nurse's most appropriate response?

Honor the partner's preference.

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 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.

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.

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.

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

Performing fundal massage

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.

A nurse is caring for a postpartum client. Which priority nursing action should the nurse take during the postpartum period?

Supporting the mother's ability to successfully feed and care for her infant

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.

Which of the following correctly defines puerperium?

The 6 weeks following birth

A nurse is providing care to a postpartum client who gave birth vaginally to a healthy newborn 48 hours ago. When talking with the client, which information would cause the nurse concern?

The client feels empty since she delivered the neonate.

A client has just been admitted to the postpartum unit after an uncomplicated vaginal birth. The client is reporting afterpains. Upon reviewing the client medical record, which factor would the nurse identify as most likely playing a role in the client's report?

The client has given birth five times.

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.

A clinical pathway is guiding care for an Rh-negative postpartum client who vaginally delivered a 9-lb, 1-oz (4,121-g) baby 5 hours ago. During the delivery, a second- degree median episiotomy was necessary. Which client outcome should be achieved during the first 12 hours postpartum?

The client will verbalize and demonstrate appropriate self-perineal care.

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.

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

coughing and deep-breathing exercises

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 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 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 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

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 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