Postpartum Period
A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response? "Gloves help protect you against infectious organisms." "Gloves guard you against my cold hands." "Gloves may protect me against infectious organisms." "Gloves are required for standard precautions."
"Gloves are required for standard precautions."
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 state that she may attempt another pregnancy after 3 months of follow-up care. Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises. 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 use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.
A primiparous non-breastfeeding client at 48 hours postpartum is to be given medroxyprogesterone before discharge. What information should the nurse include in the teaching plan before administering this medication? There is an increased risk of ovarian cancer with use of this drug. Amenorrhea is common during the first 6 months. Heavy menstrual bleeding may occur. The client may experience periods of increased energy.
Heavy menstrual bleeding may occur.
During a postpartum parenting class, a client tells the nurse that to save on the cost of formula, the client has switched her 6-month infant from formula to cow's milk. Which one of the following statements made by the nurse would be the best? "Cow's milk has as lower amounts of protein. The infant will need additional amounts of milk to meet the infant's needs." "Cow's milk has higher amounts of iron, which could interfere with blood volume." "Powdered formula can be blended with cow's milk to supplement." "Cow's milk can be safely given to an infant older than one year of age."
"Cow's milk can be safely given to an infant older than one year 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
Which of the following behaviors would indicate to the nurse that follow-up is needed for a client having difficulty attaching to her newborn? talks to the baby in a high-pitched tone when the baby's eyes are open responds verbally to any sounds emitted by the baby holds the baby in the en face position lets the baby cry to get to sleep
lets the baby cry to get to sleep
A client recently gave birth. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug? to stimulate lactation to treat eclampsia to reduce postpartum bleeding to treat erythroblastosis
to stimulate lactation
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? urine toxicology screening notifying hospital security limiting contact with visitors contacting local law enforcement
urine toxicology screening
The nurse palpates a client's fundus, and notes it is 1 in. (3 cm) above the umbilicus and displaced to the right. What would be priority nursing actions? Select all that apply. Assist to semi-Fowler's position and reassess the fundus. Carefully observe the client for any discomfort. Massage the fundus and express clots. Have the client void and reassess the fundus. Ask the client how many pads she is soaking per hour.
Have the client void and reassess the fundus. Ask the client how many pads she is soaking per hour.
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? Post accolades to the nurse at the nurses' station. Send the colleague an anonymous card. Share the feedback with the nursing colleague directly. It is a breach of confidentiality to share this information with the colleague.
Share the feedback with the nursing colleague directly.
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? The client needs application of an ice pack. The episiotomy site is infected. A hematoma will likely develop. The client has had a repair of a vaginal laceration.
The client needs application of an ice pack.
During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When the nurse is developing the client's plan of care, which problem should the nurse expect to assess for frequently? respiratory depression increased pulse rate hypertension uterine atony
uterine atony
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? "Breastfeeding alters your hormones and provides adequate protection against pregnancy." "Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding." "Combined oral contraceptive pills are a good option for breastfeeding mothers." "Spermicidal foam protects against pregnancy as effectively as other methods."
"Barrier approaches, such as condoms or cervical caps, will not interfere with breastfeeding."
A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which problem? fatigue fainting bleeding hygiene needs
fainting
A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? uterus in the midline position firm, round uterus fundus two fingerbreadths above the umbilicus fundus one fingerbreadth below the umbilicus
fundus two fingerbreadths above the umbilicus
The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem? hypoglycemia hyperbilirubinemia hemorrhage polycythemia
hemorrhage
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-in phase the taking-hold phase the binding-in phase the letting-go phase
the taking-hold phase
Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when they state which effect is the purpose of the drug? to thin the blood clots to increase the flow of lochia to increase the perspiration for diuresis to prevent further blood clot formation
to prevent further blood clot formation
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? Request a prescription to administer oxytocin. Perform an in-and-out catheter immediately. Measure blood loss by measuring the perineal pad. Check the fundus for position and consistency.
Check the fundus for position and consistency.
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? 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. Take a moderately strong analgesic medication after the infant breastfeeds on both sides. Express a small amount of breast milk before breastfeeding.
Express a small amount of breast milk before breastfeeding.
A 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 care for the neonate completely by time of discharge. The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment. The client demonstrates an understanding of her physical needs related to labor and birth. The client demonstrates an understanding of the neonate's physical needs related to labor and birth.
The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.
After the first breastfeeding, the client asks the nurse, "How often should I try to breastfeed?" What frequency should the nurse recommend? at least every hour for the first 48 hours every 2 to 3 hours for the first 48 hours every 4 to 5 hours for the first 5 days after birth whenever the client desires, until weaning occurs
every 2 to 3 hours for the first 48 hours
In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? shock disseminated intravascular coagulation (DIC) hemorrhage infection
hemorrhage
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? "Insulin will be transferred to the baby through breast milk." "Breastfeeding is not recommended for birth mothers with diabetes." "Breast milk from birth mothers with diabetes contains few antibodies." "Breastfeeding will assist in lowering maternal blood glucose."
"Breastfeeding will assist in lowering maternal blood glucose."
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 experience shorter periods between feedings." "Formula-fed infants digest their milk more rapidly." "Formula-fed infants demand to feed every 1.5 to 3 hours." "Formula-fed infants usually feed every 3 to 4 hours."
"Formula-fed infants usually feed every 3 to 4 hours."
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."
When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information? The vaccine prevents a future fetus from developing congenital anomalies. Pregnancy should be avoided for 4 weeks after the immunization. The client should avoid contact with children diagnosed with rubella. The injection will provide immunity against chickenpox.
Pregnancy should be avoided for 4 weeks after the immunization.
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 choosing an injection site that isn't tender instructing the client that she won't need an additional vaccination after her next pregnancy documenting administration of the drug in the client's chart
ensuring that the client understands the procedure and signs a consent for the vaccination
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? bleeding that increases with breastfeeding clots the size of grapes saturating a pad in less than an hour lochia that lasts longer than 1 week
saturating a pad in less than an hour
A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called? taking-in phase taking-hold phase letting-go phase taking-over phase
taking-in phase
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? Move to the entrance of the hospital and check each person leaving. Go to the obstetrics unit to determine if they need help with the situation. Call the nursery to ask which baby is missing. Observe individuals in the area for large bags or oversized coats.
Observe individuals in the area for large bags or oversized coats.
The nurse returns the newborn to the new mother after obtaining assessment data and performing newborn interventions. The nurse recognizes the best evidence of positive bonding when the mother: engages in direct eye contact with the infant. takes multiple photos of the infant to share on social media. asks the nurse many questions about caring for the infant. gently taps the baby's back after feeding.
engages in direct eye contact with the infant.
The nurse is assessing a client who is 4 hours postpartum. Based on the findings documented by the nurse, which action is most appropriate at this time? Ask the client to empty her bladder. Raise the head of the bed. Call the client's primary healthcare provider for direction. Straight-catheterize the client for half of her urine volume. Notify the charge nurse of the assessment findings.
Ask the client to empty her bladder.
A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift? Gravida, term, preterm, abortion, living. Cervical effacement, dilation, station. Support person with the client. Bottle- or breastfeeding preference.
Bottle- or breastfeeding preference.
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? Foods from home are generally discouraged on the postpartum unit. The parent can bring the client any foods that they desire. This is permissible as long as the foods are nutritious and high in iron. The client's health care provider (HCP) needs to give permission for the foods.
The parent can bring the client any foods that they desire.
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? Wear a loose-fitting bra to avoid constricting the milk ducts. Stop breast-feeding permanently. Take antibiotics until the pain is relieved. Use a warm moist compress over the painful area.
Use a warm moist compress over the painful area.
The nurse is screening a group of postpartum mothers. Which of the following clients would be the lowest priority for screening for postpartum depression? a client who is in a long-term relationship a client who has a supportive relationship with her physician a client who is in an ongoing relationship with other mothers with young children a client who has knowledge of how to recognize postpartum depression
a client who is in an ongoing relationship with other mothers with young children
A postpartum primiparous client is having difficulty breastfeeding their infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when they make which statement? "The baby needs to have as much of the nipple and areola in the mouth as possible to prevent sore and cracked nipples." "I can put breast milk on my nipples to heal the sore areas." "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk." "Feeding the baby for a half-hour on each side will not make my breasts sore."
"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."
After teaching a primiparous client about treatment and self-care of mastitis of the right breast, the nurse determines that the client needs further instruction when they make which statement? "I can apply localized heat to the infected area." "I should increase my fluid intake to 2000 mL a day." "I will need to take antibiotics for 7 to 10 days before I am cured." "I should begin breastfeeding on the right side to decrease the pain."
"I should begin breastfeeding on the right side to decrease the pain."
A 15-year-old primiparous client is being cared for in the hospital's birthing center after the vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours after birth, the client asks if she can feed the baby. Which response would be most appropriate? "I'll bring the baby to you for feeding." "I think we should ask your health care provider if this is a good idea." "It's not a good idea for you to have any contact with the baby." "I'll check with the social worker to see if the adopting parents will permit this."
"I'll bring the baby to you for feeding."
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? "I can expect to have heart palpitations for several weeks." "It's normal for me to have reddish lochia until my 6-week checkup." "Any varicosities I had during pregnancy will disappear within 2 weeks." "My menstrual flow should resume in approximately 6 to 10 weeks."
"My menstrual flow should resume in approximately 6 to 10 weeks."
A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse? "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby." "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with RH negative blood after giving birth to an Rh negative baby."
"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby."
Which client statement indicates effective teaching about burping a breastfed neonate? "Breastfed babies who are burped frequently will take more on each breast." "If I supplement the baby with formula, I will rarely have to burp the baby." "I will breastfeed my baby every 3 hours so I will not have to burp the baby." "When I switch to the other breast, I will burp the baby."
"When I switch to the other breast, I will burp the baby."
After suction and evacuation of a complete hydatidiform mole, a 28-year-old multigravid client asks the nurse when they can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? 6 months 12 months 18 months 24 months
12 months
A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period? 12 hours 24 hours 2 to 4 days 7 days
2 to 4 days
A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? Apply an ice pack to her perineum. Take a sitz bath. Perform perineal care after voiding or a bowel movement. Drink plenty of fluids.
Apply an ice pack to her perineum.
The nurse assesses a swollen ecchymosed area to the right of a laceration on a primiparous client 6 hours after a vaginal birth. What should the nurse should do next:? Apply an ice pack to the perineal area. Assess the client's temperature. Have the client take a warm sitz bath. Contact the health care provider (HCP) for prescriptions for an antibiotic.
Apply an ice pack to the perineal area.
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? Assess the client's bleeding flow and color. Ask if the client is bottle feeding. Have the client see the healthcare provider in 2 weeks. Assess the client's legs for thrombophlebitis.
Assess the client's bleeding flow and color.
A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first? Assess the lochia. Reassess in 1 hour. Catheterize the client. Obtain a prescription for a fluid bolus.
Catheterize the client.
A nurse is caring for a client with history of a warm, reddened, painful area in the breast diagnosed as mastitis as well as cracked and fissured nipples. The client expresses the desire to continue breast-feeding throughout treatment. Which instructions would the nurse include to prevent a recurrence of this condition? Select all that apply. Wash the nipples with soap and water. Change the breast pads frequently. Expose the nipples to air for part of each day. Wash hands before handling the breast and breast-feeding. Make sure that the neonate grasps the nipple only. Release the neonate's grasp on the nipple before removing the neonate from the breast.
Change the breast pads frequently. Expose the nipples to air for part of each day. Wash hands before handling the breast and breast-feeding. Release the neonate's grasp on the nipple before removing the neonate from the breast.
While caring for a multiparous client 4 hours after the vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. The fundus is firm, midline, and at the level of the umbilicus. What should the nurse do? Continue to monitor the client's vital signs. Assess the client's lochia for large clots. Notify the client's health care provider (HCP) about the findings. Offer the client an ice pack for their forehead.
Continue to monitor the client's vital signs.
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. Contact the health care provider (HCP) for a prescription for oxytocin. Encourage the client to ambulate to the bathroom and void. Gently massage the fundus to expel the clots.
Encourage the client to ambulate to the bathroom and void.
A female client who gave birth to a healthy baby 6 hours ago is having cramps in their legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take? Tell the client to massage the area. Apply warm compresses to the area. Instruct the client on how to do ankle pumps. Notify the health care provider (HCP).
Notify the health care provider (HCP).
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. Discuss the situation with the nursing student after the visit has ended. Ask the client and student who initiated the idea for these arrangements. Immediately report the incident to the student's professor.
Discuss the situation with the nursing student after the visit has ended.
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? Notify security because the neonate's father is demanding to see his baby. Teach the grandparents how to scrub and gown before entering the nursery. Discuss the unit's policy with the charge nurse. Invite everyone into the large conference room to see the neonate.
Discuss the unit's policy with the charge nurse.
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? Notify security because the neonate's father is demanding to see his baby. Teach the grandparents how to scrub and gown before entering the nursery. Discuss the unit's policy with the charge nurse. Invite everyone into the large conference room to see the neonate.
Discuss the unit's policy with the charge nurse.
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. Review the client's records for the length of the third stage of labor. Document this observation as a normal finding.
Document this observation as a normal finding.
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. 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.
Encourage the family to identify their frustrations and fears.
The nurse is caring for a new breastfeeding client who is experiencing poor latching and sore nipples. What direction would the nurse offer to best address this breastfeeding issue? Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth. Dry the nipples well after feeding to prevent fungal infection, which can increase soreness. Avoid stimulating the baby before feeding because it causes poor latching and aggressive sucking. Do not pull the baby off the breast during painful feeding; instead, reposition slightly and wait a few minutes.
Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth.
During a home visit on the fourth postpartum day, a primiparous client tells the nurse that they have been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing the baby? Apply an ice cube to the nipples. Rub the nipples gently with lanolin cream. Express a small amount of breast milk. Offer the neonate a small amount of formula.
Express a small amount of breast milk.
A primiparous client who will be bottle-feeding their neonate asks, "What is the best position for the baby to nap after feeding?" What should the nurse recommend? Place the baby in a supine position after feedings. Keep the baby wedged on their left side 20 minutes after feedings. Place the baby prone after feedings if they spit up frequently. Hold the baby upright for 15 to 20 minutes before placing them down for a nap.
Hold the baby upright for 15 to 20 minutes before placing them down for a nap.
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? Reassure the partner that the student nurse will be professional. Ask the partner to leave the premises. Ask the partner about any concerns. Honor the partner's preference.
Honor the partner's preference.
A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage the client care assignment? Call the obstetrician and ask to postpone the cesarean birth. Refuse to accept the new admission. Ask the administrative assistant to complete the new client's paperwork. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients.
Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients.
The nurse is caring for a client who is 22 hours postpartum and is saturating a peripad every 2-3 hours. What actions should the nurse take first? Begin a pad count and weigh each pad. Interview the client about symptoms. Instruct client to lie down and elevate legs. Perform lying and standing blood pressure.
Interview the client about symptoms.
During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end? It should begin early in the third trimester and end 1 month after childbirth. It should begin before conception and end 3 months after childbirth. It should begin when the client learns she's pregnant and end after childbirth. It should begin at about 5 months' gestation and end at facility discharge.
It should begin before conception and end 3 months after childbirth.
Which measure included in the care plan for a client in the fourth stage of labor requires revision? Check vital signs and fundal checks every 15 minutes. Have the client spend time with the neonate to initiate breast-feeding. Obtain an order for catheterization to protect the bladder from trauma. Perform perineal assessments for swelling and bleeding.
Obtain an order for catheterization to protect the bladder from trauma.
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? Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. 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 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.
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? 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. Feed the baby less often for the next several days. Use a mild soap while in the shower to prevent an infection.
Position the baby with as much of the areola as possible in the baby's mouth.
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? limiting fluid intake to 1 L daily to prevent overload emptying the bladder every 2 to 4 hours while awake washing the perineum with povidone-iodine after voiding avoiding the intake of acidic fruit juices until the treatment is discontinued
emptying the bladder every 2 to 4 hours while awake
A multigravida prenatal client with a history of postpartum depression tells the nurse that they are taking measures to make sure that they don't suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make? current medications fetal growth liver functions mood status
current medications
A postpartum client asks the nurse about the rhythm (symptothermal) method of family planning. The nurse explains that this method involves using chemical barriers that act as spermicidal agents. using hormones that prevent ovulation. 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.
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? dizziness hypertension diarrhea urinary frequency
dizziness
While caring for a postpartum client who is receiving treatment with bed rest and intravenous heparin therapy for a deep vein thrombosis, the nurse should contact the client's health care provider (HCP) immediately if the client exhibits which symptom? pain in their calf dyspnea hypertension bradycardia
dyspnea
When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate? administering aspirin as ordered encouraging increased fluid intake reassessing vital signs every 15 minutes requesting an antibiotic order
encouraging increased fluid intake
While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours after a cesarean birth, the client requests assistance in breastfeeding. To promote maximum maternal comfort, which position would be most appropriate for the nurse to suggest? football hold scissors hold cross-cradle hold cradle hold
football hold
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? retained placental tissue uterine inversion bladder distention perineal lacerations
perineal lacerations
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 anxiety postpartum reaction postpartum depression
postpartum baby blues
A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed? postpartum hemorrhage puerperal infection urinary tract infection pyelonephritis uterine rupture
postpartum hemorrhage
The nurse makes a home visit to a primigravid client on the fourth postpartum day after the birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that they have not been sleeping well and they have been hearing voices. The nurse determines that the client is most likely experiencing which condition? normal reactions to being a new mother postpartum psychosis the "baby blues" postpartum depression
postpartum psychosis
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? praise and encouragement detailed written instructions family availability for assistance acceptance by the client's peers
praise and encouragement
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 antigen formation in the baby's blood preventing jaundice in the baby
preventing antibody formation in their blood
During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and they are experiencing chills. During palpation of the uterus, the client indicates that they are very sore. The nurse should further assess the client for which problem? normal uterine involution retained placental fragments puerperal infection uterine atony
puerperal infection
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 makes sure that the nipple fills with formula. strokes the neonate's lips gently with the nipple. uses a nipple with regular size openings. pushes only the tip of the nipple into the neonate's mouth.
pushes only the tip of the nipple into the neonate's mouth.
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 monitoring pain status and providing necessary relief supporting self-esteem concerns about the birth assisting with parent-neonate bonding
removing the initial dressing for incision inspection
On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described? alba thrombic serosa rubra
rubra
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 tachycardia weight loss
tachycardia
Breast engorgement occurs on the second or third postpartum day in both breast-feeding and non-breast-feeding mothers. Which process causes engorgement? the body's natural response following delivery nuzzling of the neonate, which stimulates the let-down reflex vasodilation, which causes the breast to feel full a reduction in estrogen levels
vasodilation, which causes the breast to feel full
