postpartum period

A client with cardiac disease gives birth. Afterward, the nurse assesses the client for signs and symptoms of cardiac decompensation. During the postpartum period, which assessment finding indicates a need for further investigation? diuresis uterine pain weight loss tachycardia

tachycardia Explanation: Tachycardia can indicate cardiac decompensation. Weight gain, not loss, may be a sign of heart failure. Diuresis and resulting weight loss are normal after giving birth. Uterine pain may result from the uterus contracting as it shrinks and isn't an immediate concern.

The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant? "Formula-fed infants usually feed every 3 to 4 hours." "Formula-fed infants demand to feed every 1.5 to 3 hours." "Formula-fed infants experience shorter periods between feedings." "Formula-fed infants digest their milk more rapidly."

"Formula-fed infants usually feed every 3 to 4 hours." Explanation: Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? Take antibiotics until the pain is relieved. Use a warm moist compress over the painful area. Stop breast-feeding permanently. Wear a loose-fitting bra to avoid constricting the milk ducts.

Use a warm moist compress over the painful area. Explanation: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.

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 positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway affixing matching identification bands to the parents and neonate at birth affixing a security bracelet that monitors movement to a neonate

allowing volunteers to return neonates to the nursery Explanation: The new nurse requires additional teaching if allowing volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures.

A 30-year-old client with prolonged rupture of membranes is diagnosed with endometritis 36 hours after the birth of a term neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100°F (37.8°C), heart rate is 124 bpm, and respirations are 24 breaths/minute. What action should the nurse take? Administer an analgesic medication as prescribed. Monitor the vital signs every 4 hours. Provide the client with clear liquids. Contact the health care provider.

Contact the health care provider. Explanation: The nurse should contact the health care provider immediately because the client is demonstrating danger signals of septic shock. Tachycardia, or a pulse rate greater than 120 bpm, and tachypnea, or respirations of 24 breaths/min or higher, are both danger signs of septic shock. Hypotension, changes in the level of consciousness, and decreased urine output are later signs.Analgesic medications can assist the client's comfort but are not critical at this time.Providing the client with clear liquids does not address the life-threatening problem of septic shock.The vital signs should be monitored more frequently than every 4 hours if the client is developing septic shock

After a client undergoes a dilatation and curettage (D&C) to evacuate a molar pregnancy, it would be most important for the nurse to assess the client for which signs and symptoms? chorioamnionitis hemorrhage abdominal distention urinary tract infection

hemorrhage Explanation: After D&C to evacuate a molar pregnancy, the nurse should assess the client's vital signs and monitor for signs of hemorrhage because the surgical procedure may have traumatized the uterine lining, leading to hemorrhage. Urinary tract infections are not common after the evacuation of a molar pregnancy; they are most commonly related to urinary catheterization. Typically, urinary catheters are not used during the evacuation of a molar pregnancy. The client should not experience abdominal distention because the contents of the uterus have been removed. Chorioamnionitis is an inflammation of the amniotic fluid membranes. With complete mole, no embryonic or fetal tissue or membranes are present.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? infection hemorrhage disseminated intravascular coagulation (DIC) shock

hemorrhage Explanation: A full bladder prevents the uterus from contracting completely, increasing the risk of hemorrhage. It doesn't directly increase the risk of shock, DIC, or infection.

A registered nurse is staff-shared to the maternal-neonatal unit where the RN has never worked before. How can this nurse be best employed? Assign the RN a client care assignment in the postpartum unit. Use the RN as a nursing assistant in the postpartum unit. Assign the RN to the nursery. Assign the RN to the labor and delivery area.

Assign the RN a client care assignment in the postpartum unit. Explanation: The staff-shared nurse can be best employed in client care in the postpartum unit because such an assignment requires medical-surgical knowledge. In this setting, the nurse can safely use the RN's nursing skills and doesn't need to assume the role of a nursing assistant. The staff-shared nurse isn't qualified to work in the labor and delivery area or the nursery because both require specialized training to safely administer care.

A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. What factor/condition does the nurse believe is causing this experience? postpartum baby blues postpartum reaction postpartum anxiety postpartum depression

postpartum baby blues Explanation: Postpartum baby blues occurs in up to 70% of women after the birth of a child. It is a mild depression and functioning of the woman is usually not impaired. Postpartum baby blues usually begins on days 3 to 10 postpartum. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks postpartum and up to 1 year following the birth of the baby. Postpartum reaction is usually a larger term to include postpartum depression, anxiety, and psychosis.

A client whose blood type is A- gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? ensuring that the client understands the procedure and signs a consent for the vaccination instructing the client that she won't need an additional vaccination after her next pregnancy choosing an injection site that isn't tender documenting administration of the drug in the client's chart

ensuring that the client understands the procedure and signs a consent for the vaccination Explanation: Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent. The nurse should document the procedure after giving the injection. The nurse should advise the client that Rho(D) immune globulin administration will be needed after every pregnancy. Choosing an injection site that isn't tender isn't a priority.

The nurse from the nursery is bringing a newborn to a client's room. The nurse took care of the client yesterday and knows the client and baby well. The nurse should implement which action to ensure the safest transition of the infant to the birth parent? Ask the birth parent if there is anything else they need for the care of the baby. Complete the hospital identification procedure with birth parent and infant. Check the crib to determine if there are enough diapers and formula. Assess whether the birth parent is able to ambulate to care for the infant.

Complete the hospital identification procedure with birth parent and infant. Explanation: The hospital identification procedures for clients and infants need to be completed each time a newborn is returned to a family's room. It does not matter how well the nurse knows the client and infant; this validation is a standard of care in an obstetric setting. Assessing the client's ability to ambulate, asking if there is anything else the client needs to care for the infant, and checking the crib to determine if there are enough supplies are important steps that are part of the process of transferring a baby to the client, but identification verification is a safety measure that must occur first.

The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action? Ensure that this is a mutually agreed upon decision. Immediately report the incident to the student's professor. Ask the client and student who initiated the idea for these arrangements. Discuss the situation with the nursing student after the visit has ended.

Discuss the situation with the nursing student after the visit has ended. Explanation: The nurse has a professional responsibility to discuss this situation with the nursing student in private. The student needs to know that these actions are insensitive to the grieving parents and are unprofessional regardless of whether the client has agreed to it or even initiated the idea. These student actions do not value therapeutic boundaries between health care providers and their clients in the community. It may be appropriate to discuss it with the contact person from the student's academic institution; however, the first action should be to discuss it with the student in private.

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother strokes the neonate's lips gently with the nipple. pushes only the tip of the nipple into the neonate's mouth. uses a nipple with regular size openings. makes sure that the nipple fills with formula.

pushes only the tip of the nipple into the neonate's mouth. Explanation: The tip of the nipple shouldn't be pushed into the neonate's mouth. To suck effectively, the neonate needs to compress the entire nipple, not just the tip. Filling the nipple with formula reduces air swallowing. Stroking the neonate's lips gently with the nipple usually causes the mouth to open wide enough for nipple insertion. The mother should use a nipple with a regular size opening to avoid having too much formula enter the mouth once the neonate starts to suck.

While assisting a primiparous client with their first breastfeeding session, the nurse should instruct the client to perform which action in order to stimulate the neonate to open the mouth and grasp the nipple? Pull down gently on the neonate's chin and insert the nipple. Brush the neonate's lips lightly with the nipple. Place the nipple into the neonate's mouth on top of the tongue. Squeeze both of the neonate's cheeks simultaneously.

Brush the neonate's lips lightly with the nipple. Explanation: Lightly brushing the neonate's lips with the nipple causes the neonate to open the mouth and begin sucking. The neonate should be taught to open the mouth and grasp the nipple on their own. The neonate should not be forced to nurse.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and puts on clean gloves. What should the nurse do next? Ask the client to assume a side-lying position with the knees flexed. Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Place the client on a bedpan in case the uterine palpation stimulates the client to void.

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Explanation: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position, and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before the fundal evaluation. A full bladder can cause discomfort to the client, the uterus to deviate to one side, and postpartum hemorrhage.

A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal birth tells the nurse that when they ambulated to the bathroom after sleeping for 4 hours, their dark red lochia seemed heavier. Which information would the nurse include when explaining to the client about the increased lochia on ambulation? The increased lochia needs to be reported to the health care provider (HCP) immediately. The increase in lochia may be an early sign of postpartum hemorrhage. This increase in lochia usually indicates retained placental fragments. The increased lochia occurs from lochia pooling in the vaginal vault.

The increased lochia occurs from lochia pooling in the vaginal vault. Explanation: Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and flows out when the client arises. If the client had reported that their lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed, and the HCP would be notified. Early postpartum hemorrhage occurs during the first 24 hours, but typically the fundus is soft or "boggy." The client's fundus here is firm and midline. Late postpartum hemorrhage, occurring after the first 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site

Which measure would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? emptying the bladder every 2 to 4 hours while awake avoiding the intake of acidic fruit juices until the treatment is discontinued limiting fluid intake to 1 L daily to prevent overload washing the perineum with povidone-iodine after voiding

emptying the bladder every 2 to 4 hours while awake Explanation: The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep their bladder empty. In addition, they should maintain adequate fluid intake; 3000 mL a day is recommended. Intake of acidic fruit juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infection. The client should wear cotton underwear and avoid tight-fitting slacks. The client does not need to wash with povidone-iodine after voiding. Plain warm water is sufficient to keep the perineal area clean.

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor? overdistention of the uterus from hydramnios lengthy and prolonged second stage of labor trauma during labor and birth moderate fundal massage after birth

overdistention of the uterus from hydramnios Explanation: The most likely cause of this client's uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth is not a likely cause, and no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps contract the uterus; it does not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech presentation. Therefore, it is unlikely that they had a long labor.

The nurse evaluates the parenting skills of an adolescent primigravida changing their baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support? family availability for assistance detailed written instructions praise and encouragement acceptance by the client's peers

praise and encouragement Explanation: The adolescent client may have special needs during the postpartum period. Praise and encouragement of the client's mothering skills are important for building the client's confidence and self-esteem. Although they may be helpful in some instances, detailed written instructions or prolonged verbal instructions are inappropriate. Lengthy explanations, either verbal or in writing, may overwhelm the first-time mother, adding to their fears and feelings of inadequacy. Family availability is important but not essential. For example, it is not essential that the client's family assist them. However, the nurse can instruct the client while the family is present. Peer acceptance is a major component of adolescence, but a lack of knowledge or experience about infant care is unrelated to peer acceptance. The reality of caring for a neonate may be a crisis for the adolescent.

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the client and their partner to do? Relate to each twin individually to enhance the attachment process. Plan for each parent to spend equal amounts of time with each twin. Avoid assistance from other family members until attachment occurs. Bottle-feed the twins to prevent exhaustion and fatigue.

Relate to each twin individually to enhance the attachment process. Explanation: It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individually, rather than as a unit, to enhance the attachment process. Birth parents of twins are usually able to breastfeed successfully because the milk supply increases on demand. However, possible fatigue and exhaustion require that the birth parent rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends because caring for twins or other multiple births (e.g., triplets) can be exhausting for the family.

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and their breasts are soft. The client has scant lochia and is voiding sufficiently. The client reports pain in the lower back. What action should the nurse take next? Instruct the client to perform abdominal exercises. Ask the client how long they were in labor. Administer a prescribed mild analgesic medication. Contact the health care provider for a prescription to obtain a urinalysis.

Administer a prescribed mild analgesic medication. Explanation: After giving birth, it is not unusual for postpartum clients to have backache, which results from stretching of the muscles during the labor and birth process. The nurse can provide the client with a mild analgesic medication to help alleviate the backache.The client is not demonstrating any evidence of a urinary tract infection at this time, so calling the health care provider to obtain a prescription for a urinalysis is not necessary.Although asking the client how long they were in labor may encourage the client to discuss their labor and birth experience and provide the nurse with additional information, it will not alleviate the client's backache.On the day of birth, it is too soon for the client to begin abdominal exercises

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. Reassure the partner that the student nurse will be professional. Ask the partner about any concerns. Ask the partner to leave the premises.

Honor the partner's preference. Explanation: When providing services such as a postpartum visit in someone's home, the nurse needs to respect the culture, values, and personal preferences of the resident family members. The other responses are negating of the family's wishes and could be seen as confrontational and not client centered.

After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? every 4 to 5 hours for the first 5 days after birth at least every hour for the first 48 hours whenever the client desires, until weaning occurs every 2 to 3 hours for the first 48 hours

every 2 to 3 hours for the first 48 hours Explanation: Soon after giving birth, the client should breastfeed every 2 to 3 hours until the milk supply is established.Feeding every hour is not necessary and will lead to maternal exhaustion.Feeding every 4 to 5 hours is not often enough to help establish the milk supply.Feeding whenever the client desires is inappropriate because the client may only feel like feeding less often, thus not providing enough stimulation for milk production while not supplying the neonate with the needed nutrition.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? Close all of the doors on the unit. Immediately evacuate the unit. Permit the mothers and their neonates to continue sleeping. Do nothing because it's most likely a fire drill.

Close all of the doors on the unit. Explanation: The nurse should respond quickly by closing all of the doors on the unit. This action prevents the spread of smoke in case of a fire. The nurse shouldn't begin evacuating the unit until given notification to do so. The nurse shouldn't ignore the alarm because fire drills are necessary to prepare the staff for a fire. The mothers should be awakened in case evacuation is necessary.

While the nurse is caring for a primiparous client on the first postpartum day, the client asks, "How is that person doing who lost their baby from prematurity? We were in labor together." Which response by the nurse would be most appropriate? Explain to the client that "nurses are not allowed to discuss other clients on the unit." Ignore the client's question and continue with morning care. Tell the client, "I'm not sure how the other person is doing today." Tell the client, "I need to ask their permission before discussing their well-being."

Explain to the client that "nurses are not allowed to discuss other clients on the unit." Explanation: Legal regulations and ethical decision-making require that the nurse maintain confidentiality at all times. The nurse's best response is to explain to the client that nurses are not allowed to discuss other clients on the unit. Ignoring the client's question is inappropriate because doing so would interfere with the development of a trusting nurse-client relationship. Confidentiality must be maintained at all times. Telling the client that the nurse is not sure may imply that the nurse will find out and then tell the client about the other woman. Asking the other client for permission to discuss their situation is inappropriate because confidentiality must be maintained at all times.

While making a home visit to a multigravid client 2 weeks after the birth of term twins, the nurse observes that the client looks pale, has dark circles around their eyes, and is breastfeeding one of the twins. The client's apartment is clean, and nothing appears out of place. The client tells the nurse that they completed three loads of laundry this morning. What is the priority need to address for this client? Possible anemia related to large volume of blood loss and twin birth Risk for imbalanced nutrition: Less than body requirements related to twin birth Anxiety related to inability to cope with twins who are breastfeeding Fatigue related to home maintenance and caring for twins.

Fatigue related to home maintenance and caring for twins. Explanation: Most postpartum clients have excessive fatigue after birth. This multigravida has dark circles around their eyes and is pale, which can indicate anemia or excessive sleep deprivation. The client maintains a spotless environment, has completed three loads of laundry, and is trying to breastfeed twins.There is no evidence of anxiety.There is no evidence of imbalanced nutrition.Anemia is not a nursing diagnosis.

Twenty-four hours after giving birth to a term neonate, a primipara receives acetaminophen with codeine for perineal pain. One hour after the nurse administers the medication, which finding should alert the nurse to the development of a possible side effect? diarrhea dizziness urinary frequency hypertension

dizziness Explanation: Analgesic medications with narcotics have numerous side effects, including respiratory depression, dizziness, light-headedness, hypotension, and fainting. Other side effects include constipation, nausea and vomiting, and urinary retention.Hypotension, not hypertension, is a possible adverse effect of narcotic analgesics.Constipation, not diarrhea, is a possible adverse effect of narcotic analgesics.Urinary retention, not urinary frequency, is a possible adverse effect of narcotic analgesics.

The nurse is caring for a client 24 hours postpartum from a normal, vaginal birth. For which client reported symptom will the nurse prioritize further assessment? feeling warm and flushed feeling pain and warmth behind left knee feeling chilled and cold feeling too excited to sleep

feeling pain and warmth behind left knee Explanation: Pain and warm behind knee may indicate thrombosis in popliteal vein, which would be of concern for a postpartum client. This subjective finding requires immediate intervention assessment due to the increased risk for deep vein thrombosis in the postpartum client. Maternal chills are a normal vasomotor response to the birth. An elevated temperature in the first 24 hours is also normal. Insomnia in the immediate postpartum period is common as the body adjusts to the release of endorphins.

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 nursing intervention takes highest priority? massaging the uterus gently administering oxytocin as ordered reassessing the client in 1 hour notifying the physician or nurse-midwife

massaging the uterus gently Explanation: If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

The nurse is caring for a multigravida client who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment? pulse of 60 bpm hemoglobin 12.1 g/dL (121 g/L) white blood cell (WBC) count of 15,000/μL (15 X 109/L) temperature of 100.8°F (38.2°C)

temperature of 100.8°F (38.2°C) Explanation: Within the first 24 hours postpartum, maternal temperature may increase to 100.4°F (38°C), a normal postpartum finding attributed to dehydration. A temperature above 100.4°F (38°C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal range. The WBC count is normally elevated as a response to the inflammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure from the uterus on vessels, blood flow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.

A client who is 6 months postpartum asks the nurse about an effective method of birth control. What is the nurse's most appropriate response? "Combined oral contraceptive pills are a good option for breastfeeding mothers." "Breastfeeding alters your hormones and provides adequate protection against pregnancy." "Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding." "Spermicidal foam protects against pregnancy as effectively as other methods."

"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding." Explanation: Condoms are classified as barrier contraception in that they create a physical barrier to prevent the transmission of sexually transmitted infections. Cervical caps are another form of barrier contraception that are safe for breastfeeding mothers; they provide 85-98% effectiveness rate against pregnancy. Breastfeeding reduces the risk for pregnancy but not as much as other methods of birth control. The "Minipill," a progestin-only oral contraceptive, can be used during lactation, but combined birth control pills that contain estrogen should not be taken, because they can interfere with production of breast milk. Spermicidal foam is only 71-82% effective against pregnancy, which is lower than the other forms mentioned.

A client with diabetes who just gave birth plans to breastfeed. The nurse determines that the client's understanding of breastfeeding instructions is sufficient when the client makes which statement? "Breastfeeding is not recommended for birth mothers with diabetes." "Breast milk from birth mothers with diabetes contains few antibodies." "Insulin will be transferred to the baby through breast milk." "Breastfeeding will assist in lowering maternal blood glucose."

"Breastfeeding will assist in lowering maternal blood glucose." Explanation: Breastfeeding consumes maternal calories and requires energy that increases the maternal basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not transferred to the infant through breast milk. Breastfeeding is recommended for clients with diabetes because it lowers blood glucose levels. The number of antibodies in breast milk is not altered by maternal diabetes.

The nurse provides health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding their neonate. Which client statement indicates that this teaching has been effective? "My menstrual flow should resume in approximately 6 to 10 weeks." "Any varicosities I had during pregnancy will disappear within 2 weeks." "I can expect to have heart palpitations for several weeks." "It's normal for me to have reddish lochia until my 6-week checkup."

"My menstrual flow should resume in approximately 6 to 10 weeks." Explanation: For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks.Heart palpitations for several weeks are not normal and require further investigation.Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation.Although varicosities may fade, they rarely disappear completely after childbirth.

A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on the perineum. However, the perineum is slightly edematous, and the client is reporting pain rated 6 on a scale of 0 to 10. Which nursing intervention would be the most appropriate at this time? Replace ice packs on the perineum. Initiate anesthetic sprays to the perineum. Administer pain medication per prescription. Begin sitz baths.

Administer pain medication per prescription. Explanation: Pain medication is the first strategy to initiate at this pain level. When trauma has occurred in any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.

A nurse is caring for a woman who gave birth to a baby boy 2 hours ago. The nurse notes the client's perineal pad contains some small clots and a moderate amount of lochia has accumulated under the buttocks. What is the first action the nurse should take at this time? Perform an in-and-out catheter immediately. Measure blood loss by measuring the perineal pad. Check the fundus for position and consistency. Request a prescription to administer oxytocin.

Check the fundus for position and consistency. Explanation: Although the greatest risk for postpartum hemorrhage is within the first hour following birth, a client can develop an early postpartum hemorrhage anytime within the first 24 hours after birth. As soon as the nurse notices an increased amount of lochia and clots, the fundus must be assessed for firmness and position. Normally, it should be firm, midline, and either just above or below the umbilicus. Massaging the fundus if it is not firm will assist with a uterine contraction to help decrease blood loss postpartum. Administering oxytocin would not be the first action for the nurse to take. Performing an in-and-out catheterization at this time is not appropriate. The nurse should assist the client to the washroom to void on their own first. The nurse can measure the blood loss by measuring the perineal pad; however, this would be done after the nurse has first assessed the fundus.

A 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. Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises. Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. Client will state that she may attempt another pregnancy after 3 months of follow-up care.

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative. Explanation: After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform mole. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.

The nurse cares for a primigravid client in the fourth stage of labor. The client had a midline episiotomy and epidural anesthesia. While assessing the client's pulse 30 minutes after the birth, the nurse determines that the pulse rate is 60 bpm. What action should the nurse take? Contact the client's health care provider to notify them about the pulse rate. Recheck the pulse in 30 minutes and compare the two readings. Check the client's record to determine the amount of blood loss. Do nothing because this pulse rate is considered a normal finding.

Do nothing because this pulse rate is considered a normal finding. Explanation: Bradycardia, a pulse rate of 60 bpm or less, is a normal assessment finding for a client 6 to 10 days postpartum, as the woman's body is adjusting to the nonpregnant state.The health care provider does not need to be notified because the pulse rate is within the normal parameters for the postpartum period.Checking the client's record for the amount of blood loss would be appropriate if the client's rate was elevated (e.g., above 100 bpm), suggesting possible hemorrhage. If the client's pulse was rapid and thready, shock might be possible.Rechecking the pulse rate in 30 minutes and then comparing the two readings is unnecessary. The pulse rate, because it is within normal postpartum parameters, would need to be checked according to the agency's policy for vital sign monitoring after birth.

The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, the nurse would expect which birth mother to have the most severe afterbirth pains? G3, P3 client who is breastfeeding their infant G2, P2 cesarean client who had a cesarean birth and who is bottle-feeding their infant G4, P1 client who is breastfeeding their infant G3, P3 client who is bottle-feeding their infant

G3, P3 client who is breastfeeding their infant Explanation: The major reasons for afterbirth pains are breastfeeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas so they maintain a contracted uterus. The release of oxytocin when breastfeeding also stimulates uterine contractions. There are no data to suggest any of these clients have had an overdistended uterus or currently have clots within the uterus. The G3, P3 client who is breastfeeding has the highest parity of the clients listed, which—in addition to breastfeeding—places them most at risk for afterbirth pains. The G2, P2 client who had a cesarean birth may have cramping, but it should be less than the G3, P3 client. The G3, P3 client who is bottle-feeding would be at risk for afterbirth pains because they have given birth to several children, but their choice to bottle-feed reduces the risk for pain.

A 24-year-old primipara who has given birth to a healthy neonate plans to bottle-feed the baby. What information regarding normal weight gain should the nurse include in the teaching plan? Adding rice cereal to the bottle is a good way to increase calories if weight gain is slow. Babies typically double their birth weight by 3 months. Gaining 30 g per day is a normal weight gain pattern. It is normal for a baby to lose 15% of weight before beginning to gain weight.

Gaining 30 g per day is a normal weight gain pattern. Explanation: Gaining 1 oz (30 g) a day is normal for a neonate. Initial weight loss that exceeds 10% of birth weight is abnormal. Adding rice cereal to a bottle without a medical indication increases the risk for aspiration and may promote obesity. Doubling the birth weight is typical at 5 months.

A primiparous client who is breastfeeding develops endometritis on the third postpartum day. What instructions should the nurse give to the client? The client needs to remain in bed in a side-lying position as much as possible. The condition typically is treated with intravenous (IV) antibiotic therapy. The client may require oxytocin and frequent uterine massage. The neonate will need to be bottle-fed for the next few days.

The condition typically is treated with intravenous (IV) antibiotic therapy. Explanation: Postpartum infection is a leading cause of maternal mortality in the United States. Typical treatment for the condition is IV antibiotic therapy with drugs such as clindamycin, gentamicin, or both. Cultures of the lochia will also be obtained. The neonate can continue to breastfeed as long as the birth mother desires. A switch to bottle-feeding is not necessary. The uterus tends to be firm, with increased cramping to rid the uterus of the infection. The client should be encouraged to remain in the Fowler position when in bed to allow for drainage of the lochia.

The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? a primiparous client at 48 hours postpartum after cesarean birth of a term neonate a primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate vaginally a multiparous client at 48 hours postpartum who is being discharged a multiparous client at 24 hours postpartum whose infant is in the special care nursery

a primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate vaginally Explanation: The primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client.

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) of which finding? lochia that lasts longer than 1 week bleeding that increases with breastfeeding clots the size of grapes saturating a pad in less than an hour

saturating a pad in less than an hour Explanation: A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. It is also normal to have some increases in lochia early on with breastfeeding, which causes uterine contractions. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum.

After instructing a primiparous client about suture care after a third-degree laceration repair, the nurse understands that which client statement indicates successful teaching? "I wipe the area from front to back using a blotting motion." "I can use ice packs for 3 to 4 days after birth." "I will use hot, sudsy water to clean my stitches." "Before bedtime, I will use a cold water sitz bath."

"I wipe the area from front to back using a blotting motion." Explanation: 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 for contamination. Hot, sudsy water may increase the client's discomfort and may even burn the client in a very tender area. After the first 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the first 24 hours.

A neonate is returned to the mother's room from the nursery. Within a few minutes, the mother begins to undress her baby to check the diaper. How should the nurse respond? "Please remember to keep the baby covered and warm as much as possible." "We just changed the diaper, so it should be fine. Take this time to rest." "Let me know if you need any assistance or supplies for you or the baby." "I will need to take the baby back to the nursery to recheck the temperature."

"Let me know if you need any assistance or supplies for you or the baby." Explanation: The behavior demonstrated by the mother is normal during the "taking-hold" phase. This phase is characterized by a focus on the newborn, including dressing and undressing the baby, checking the umbilical cord stump, and performing diaper changes. The nurse should anticipate and support this behavior; criticizing the mother or discouraging the action is inappropriate. It is unlikely that the neonate would become chilled during this brief time of being undressed. Therefore, rewrapping the neonate and returning to the nursery to check temperature isn't necessary.

The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care? Ask if the client is bottle feeding. Assess the client's legs for thrombophlebitis. Have the client see the healthcare provider in 2 weeks. Assess the client's bleeding flow and color.

Assess the client's bleeding flow and color. Explanation: The client is 2 weeks postpartum and the fundus should be deep in the pelvis. Six to 12 hours after birth, the fundus should be at the umbilicus. Then, each postpartum day, the fundus should decrease one finger breadth under the umbilicus. Bottle feeding will not affect the level of the fundus. Assessment of the client's legs will not affect the client's fundus level. However, bleeding and color will provide further assessment of the client's postpartum healing status. Waiting to 2 weeks for the client to see the healthcare provider is too long.

During a home visit to a breastfeeding primiparous client 1 week after birth, the client tells the nurse that their nipples have become sore and cracked from the feedings. Which instruction should the nurse give the client? Position the baby with as much of the areola as possible in the baby's mouth. Feed the baby less often for the next several days. Use a mild soap while in the shower to prevent an infection. Wipe off any lanolin creams from the nipple before each feeding.

Position the baby with as much of the areola as possible in the baby's mouth. Explanation: Even if the nipples are sore and cracked, the client should position the baby with the entire areola in the baby's mouth so that the nipple is not compressed between the baby's gums during feeding. The best method is to prevent cracked nipples before they occur. This can be done by feeding frequently and using proper positioning. Warm, moist tea bags can soothe cracked nipples because of the tannic acid in the tea. Creams on the nipples should be avoided; wiping off any lanolin creams from the nipple before each feeding can cause further soreness. Feeding the baby less often for the next few days will cause engorgement (and possible neonatal weight loss), leading to additional problems. Soap use while in the shower should be avoided to prevent drying and removal of protective oils.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client? The newborn will be monitored closely for possible sensitization blood reaction. The father of the newborn will need to have Rh-factor testing performed. The client will need Rh immunoglobulin injection within 72 hours. The infant will require Rh immunoglobulin injection within 72 hours.

The client will need Rh immunoglobulin injection within 72 hours. Explanation: A mother who is Rh-factor negative should receive Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the client. During birth, the newborn's Rh-positive cells can enter maternal circulation. Ideally, the mother should have received a schedule of RhoGAM to prevent initial isoimmunization against fetal erythrocytes and the formation of antibodies. Since the newborn's Rh factor is known, the father's status is not relevant (but would be positive because Rh negativity is a recessive trait). The newborn is not given the RhoGAM; it is the mother who is at risk for a sensitization reaction.

Four hours after the cesarean birth of a neonate weighing 4000 g (8 lb, 13 oz), the primiparous client asks, "If I get pregnant again, will I need to have a cesarean?" When responding to the client, the nurse should base the response about vaginal birth after cesarean (VBAC) on which standard of practice? VBAC is not possible because the neonate was large for gestational age. A history of rapid labor is a necessary criterion for VBAC. A low transverse incision contraindicates the possibility for VBAC. VBAC may be possible if the client has not had a classic uterine incision.

VBAC may be possible if the client has not had a classic uterine incision. Explanation: VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A health care provider (HCP) must be available, and a cesarean birth must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. An estimated fetal weight of more than 4000 g (8 lb, 13 oz) by itself is not a contraindication if the client does not have diabetes.

When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? blindness secondary to gonorrhea strabismus resulting from neonatal maturation cataracts from beta-hemolytic streptococcus chorioretinitis from cytomegalovirus

blindness secondary to gonorrhea Explanation: The instillation of erythromycin into the neonate's eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the birth parent. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate's eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a birth parent with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.

A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen orally. When does the nurse instruct the client to take the medication? before going to bed midway between feedings immediately after a feeding when providing supplemental formula

immediately after a feeding Explanation: Taking ibuprofen 200 mg orally immediately after breastfeeding helps minimize the neonate's exposure to the drug because drugs are most highly concentrated in the body soon after they are taken. Most birth parents breastfeed on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decreased by the next breastfeeding session. Taking the medication before going to bed is inappropriate because, although the birth parent may go to bed at a certain time, the neonate may wish to breastfeed soon after the birth parent goes to bed. If the parent takes the medication midway between feedings, its peak action may occur midway between feedings. Breast milk is sufficient for the neonate's nutritional needs. Most breastfeeding parents should not be encouraged to provide supplemental feedings to the infant because this may result in nipple confusion.

A 25-year-old primiparous client who gave birth 2 hours ago has decided to breastfeed their neonate. Which instruction should the nurse address as the highest priority in the teaching plan about preventing nipple soreness? placing as much of the areola as possible into the baby's mouth smoothly pulling the nipple out of the mouth after 10 minutes removing any remaining milk left on the nipple with a soft washcloth keeping plastic liners in the bra to keep the nipple drier

placing as much of the areola as possible into the baby's mouth Explanation: Several methods can be used to prevent nipple soreness. Placing as much of the areola as possible into the neonate's mouth is one method. This action prevents compression of the nipple between the neonate's gums, which can cause nipple soreness. Other methods include changing position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple soreness. Instead, air drying is recommended. Pulling the baby's mouth out smoothly after only 10 minutes may prevent the baby from receiving the entire feeding and increases nipple soreness. Any breast milk remaining on the nipples should not be wiped off because the milk has healing properties.

A client who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that they will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when they report that Rho(D) immune globulin has which action? protecting their next baby if it is Rh negative preventing antibody formation in their blood preventing jaundice in the baby preventing antigen formation in the baby's blood

preventing antibody formation in their blood Explanation: Rho(D) immune globulin is given to new birth parents who are Rh negative and not previously sensitized and who have given birth to an Rh-positive infant. Rho(D) immune globulin must be given within 72 hours of the birth of the infant because antibody formation begins at that time. The vaccine is used only when the client has borne an Rh-positive infant—not an Rh-negative infant. Rho(D) immune globulin is not given to a newborn and does not affect antigen formation. Administering Rho(D) immune globulin after birth reduces the risk for hyperbilirubinemia in newborns from future pregnancies, but it will not reduce the risk to the current newborn.

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be thin and white. continuous with red clots. brown and scant. red and moderate.

red and moderate. Explanation: During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? removing the initial dressing for incision inspection assisting with parent-neonate bonding supporting self-esteem concerns about the birth monitoring pain status and providing necessary relief

removing the initial dressing for incision inspection Explanation: Nursing care should never include removing the initial dressing put on in the operating room. Therefore, if a nurse performs this action, intervention is needed. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate and therefore incorrect answers to this question.

During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing? the taking-hold phase the taking-in phase the binding-in phase the letting-go phase

the taking-hold phase Explanation: The taking-in phase is the period after birth characterized by the women's dependency and passivity with others. Maternal needs are dominant and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is the period after birth characterized by a woman becoming more independent and most interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together.

An adolescent primiparous client 24 hours postpartum asks the nurse how often they can hold their newborn without "spoiling" the baby. Which response would be most appropriate? "Hold them when they are fussy or crying." "Hold them as much as you want to hold them." "Try to hold them infrequently to avoid overstimulation." "You can hold them periodically throughout the day."

"Hold them as much as you want to hold them." Explanation: According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, singing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The birth parent can hold the neonate as often as they want, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? "Medroxyprogesterone has a high failure rate; use a barrier form of protection also." "Medroxyprogesterone can't be given to breast-feeding women." "Medroxyprogesterone is effective for only 2 months at a time." "Medroxyprogesterone needs to be administered every 12 weeks."

"Medroxyprogesterone needs to be administered every 12 weeks." Explanation: Medroxyprogesterone will provide effective birth control for 3 months, and it may be the birth-control method of choice for clients who are breast-feeding because studies haven't established any contraindications. There is no evidence that the drug has a high failure rate.

Which client statement indicates effective teaching about burping a breastfed neonate? "I will breastfeed my baby every 3 hours so I will not have to burp the baby." "Breastfed babies who are burped frequently will take more on each breast." "When I switch to the other breast, I will burp the baby." "If I supplement the baby with formula, I will rarely have to burp the baby."

"When I switch to the other breast, I will burp the baby." Explanation: Breastfed neonates do not swallow as much air as bottle-fed neonates, but they still need to be burped. Good times to burp the neonate are when the birth parent switches from one breast to the other and at the end of the breastfeeding session. Neonates do not eat more if they are burped frequently. Breastfeeding parents are advised not to supplement the feedings with formula because this may cause nipple confusion and decrease milk production. If supplements are given, the baby still needs to be burped. Neonates who are fed every 3 hours still need to be burped.

While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next? Massage the client's fundus vigorously. Ask the client if they passed clots with their previous births. Document this observation as a normal finding. Review the client's records for the length of the third stage of labor.

Document this observation as a normal finding. Explanation: The passage of two small blood clots from a multiparous woman 1 hour after a vaginal birth is not an unusual occurrence. The nurse should continue to monitor the client and document this as a normal finding.The nurse should never massage a postpartum client's fundus vigorously because of the risk for uterine inversion and discomfort to the birth parent.Asking whether the client passed clots with previous births is irrelevant.The length of the third stage of labor has no relation to whether or not the client passes clots.

Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next? Document this as a normal finding in the client's record. Gently massage the fundus to expel the clots. Contact the health care provider (HCP) for a prescription for oxytocin. Encourage the client to ambulate to the bathroom and void.

Encourage the client to ambulate to the bathroom and void. Explanation: At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding, and if voiding does not return it to midline, it should be reported to the HCP. Oxytocin is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.

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? Explain that the unit is short staffed and that the nurses are doing the best they can. Encourage the family to identify their frustrations and fears. Call the nurse manager to speak with the couple. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit.

Encourage the family to identify their frustrations and fears. Explanation: This response will assist the family in identifying their frustrations and fears so the nurse can work toward resolving their issues. It is inappropriate to tell the client about staffing-related issues or to give them a time limit for which they are able to express their concerns. The nurse manager may need be brought into the situation but first the nurse should try to work toward resolving the issues with the clients.

A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? Call the nursery to ask which baby is missing. Go to the obstetrics unit to determine if they need help with the situation. Move to the entrance of the hospital and check each person leaving. Observe individuals in the area for large bags or oversized coats.

Observe individuals in the area for large bags or oversized coats. Explanation: The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be the responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.

Which measure included in the care plan for a client in the fourth stage of labor requires revision? Perform perineal assessments for swelling and bleeding. Have the client spend time with the neonate to initiate breast-feeding. Obtain an order for catheterization to protect the bladder from trauma. Check vital signs and fundal checks every 15 minutes.

Obtain an order for catheterization to protect the bladder from trauma. Explanation: While catheterization is done for a postpartum complication of urinary retention, it isn't routinely done to protect the bladder from trauma. The other options are appropriate measures to include in the care plan during the fourth stage of labor, which begins with placental expulsion and extends through the next 1 to 2 hours.

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that their breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure? Take a moderately strong analgesic medication after the infant breastfeeds on both sides. Discontinue breastfeeding immediately and replace it with bottle-feeding during the night. Apply ice packs to the breasts for 20 minutes just before breastfeeding the newborn. Express a small amount of breast milk before breastfeeding.

Express a small amount of breast milk before breastfeeding. Explanation: The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breastfeed. Frequent feedings with complete emptying of the breasts should alleviate engorgement.There is no reason why the client needs to discontinue breastfeeding. Rather, more frequent breastfeeding is indicated.Ice packs can be used to relieve edema and pain but should be used between feedings, not immediately before a feeding. Warm compresses may be used to help stimulate milk flow.Although the client's breasts are tender, this tenderness is a result of the engorgement. A strong analgesic medication will not alleviate breast engorgement. Expressing the milk and feeding the neonate are most effective in relieving the problem.

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate? A hematoma will likely develop. The episiotomy site is infected. The client has had a repair of a vaginal laceration. The client needs application of an ice pack.

The client needs application of an ice pack. Explanation: An episiotomy that is edematous and slightly reddened 8 hours after birth is normal. Therefore, the nurse should offer the client an ice pack to provide some relief from the perineal pain for the first 24 hours. An infection is present if greenish, purulent drainage is observed from the site. The edema and discoloration of the episiotomy at this time after birth are normal and do not indicate that a hematoma is likely to develop. A laceration when repaired should appear intact with edges well approximated, clean, and dry.

A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? The implants cost less over the long term than other contraceptive methods. The implants require a lower hormonal dose than other hormonal contraceptive methods. The implants can be removed easily if pregnancy occurs. The implants provide effective, continuous contraception that isn't user dependent.

The implants provide effective, continuous contraception that isn't user dependent. Explanation: Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception that isn't user dependent. The effectiveness of other methods, such as the condom, diaphragm, and oral contraceptives, depends at least partly on the user's knowledge, skills, and motivation.

A primiparous client is on a regular diet 24 hours postpartum. The client's parent asks the nurse if they can bring some "special foods from home." The nurse responds, based on the understanding of which principle? The client's health care provider (HCP) needs to give permission for the foods. Foods from home are generally discouraged on the postpartum unit. This is permissible as long as the foods are nutritious and high in iron. The parent can bring the client any foods that they desire.

The parent can bring the client any foods that they desire. Explanation: On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the HCP's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease: certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the parent to bring the client "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.

A postpartum client asks the nurse about the rhythm (symptothermal) method of family planning. The nurse explains that this method involves using hormones that prevent ovulation. using chemical barriers that act as spermicidal agents. using mechanical barriers that prevent sperm from reaching the cervix. determining the fertile period to identify safe times for sexual intercourse.

determining the fertile period to identify safe times for sexual intercourse. Explanation: The symptothermal method of family planning combines basal body temperature measurement with analysis of cervical mucus changes to determine the fertile period more accurately and thus identify safe and unsafe periods for sexual intercourse. A natural family planning method doesn't involve use of chemical barriers, hormones, or mechanical barriers

The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The client is bottle-feeding the baby. Which client finding indicates a problem at this time? menstrual discharge striae that are silver in color soft breasts without milk firm fundus at the symphysis

firm fundus at the symphysis Explanation: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Menstruation can normally return after 6 to 8 weeks in nonbreastfeeding clients. Other normal expectations include striae that are beginning to fade to silver and breasts that are soft without evidence of milk production (in a bottle-feeding client).

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? firm, round uterus uterus in the midline position fundus one fingerbreadth below the umbilicus fundus two fingerbreadths above the umbilicus

fundus two fingerbreadths above the umbilicus Explanation: Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum.

During the early postpartum period, a nurse is evaluating several clients' attachment to their neonates. Which client is the highest priority for the nurse? one whose parent died recently one with little knowledge of parent-neonate attachment one who lost a job recently one who is an only child

one whose parent died recently Explanation: A person in the process of detachment, which is necessary after a parent's death, may have difficulty forming an attachment to a neonate. To promote parent-neonate attachment, the nurse must be aware of recent family events. The nurse can overcome a parent's lack of knowledge about attachment through teaching and by providing the appropriate environment. Although job loss is stressful, it's less of a barrier to attachment than parental loss. Being an only child has little or no effect on one's ability to form an attachment with a neonate.

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further? perineal lacerations uterine inversion retained placental tissue bladder distention

perineal lacerations Explanation: A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspection. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case, the fundus would be soft, possibly boggy, and displaced from the midline.

The community health nurse is providing education to a client who gave birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage? peripad soaked over the course of 1 hour passing a quarter-sized clot foul smelling lochia backache

peripad soaked over the course of 1 hour Explanation: With a late postpartum hemorrhage (greater than 72 hours), women report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.

A nurse is providing care for a postpartum client. Which condition increases this client's risk for a postpartum hemorrhage? hypertension severe pain placenta previa uterine infection

placenta previa Explanation: The client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the lower uterine segment doesn't contract as well as the fundal part of the uterus; therefore, more bleeding occurs. Hypertension, severe pain, and uterine infection don't increase the client's risk for postpartum hemorrhage.

The nurse is caring for a woman who gave birth vaginally to a healthy 6 pound (2.72 kg) newborn after a 2-hour labor at 37 weeks gestation. For which complication will the nurse assess as a priority due to the increased risk in this client? delay in lactation postpartum hemorrhage postpartum infection delayed infant bonding

postpartum hemorrhage Explanation: The client's labor was under 3 hours in length, which meets the definition for precipitous labor. This increases the risk for postpartum hemorrhage but decreases the risk for infection. The client is at early term (37 weeks) and gave birth vaginally without any noted complications, so there should be no delay in either lactation or infant bonding.

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) of which finding? lochia that lasts longer than 1 week bleeding that increases with breastfeeding saturating a pad in less than an hour clots the size of grapes

saturating a pad in less than an hour Explanation: A postpartum client who saturates a pad in an hour or less at any time in the postpartum period is considered to be hemorrhaging. As the normal postpartum client heals, bleeding changes from red to pink to off-white. It also decreases in amount each day. It is also normal to have some increases in lochia early on with breastfeeding, which causes uterine contractions. Passing blood clots the size of a fist or larger is a reportable problem. Lochia varies in how long it lasts and is considered normal up to 6 weeks postpartum

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care? contacting local law enforcement urine toxicology screening notifying hospital security limiting contact with visitors

urine toxicology screening Explanation: A urine toxicology screening will be collected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal system will be activated to provide and ensure protective custody for this child. Hospital security would not become involved unless the birth parent is obtaining or using drugs on hospital premises. The parent and infant have the same privileges as any hospitalized clients unless the safety of the infant is jeopardized; thus, limiting contact with visitors would not be appropriate. Local law enforcement agencies would be contacted only if the parent initiates the use of drugs on hospital premises, and such contact would be made through the hospital security system.