applying knowledge for Normal Postpartum q

After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 mL/hr." The client has 750 mL in her IV and the IV tubing delivers fl uid at the rate of 10 gtt/mL. To what drip rate should the nurse set the intravenous? ______ gtt/min

42 gtt/min TEST-TAKING TIP: There are three things to remember when calculating the answer to this question: (1) the quantity of fl uid left in the IV is irrelevant because the physician has ordered the rate per hour; (2) the dosage of the medication is irrelevant because the volume of the fl uid is not related to the medication dosage; and (3) time is always converted to minutes when a drip rate is calculated. (When a pump is being calibrated, on the other hand, the drip rate is programmed in mL/hr.)

The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. On admission to the labor room. 2. In the client's room after the delivery. 3. When the client put the baby to the breast for the first time. 4. The day before the client and baby are to leave the hospital.

answer: 1 1. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room. 2. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room. 3. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room. 4. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room. TEST-TAKING TIP: Discharge teaching should begin upon entry to the hospital. If nurses wait until the time of discharge, clients are expected to process a large amount of information during a very stressful time. Even when initiated early in the hospital stay, the nurse will likely need to repeat his or her instructions many times before the client is fully prepared to leave the hospital.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

answer: 2 1. Athough there is evidence that some fathers experience postpartum depression during the months following a birth, fathers have not been shown to experience postpartum blues. 2. This information is correct. The blues usually resolve within 2 weeks of delivery. 3. Medications are usually not administered to relieve postpartum blues. Medications can be prescribed for clients who experience postpartum depression or postpartum psychosis. 4. This information is incorrect. The majority of women will experience postpartum blues during the fi rst week or two postpartum. TEST-TAKING TIP: There are three psychological changes that mothers may experience postpartum: postpartum blues, postpartum depression, and postpartum psychosis. Postpartum blues is a normal phenomenon experienced by the majority of women and is related to fatigue, hormonal shifts, and the enormous responsibility of becoming a mother. Postpartum depression and postpartum psychosis are pathological conditions that only some women experience

A nurse reports that a client has moderate lochia flow. Which of the following pads would be consistent with her evaluation? (Please mark the appropriate pad with an "X.")

moderate is 4-6 inches on pad so the third pad is correct. scant: 1 inch on pad light: 1-4 inches on pad moderate: 4-6 inches on pad heavy/large: 1 saturated pad in 1 hour excessive/massive saturated pad in 15 minutes

A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth. ___________ mL

0.4 ML

A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? 1. Weight of the uterine body is significantly reduced. 2. Excess blood volume from pregnancy is circulating in the woman's periphery. 3. Cervix is fully dilated and the lochia flows freely. 4. Maternal blood pressure drops precipitously once the baby's head emerges.

ANSWER: 2 1. Although the weight does drop precipitously when the baby is born, this is not the primary reason for the client's cardiovascular compromise. 2. This response is true. Once the placenta is birthed, the reservoir for the mother's large blood volume is gone. 3. This response is not accurate. The cervix begins to contract shortly after delivery and the lochial fl ow is not related to the cardiovascular compromise that affects all postpartum patients. 4. This is a false statement. Maternal blood pressure does not drop precipitously when the baby's head emerges. TEST-TAKING TIP: It is essential that the nurse closely monitor the vital signs of a newly delivered gravida. Because of the surge in blood volume resulting from the delivery of the placenta, the woman is at high risk for cardiovascular compromise. Women frequently develop bradycardia, a normal finding, as a result of the increased peripheral blood volume.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

ANSWER:2 1. This is an incorrect statement. 2. This statement is accurate. Mothers often do not feel bladder pressure after delivery. 3. Local anesthesia does not affect a client's ability to feel bladder distention. 4. This statement is inappropriate. The nurse should escort the woman to the bathroom to urinate. TEST-TAKING TIP: During pregnancy, the bladder loses its muscle tone because of the pressure exerted on it by the gravid uterus. As a result, after delivery mothers often fail to feel when their bladders become distended.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

ANswer: 4 1. It is not unusual for post-cesarean section clients to have had no bowel movements. The client should be advised to drink fl uids and to ambulate to stimulate peristalsis. 2. This response is inappropriate. This client is obviously very concerned about her bowel pattern. 3. This response is inaccurate. Clients who have received antibiotics often complain of diarrhea as a result of the change in their intestinal fl ora. Narcotic analgesics, however, are constipating medications. 4. Consuming fl uids and fi ber and exercising all help clients to reestablish normal bowel function. TEST-TAKING TIP: This client is 2 days postoperative. She may not be consuming a normal diet as yet, but she will be able to ambulate and to drink fl uids. Once she is able to consume foods, she should be encouraged to eat nutritious, high-fi ber foods such as fresh fruits and vegetables

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime

Answer: 1 1. Lying prone on a pillow helps to relieve some women's afterbirth pains. 2. Contracting the abdominal muscles has not been shown to alleviate afterbirth pains. 3. Ambulation has not been shown to alleviate afterbirth pains. 4. Drinking ice tea has not been shown to alleviate afterbirth pains. TEST-TAKING TIP: Afterbirth pains can be quite uncomfortable, especially for multiparas. The nurse should suggest that the clients take prn medications—ibuprofen is especially helpful—and try complementary therapies like lying on a small pillow and placing a hot water bottle on the abdomen

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fi ber foods and drink fl uids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

Amswer: 2 This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area. 2. This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum. 3. This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area. 4. This is not the best response because the answer implies that the stitches are near the rectum. The stitches are not near the rectal area. TEST-TAKING TIP: Women often are fearful of having a bowel movement when they have had an episiotomy or a laceration. Unless they have a third- or fourthdegree laceration, they should be assured that the stitches are a distance away from the rectal area.

A woman had a 3,000-gram baby via normal spontaneous vaginal delivery 12 hours ago. Place an "X" on the location where the nurse would expect to palpate her fundus.

An "X" should be placed on the line drawing at the level of the umbilicus. TEST-TAKING TIP: By 12 hours after delivery, the fundus is usually felt at the level of the umbilicus. Every postpartum day thereafter, the fundus will descend about 1 cm.

The nurse has provided teaching to a postop cesarean client who is being discharged on Colace (docusate sodium) 100 mg PO tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman understands that her urine may turn orange.

Answer: 1 1. Colace capsules should not be crushed, broken, or chewed. 2. The capsule should be taken with juice or food to minimize the bitter taste. 3. Headache is not a side effect of Colace. 4. The medication does not change the color of a client's urine. TEST-TAKING TIP: The medication, a stool softener, is contained in a capsule that must be swallowed whole. Many physicians order Colace for postoperative cesarean section clients until their bowel patterns return to normal.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

Answer: 1 1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement. 2. Massaging of the breast will stimulate more milk production. That is not the best action to take. 3. It is unnecessary to culture the breast. This client is engorged; she does not have an infection. 4. It is unnecessary to assess this client's temperature and pulse rate. This client is engorged; she is not infected. TEST-TAKING TIP: The lactating breast produces milk in response to being stimulated. When a feeding is skipped, milk is still produced for the baby. When the baby is not fed, breast congestion or engorgement results. Not only is engorgement uncomfortable, it also gives the body the message to stop producing milk, resulting in an insuffi cient milk supply.

Which of the following nursing interventions would be appropriate for the nurse to perform to achieve this client care goal: The client will not develop postpartum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fl uid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high-fi ber foods

Answer: 1 1. Early ambulation does help to prevent thrombophlebitis. 2. Oral fl uid intake does not directly prevent thrombophlebitis. 3. Massaging of the legs is not helpful and in some situations can actually be harmful. If there is a clot in one of a client's lower extremity blood vessels, it can be dislodged when the leg is vigorously massaged. 4. High-fi ber foods will prevent constipation, not thrombophlebitis. TEST-TAKING TIP: Postpartum clients are at high risk for thrombophlebitis because of an increase in the quantity of circulating clotting factors. To prevent clot formation, clients should ambulate as soon as possible after delivery. If they must be bed bound because of complications, the nurse should contact the physician for an order for antiembolic stockings and/or antiembolic pressure boots and have the client perform active range-of-motion exercises.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

Answer: 1 1. Fundal assessment is the priority nursing action. 2. Pain level assessment is important, but it is not the priority nursing action. 3. Performing pericare is important, but it is not the priority nursing action. 4. Breast assessment is important, but it is not the priority nursing action. TEST-TAKING TIP: Hemorrhage is one of the primary causes of morbidity and mortality in postpartum women. It is essential, therefore, that nurses repeatedly assess a client's postpartum uterine contraction. When the uterus is well contracted, a woman is unlikely to bleed heavily after delivery.

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

Answer: 1 1. It is appropriate to apply an ice pack to the area. 2. The sitz bath is an appropriate intervention beginning on the second postpartum day, not 2 hours after delivery. Sitz baths are usually performed 2 to 3 times a day. 3. It is not necessary for the client to sit on a pillow. 4. It is unnecessary for the client to be advised to put nothing in her rectum. Second-degree lacerations do not reach the rectum. TEST-TAKING TIP: A second-degree laceration affects the skin, vaginal mucosa, and underlying muscles. (It does not affect the rectum or rectal sphincter.) Because of the injury, the area often swells, causing pain. Ice packs help to reduce the infl ammatory response and numb the area.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary healthcare provider. 4. Increase the intravenous infusion.

Answer: 1 1. The appropriate action is to provide the client with warm blankets. 2. Postpartum shaking is very common. It is unnecessary to place the client in the Trendelenburg position. 3. Postpartum shaking is very common. It is unnecessary to notify the client's healthcare provider. 4. Postpartum shaking is very common. It is unnecessary to increase the client's intravenous fl uid rate. TEST-TAKING TIP: Postpartum shaking is thought to be caused by nervous responses and/or vasomotor changes. The shaking is very common and, unless accompanied by a fever, is of no physiological concern. The best action by the nurse is supportive—providing the client with a warm blanket and reassuring her that the response is within normal limits.

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are fi rm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary healthcare provider to order a milk suppressant.

Answer: 1 1. The client should apply ice packs to her axillae and breasts. 2. Engorgement will not be relieved by applying lanolin to the breasts. And the act of applying the lanolin may actually stimulate milk production. 3. If the woman expresses milk from her breasts, she will stimulate the breasts to produce more milk. 4. The Food and Drug Administration (FDA) recommends that milk suppressants not be administered because of the serious side effects of the medications (see http:// www.mayoclinic.org/healthy-lifestyle/ labor-and-delivery/expert-answers/lactation -suppression/faq-20058016). TEST-TAKING TIP: Breast milk is produced in the glandular tissue of the breast. An adequate blood supply to the area is required for the milk production. When cold is applied to the breast, the blood vessels constrict, decreasing the blood supply to the area. This is a relatively easy, nonhazardous action that helps to suppress breast milk production.

An Asian client's temperature 10 hours after delivery is 100.2°F but, when encouraged, she refuses to drink her ice water. Which of the following nursing actions is most appropriate? 1. Replace the ice water with hot water. 2. Notify the client's healthcare provider. 3. Reassess the temperature in one-half hour. 4. Remind the client that drinking is very important.

Answer: 1 1. This action is appropriate. Asians, many of whom believe in the hot-cold theory of disease, will often not drink cold fl uids or eat cold foods during the postpartum period. 2. This action is not necessary at this time. 3. It is unlikely that the temperature will change signifi cantly in 30 minutes. 4. This information is correct but it does not take into consideration the client's beliefs and traditions. TEST-TAKING TIP: The knowledge that consuming fl uids is important is not in confl ict with this client's traditions. There is no reason the client must consume cold fl uids. The nurse should provide the client with the warm fl uids required by her beliefs.

The obstetrician has ordered a postop cesarean section client's patient-controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.

Answer: 1 1. This answer is correct. Because the medication in a PCA pump is controlled by law, the medication must be wasted in the presence of another nurse. 2. This answer is inappropriate. A pain level of 0 is unrealistic after abdominal surgery. The nurse, however, should request that the doctor order one of the many oral analgesics to control the woman's discomfort. 3. This answer is inappropriate. Unless the nurse has a rationale to question the order, he or she should discontinue the medication as soon as the order has been received. 4. This answer is inappropriate. Once the intravenous has been punctured and used for one client, the bag cannot be reused. TEST-TAKING TIP: There are a number of considerations that the nurse must make when giving medications, especially when administering controlled substances. The nurse is legally bound to account for the administration of or the disposal of narcotic medications. If any narcotic is wasted, a second nurse must cosign the disposal.

The nurse is caring for a Seventh Day Adventist woman who delivered a baby boy by cesarean section. Which of the following questions should be asked regarding this woman's care? 1. "Would you like me to order a vegetarian diet for you?" 2. "Is there anything special you will need for your Sabbath on Sunday?" 3. "Would you like to telephone your clergy to set up a date for the baptism?" 4. "Will a rabbi be performing the circumcision on your baby?"

Answer: 1 1. This question is appropriate. Seventh Day Adventists usually follow vegetarian diets. 2. This question is inappropriate. The Seventh Day Adventist Sabbath is on Saturday, not on Sunday. 3. This question is inappropriate. Baptism in the Seventh Day Adventist tradition is performed after the child reaches the age of accountability. 4. This question is inappropriate. Rabbis are the leaders of people of the Jewish faith. And mohels, who are not necessarily rabbis, perform ritual Jewish circumcisions. TEST-TAKING TIP: There are a number of religious traditions. The nurse should be familiar with the major precepts of each religion to provide clients with holistic care.

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

Answer: 1 1. This response is correct. Reassuring the client is appropriate. 2. It is unlikely that the client has a urinary tract infection. 3. The urine will be blood tinged from the lochia. 4. This question is unnecessary. It is unlikely that the client has a urinary tract infection. TEST-TAKING TIP: Frequent urination is normal after a delivery. The urine of a postpartum client will be blood tinged. This does not mean that the client has red blood cells in her urine, but rather that the lochia from the vagina has contaminated the sample. Unless a catheterized sample is obtained, it is virtually impossible to obtain an uncontaminated urine sample in the postpartum period

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum checkup. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her fi rst postpartum menstrual period.

Answer: 1 1. This response is correct. The couple is encouraged to wait until after involution is complete. 2. Although some clients do begin having intercourse once the episiotomy is healed and lochia stops, it is recommended that clients wait the full 6 weeks. 3. The couple is encouraged to wait until after involution is complete. 4. The couple is encouraged to wait until after involution is complete. TEST-TAKING TIP: There have been some cases, albeit rare, of women dying from air emboli when they had intercourse early in the puerperium. It is recommended that couples wait 6 weeks before resuming intercourse.

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

Answer: 1 1. This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant. 2. This statement is incorrect. The immune systems of women during their pregnancies and immediately postpartum are slightly depressed. 3. This statement is incorrect. The baby will be susceptible to rubella whether or not the woman receives the vaccine. 4. In general, insurance companies will pay for vaccinations whenever they are needed.

A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. Surgical masks must be worn by the mother when she holds the baby. 4. Antibodies transported through the breast milk will protect the baby.

Answer: 1 1. This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection. 2. This is unnecessary. There is no risk to the baby whether the mother is bottle feeding or breastfeeding. 3. This statement is incorrect. There is no risk to the baby. 4. This statement is incorrect. TEST-TAKING TIP: If rubella is contracted during pregnancy, the fetus is at very high risk for injury. Whenever gravid clients are found to be nonimmune to rubella— defi ned as a titer of 1:8 or lower—they are advised to receive the vaccine during the early postpartum period and are counseled regarding the teratogenic properties of the vaccine. As important, if a nonpregnant woman of childbearing age is found to be rubella nonimmune, she is strongly advised to receive the immunization to protect any unborn children she may have in the future.

A nurse is performing a postpartum assessment on a client who delivered by cesarean section. Which of the following actions will the nurse perform? Select all that apply. 1. Auscultate the abdomen. 2. Palpate the fundus. 3. Assess the nipple integrity. 4. Assess the central venous pressure.

Answer: 1, 2, 3, and 5 are correct. 1. The nurse should auscultate the abdomen for presence of bowel sounds. 2. The nurse should palpate the firmness of the fundus. 3. The nurse should assess the nipple integrity, especially if the client is breastfeeding. 4. The central venous pressure is not assessed. 5. The nurse should auscultate the lung fi elds. TEST-TAKING TIP: Cesarean clients are surgical clients as well as postpartum clients. They should be monitored for complications associated with major abdominal surgery, for example, paralytic ileus and pneumonia. They should also be monitored for complications associated with labor, delivery, and the postpartum, for example, boggy uterus and cracked nipples. Some are reticent to palpate the fundus because of the pain it causes, but if the fundus does not contract effectively, the client is at high risk for hemorrhage—a very serious postpartum complication.

During a postpartum assessment, it is noted that a G1 P1001 woman who delivered vaginally over an intact perineum has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure

Answer: 1, 2, and 5 are correct. 1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 3. Oxytocin will have no effect on the hemorrhoids. 4. It is impossible to tell whether or not the hemorrhoids will change with subsequent pregnancies. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids. TEST-TAKING TIP: Hemorrhoids are varicose veins of the rectum. They develop as a result of the weight of the gravid uterus on the client's dependent blood vessels. In addition to the actions noted previously, the client should be advised to eat high-fi ber foods and drink fl uids to prevent constipation.

A nurse is performing a postpartum assessment on a client who delivered vaginally. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

Answer: 1,3,4, 5 1. The nurse should palpate the breasts to assess for fullness and/or engorgement. 2. The postpartum assessment does not include carotid auscultation. 3. The nurse should check the client's vaginal discharge. 4. The nurse should assess the client's extremities. 5. The nurse should inspect the client's perineum. TEST-TAKING TIP: The best way to remember the items in the postpartum assessment is to remember the acronym BUBBLEHE. The letters stand for: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemorrhoids and too inquire about most recent bowel movement); L—lochia; E—episiotomy (and perineum); H—Hormones (for emotions); and E—extremities. It is important to note that Homans sign is no longer recommended. Rather, careful inspection of the calves without dorsifl exing the foot for signs of DVT should be performed.

Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

Answer: 2 1. Although breastfeeding does have a protective effect on postpartum blood loss, involution can take up to 6 weeks in breastfeeding women as well as bottlefeeding women. 2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 diabetes later in life. 3. Women who breastfeed have not been shown to have higher levels of bone density later in life. 4. Breastfed babies are less likely to develop infections than are bottle-fed babies. The mothers, however, have not been shown to have the same protection. TEST-TAKING TIP: Breastfeeding has many benefi cial properties for both mothers and babies. It is a nursing responsibility to provide couples with the knowledge so that they can make fact-based decisions about how they will feed their babies.

The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the fi rst newborn she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to newborn care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

Answer: 2 1. Although the client is showing signs of positive bonding, she defi nitely needs a great deal of teaching. 2. This response is correct. The client is showing signs of positive bonding—en face positioning and stroking of the baby's cheeks—and is in need of information on child care. 3. This action is absolutely inappropriate at this time. There are no signs of poor bonding or of abuse. 4. There are no signs of poor bonding. TEST-TAKING TIP: This client has never held a newborn before. The nurse, therefore, should be prepared to provide the client with information on newborn care. Two signs of positive bonding are holding a baby in the en face position—so that the mother is looking directly into the baby's eyes—and stroking the baby's cheeks.

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

Answer: 2 1. An assessment of the woman's pulse rate is important, but it is not the most important assessment. 2. An assessment of the woman's fundus is the most important assessment to perform on this client. 3. An assessment of the woman's bladder is important, but it is not the most important assessment. 4. An assessment of the woman's breasts is important, but it is not the most important assessment. TEST-TAKING TIP: This client's gravidity and parity indicate that she is a grand multipara. She has been pregnant 10 times, carrying 6 babies to term and 4 babies preterm. Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period. The nurse must, therefore, monitor the postpartum contraction of her uterus very carefully.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.

Answer: 2 1. Clients in the taking in phase are not receptive to teaching. 2. During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase. 3. Clients in the taking in phase do not focus on future issues or needs. 4. Clients in the taking in phase are not receptive to teaching. TEST-TAKING TIP: The taking in postpartum phase is the fi rst phase that clients pass through after they deliver their baby. During this time they are especially "me oriented." They wish and need to be cared for. This is a time when they should be given a bed bath and allowed to rest. They take in nourishment and take in the experience that they have just been through. Primigravid and cesarean section clients often proceed more slowly through this phase than other clients.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

Answer: 2 1. Diaphoresis has usually subsided by this time. 2. The nurse would expect that the client would have lochia alba. 3. The nurse would not expect the client's nipples to be cracked. 4. The nurse would not expect the client to be hypertensive. TEST-TAKING TIP: The normal progression of lochial change is as follows: lochia rubra, days 1 to 3; lochia serosa, days 3 to 10; and lochia alba, days 10 until discharge stops. There is some variation in the exact timing of the lochial change, but it is important for the client to know that the lochia should not revert backward. In other words, if a client whose lochia is alba again begins to have bright red discharge, she should notify her healthcare practitioner.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fi ngers. 4. The nurse precedes the assessment with a sterile vaginal exam.

Answer: 2 1. Fundal height is measured using a centimeter tape during pregnancy, not in the postpartum period. 2. The nurse should stabilize the base of the uterus with his or her dependent hand. 3. The fundus should be palpated using the fl at surface of the fi ngers. 4. No vaginal examination should be performed by the nurse. TEST-TAKING TIP: If the base of the uterus is not stabilized during the assessment, there is a possibility that the uterus may invert or prolapse. While stabilizing the base, the nurse should gently assess for the fundus by palpating the abdomen with the fl at part of the fi ngers until the fundus is felt.

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

Answer: 2 1. Ibuprofen is usually administered every 4 to 6 hours. 2. This statement is correct. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is administered orally. 4. This is not the reason ibuprofen is especially effective for postpartum cramping. TEST-TAKING TIP: Prostaglandins are produced as part of the infl ammatory response. When ibuprofen is administered, the client receives the pain-reducing action of the medication as well as its anti-infl ammatory properties.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours 4. Spray the perineum with povidone-iodine after toileting.

Answer: 2 1. It is unnecessary to apply antibiotic ointment to the perineum after delivery. 2. Clients should be advised to change their pads at each voiding. 3. The clients should void about every 2 hours, but this action is not an infection control measure. 4. It is unnecessary to spray the perineum with a povidone-iodine solution. Plain water, however, should be sprayed on the perineum. TEST-TAKING TIP: Postpartum women should be advised to perform three actions to prevent infections: (1) change their peripads at each toileting because blood is an excellent medium for bacterial growth; (2) spray the perineum from front to back with clear water to cleanse the area; and (3) wipe the perineum after toileting from front to back to prevent the rectal fl ora from contaminating sterile sites

A mother, G1 P1, who delivered a 2,800 gram baby vaginally 30 minutes earlier, is transferred to the postpartum unit. She pushed for 45 minutes and the placenta was delivered 10 minutes later. She is receiving an intravenous with 20 units oxytocin added. The postpartum nurse questions why the oxytocin was added to the IV bag. Which of the following responses by the transferring nurse is most likely? 1. "The medication was added 10 minutes ago to prevent excess bleeding during her transfer." 2. "The medication was added immediately after the baby's birth to promote placental delivery." 3. "The medication was added after the placenta was delivered because of its rapid separation." 4. "The medication was added while she was pushing to speed up the baby's birth."

Answer: 2 1. Patient transfer from labor and delivery to postpartum does not stimulate excess bleeding. It is unlikely that this is the rationale for the medication administration. 2. It is likely that the medication was added during the 3 rdstage of labor to promote placental delivery. 3. Placental delivery usually occurs between 5 minutes and 30 minutes after the birth. This is an unlikely rationale for the medication administration. 4. The client's 2 ndstage of labor lasted 45 minutes. That is a relatively short period of time for a primipara. As important, 20 units of oxytocin is an unsafe dosage to be administered before the fetus is birthed. TEST-TAKING TIP: Postpartum hemorrhage (PPH) is a leading cause of maternal death. One effective means of preventing PPH is active management of the 3 rd stage of labor. In other words, oxytocin is administered after the birth of the baby to promote uterine contraction and placental delivery. The oxytocin is usually added to the client's IV infusion and the infusion is continued until the fl uid is fully absorbed

A post-cesarean section, breastfeeding client whose subjective pain level is 2/5 requests her as-needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

Answer: 2 1. The client's subjective pain level is 2/5. It is unlikely that she needs stronger medication. 2. This statement is correct. One of the common side effects of narcotics is constipation. 3. This statement is incorrect. As long as the client feeds her baby frequently, the use of narcotics should not affect her milk production. 4. This statement is incorrect. This client's narcotic use is short term. Postoperative narcotic medications are considered safe for the breastfeeding baby. If the mother were a chronic narcotic user, the baby's response would be a concern. TEST-TAKING TIP: Because clients who take narcotics are at high risk for constipation, the nurse should inform clients of the potential and advise them to take necessary precautions. For example, the clients should be advised to drink fl uids, eat high-fi ber foods, and ambulate regularly.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm 3 3. Red blood cell count, 5 million cells/mm 3 4. Hemoglobin, 15 grams/dL.

Answer: 2 1. The hematocrit is often low in postpartum clients. 2. The nurse would expect to see an elevated white cell count. 3. The red blood cell count is often low in postpartum clients. 4. The hemoglobin is often low in postpartum clients. TEST-TAKING TIP: If the test taker is familiar with normal laboratory values, he or she could easily deduce the answer to this question by comparing the values. Three of the values—hematocrit, hemoglobin, and red blood cell count— relate to the oxygen-carrying properties of the blood, and all of these values are on the upper end of normal. Only one answer, white blood cell count, is different from the others. The white blood cell count elevates late in the third trimester and stays elevated during labor and the early postpartum period to protect the mother from infection during the delivery and puerperium

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following fi ndings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

Answer: 2 1. The nurse would not expect to see any drainage. 2. The nurse would expect to see wellapproximated edges. 3. The nurse would not expect to see ecchymosis. 4. The nurse would not expect to see redness. TEST-TAKING TIP: The best tool to use when assessing any incision is the REEDA scale. The nurse assesses for: R—redness, E—edema, E—ecchymosis, D—drainage, and A—poor approximation. If there is evidence of any of the fi ndings, they should be documented, monitored, and reported.

A client, G1 P0101, postpartum 1 day is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take fi rst? 1. Notify the woman's primary healthcare provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

Answer: 2 1. This action may be needed, but it is not the fi rst action that should be taken. 2. This action is the fi rst that the nurse should take. 3. This action may be needed, but it is not the fi rst action that should be taken. 4. This action is needed, but it is not the fi rst action that should be taken. TEST-TAKING TIP: When a postpartum client's bladder is distended, the uterus becomes displaced and boggy. The client should be escorted to the bathroom to void; the lochia fl ow should also be assessed. However, before escorting the client to urinate, the nurse should gently massage the uterus.

The nurse is caring for a client, post-op 1 day from an emergency cesarean section with her husband in attendance. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."

Answer: 2 1. This comment is inappropriate. It does not acknowledge the client's likely disappointment about having to have a cesarean section. 2. This comment conveys sensitivity and understanding to the client. 3. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section. 4. This comment may be true, but it does not acknowledge the client's likely disappointment about having to have a cesarean section. TEST-TAKING TIP: Clients who must have cesarean sections when they had developed birth plans for vaginal deliveries are often very disappointed. They may express regret and/or anger over the experience. The nurse must realize that such clients are not angry with the nurse but rather at the situation. It is essential for the nurse to accept the clients' feelings with understanding and caring.

The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be advised that her Kegel exercises should be performed during all bowel movements.

Answer: 2 1. To perform Kegel exercises, the client should be advised to contract and relax the muscles that stop the urine fl ow. 2. This is a correct statement. 3. Kegel exercises can be performed in any position. 4. Kegels can be performed at any time of day and in any position but, to determine which muscles are contracted during Kegels, the client should be taught to stop her urine fl ow midstream. TEST-TAKING TIP: Doing Kegel exercises during the postpartum period helps clients to regain the muscle tone in the pubococcygeal muscles that may have been affected during pregnancy and labor and delivery. Clients should be advised to perform them periodically throughout the day. They can be performed in any position and in any location.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

Answer: 2 Clients are not recommended to pump their breasts after feedings unless there is a specifi c reason to do so. 2. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours. 3. Clients should not restrict babies' feeding times. Babies feed at different rates. Babies themselves, therefore, should regulate the amount of time they need to complete their feeds. 4. Clients are not recommended to supplement with formula unless there is a specifi c reason to do so. TEST-TAKING TIP: This question is similar to the preceding question except that this question tests the nurse's ability to evaluate a client's response rather than to perform a nursing action.

A breastfeeding woman, 1½ months postdelivery, calls the nurse in the obstetrician's offi ce and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection refl ex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

Answer: 2 The woman is not exhibiting symptoms of galactorrhea, which occurs when a woman produces breast milk even though she has not delivered a baby. 2. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection refl ex. 3. This is incorrect. Galactosemia is a genetic disease. Babies who have the disease are unable to digest galactose, the predominant sugar in breast milk. 4. This is an unlikely explanation of the problem. TEST-TAKING TIP: It is important for the nurse in the obstetrician's offi ce to warn breastfeeding clients of this situation. Because clients are strongly encouraged to refrain from having intercourse until they are 6 weeks postpartum, the postpartum nurse may not include this information in the client's discharge instructions. When the client is seen for her postpartum check, however, the information should be included.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fl uid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

Answer: 3 1. It is unlikely that the woman is febrile. 2. The woman should maintain an adequate fl uid intake. 3. Diaphoresis is normal during the postpartum period. 4. There is no need to report the diaphoresis to the baby's pediatrician. TEST-TAKING TIP: Because the client's blood volume is returning to its nonpregnant level, the client loses fl uids via both the kidneys and through insensible loss. As a result, postpartum women often awake from sleep with their nightwear saturated with perspiration.

A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

Answer: 2 This is unnecessary. PCA pumps monitor the number of attempts patients make. 2. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered. 3. This is a false statement. Family members should not press the button for the client. 4. This information is untrue. It is unnecessary for family members to inform the nurse. It is not unusual for clients to fall asleep when receiving PCA. TEST-TAKING TIP: It is important for the nurse to teach a client's family members not to touch the PCA pump. Even though the pump is programmed with a minimum time between medication attempts, there is a possibility that the client could receive an overdose of medication if someone else controls the administrations. If a client is able to push the button herself, she is, by defi nition, awake and alert.

One nursing diagnosis that a nurse has identified for a postpartum client is Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell (WBC) count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

Answer: 2, 3, and 4 are correct. 1. Although clients should drink fl uids, this is not a goal related to the identifi ed nursing diagnosis. 2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. 5. Sitz baths are not given to prevent infections. They do help to soothe the pain and/or the infl ammation associated with episiotomies and hemorrhoids. TEST-TAKING TIP: The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacterial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A temperature above 100.4°F/38°C after the fi rst 24 hours postpartum is indicative of a puerperal infection.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

Answer: 2,4 2 and 4 are correct. 1. The client should perform pericare at each toileting and whenever she changes her peripad. 2. This statement is correct. The woman should wash her hands before and after performing pericare. 3. When a client sits in a warm water bath, she is taking a sitz bath. 4. This statement is accurate. 5. Hydrogen peroxide is not added to a perineal irrigation bottle (peri bottle). TEST-TAKING TIP: A postpartum client is taught to spray warm tap water with nothing added on the perineum, from front to back, after each toileting and whenever she changes her peripads. She should also be taught to wash her hands before and after the procedure.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

Answer: 3 1. Although this is an important goal, it is not the most important. 2. Although this is an important goal, it is not the most important. 3. This is the most important goal during the immediate postdelivery period. 4. Although this is an important goal, it is not the most important. TEST-TAKING TIP: When establishing priorities, the test taker should consider the client's most important physiological functions—that is, the C-A-B— circulation, airway, and breathing. If the client were to bleed heavily, her circulation would be compromised. None of the other goals is directly related to the C-A-Bs.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on the third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach the client to contract her buttocks before sitting. 4. Irrigate the incision twice daily with antibiotic solution.

Answer: 3 1. Episiotomy sutures are not removed. 2. Clients who have had episiotomies may or may not require pain medication. The medicine should be offered throughout the day because it is usually ordered prn. 3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line. 4. It is not recommended to irrigate episiotomy incisions. TEST-TAKING TIP: Clients who have had episiotomies often avoid sitting normally. Nurses should encourage them to take medications as needed, to contract their buttocks before sitting, and to sit normally rather than trying to favor one buttock over the other. Mediolateral incisions, incisions that are cut at approximately a 45-degree angle from the perineum, tend to be more painful than midline incisions—incisions cut posteriorly from the vagina toward the rectum.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

Answer: 3 1. It is inappropriate for the nurse to delegate this action. Physical assessment is a skill that requires professional nursing judgment. 2. It is inappropriate for the nurse to delegate this action. Teaching is a skill that requires professional nursing knowledge. 3. This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation. 4. It is inappropriate for the nurse to delegate this action. The chart is a legal document and documentation is a skill that requires professional nursing knowledge. TEST-TAKING TIP: Delegation is an important skill. Nurses are unable to meet all the needs of all of their patients. They must ask other healthcare workers, for example, licensed practical nurses and nursing assistants, to meet some of the clients' needs. It is essential, however, that the nurse delegate appropriately. Assessment, teaching, and documentation are tasks that should not be delegated to nursing assistants.

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specifi c gravity of the next voiding.

Answer: 3 1. It is unlikely that this client needs to be catheterized. 2. It is unnecessary to measure this client's output. 3. This response is correct. Polyuria is normal. 4. It is unnecessary to do a specifi c gravity on the client's output. TEST-TAKING TIP: This client's physical assessment is normal. If the client's bladder were distended, the client's fundus would be elevated in the abdomen and the client would have excess blood loss. It is unnecessary, therefore, either to catheterize the woman or to measure her output. Polyuria is normal because the client no longer needs the large blood volume she produced during her pregnancy.

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

Answer: 3 1. Milk inhibits the absorption of iron. Milk and iron should not be consumed at the same time. 2. There is no recommendation that iron be taken with ginger ale. 3. The nurse would recommend that the iron be taken with orange juice because ascorbic acid, which is in orange juice, promotes the absorption of iron into the body. 4. There is no recommendation that iron be taken with chamomile tea. TEST-TAKING TIP: Since ascorbic acid promotes the absorption of iron into the body, it is appropriate for the nurse to recommend that the client take her iron supplement with a food source high in ascorbic acid, such as orange juice.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

Answer: 3 1. Nipple shields should be used sparingly. Other interventions should be tried fi rst. 2. Soap will deplete the breast of its natural lanolin. It is recommended that women wash their breasts with warm water only while breastfeeding. 3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples. 4. It is inappropriate to recommend that the woman switch to formula at this time. TEST-TAKING TIP: If a mother rotates positions at each breastfeeding, the baby is likely to put pressure on varying points on the nipple. A good, deep latch, however, is the most important way to prevent nipple soreness and cracking. The mother could also apply lanolin to her breasts after each feeding.

A medication order reads: Methergine (ergonovine) 0.2 mg PO q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia fl ow. 3. Blood pressure. 4. Episiotomy.

Answer: 3 1. The apical pulse need not be assessed before Methergine is administered. 2. The vaginal discharge need not be assessed before Methergine is administered. 3. The blood pressure should be assessed before administering Methergine. 4. The episiotomy need not be assessed before Methergine is administered. TEST-TAKING TIP: Methergine is an oxytoxic agent that works directly on the myofi brils of the uterus. The smooth muscle of the vascular tree is also affected. The blood pressure may elevate, therefore, to dangerous levels. The medication should be held if the blood pressure is 130/90 or higher and the woman's healthcare practitioner should be notifi ed if appropriate

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

Answer: 3 1. The client is not exhibiting signs of social isolation. 2. The client is not exhibiting signs of child neglect. 3. The client is exhibiting normal postpartum behavior. 4. The client is not exhibiting signs of postpartum depression. TEST-TAKING TIP: This client is exhibiting signs of the postpartum taking in phase. She is a primigravida who delivered only 2 hours earlier. Her comments are well within those expected of a client at this point during her postpartum period.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

Answer: 3 1. The client should not develop a headache from Methergine. 2. The client should not become nauseated from Methergine. 3. Cramping is an expected outcome of the administration of Methergine. 4. The client should not become fatigued from Methergine. TEST-TAKING TIP: Methergine is administered to postpartum clients to stimulate their uterus to contract. As a consequence, clients frequently complain of cramping after taking the medication. The nurse can administer the prn pain medication to the client at the same time the Methergine is administered to help to mitigate the client's discomfort.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

Answer: 3 1. The involution is normal. 2. The involution is normal and the lochia is rubra. 3. This response is correct. The involution is normal and the lochia is rubra. 4. The lochia is moderate rubra. TEST-TAKING TIP: Lochia rubra is bright red, lochia serosa is pinkish to brownish, and lochia alba is whitish. The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days postpartum, it is usually felt 2 cm below the umbilicus, and so on.

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11 g/dL and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 g/dL; Hct 37%. 2. Hgb 11 g/dL; Hct 33%. 3. Hgb 10.5 g/dL; Hct 31%. 4. Hgb 9 g/dL; Hct 27%.

Answer: 3 1. The nurse would not expect the values to rise. These results may indicate that the client is dehydrated or third spacing fluids (i.e., fl uid is shifting into her interstitial spaces). 2. The nurse would not expect the values to remain the same. On average, clients lose about 500 mL of blood during spontaneous vaginal deliveries. 3. The nurse would expect these values—a slight decrease in both hemoglobin and hematocrit values. 4. The nurse would not expect the values to drop to these levels. TEST-TAKING TIP: Because clients lose blood during their deliveries, the nurse would expect to see approximately a 2% drop in the hematocrit and about a 0.5 gm/dL drop in the hemoglobin. If the hematocrit drops below 30%, the nurse should notify the healthcare practitioner.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

Answer: 3 1. The urinary output increases during the early postpartum period. 2. The blood pressure should remain stable during the postpartum. 3. The blood volume does drop precipitously during the early postpartum period. 4. The estrogen levels drop during the early postpartum period. TEST-TAKING TIP: During pregnancy, the blood volume increases by almost 50%. Once the placenta is delivered, the client no longer needs the added blood volume. Immediately after delivery, therefore, the woman experiences marked diuresis and diaphoresis as the blood volume drops.

A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just fi nished repairing the incision. The client's legs are in stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

Answer: 3 1. There is nothing in the scenario that indicates that the client's feet and ankles need to be assessed. 2. This is unnecessary. The blood pressure can be assessed while a client is breastfeeding. 3. This action is very important. If the legs are removed from the stirrups one at a time, then the woman is at high risk for back and abdominal injuries. 4. It is unnecessary to measure the episiotomy. It is suffi cient to document the type of episiotomy that was performed. TEST-TAKING TIP: Stirrups may not be used during normal spontaneous deliveries; however, when forceps or vacuum-extractors are used, physicians often request that the client's legs be placed in stirrups. The nurse should raise the woman's legs simultaneously when placing her legs in stirrups and lower her legs simultaneously when the delivery is complete to prevent injury. The nurse should also position the legs with care. Pressure on the popliteal space can lead to thrombus formation.

A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

Answer: 3 1. This is not the best response by the nurse. 2. This is not the best response by the nurse. 3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy. 4. This is not the best response by the nurse. TEST-TAKING TIP: The test taker must be familiar with the growth and development of children at all ages and be prepared to convey this information to new parents. Older siblings, especially toddlers, often express jealousy when a new baby enters the home. This is normal, but the parents must be aware of the potential for toddlers to inadvertently injure the baby

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

Answer: 3 1. This response is inappropriate. It is likely that as long as the woman breastfeeds she will experience vaginal dryness. 2. This is an inappropriate response. It is unlikely that a proliferation of Candida is the problem. 3. This response is correct. The woman should be encouraged to use a lubricating jelly or oil. 4. It is unlikely that the problem is related to the episiotomy repair. TEST-TAKING TIP: When women breastfeed, their estrogen levels remain low. As a result, they often complain of vaginal dryness and dyspareunia. The woman should be advised to try an over-the-counter lubricant. If that is not helpful, the woman may be prescribed an estrogen-based vaginal cream by her healthcare practitioner.

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? 1. White blood cells, 12,500 cells/mm 3 2. Red blood cells, 4,500,000 cells/mm 3 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

Answer: 3 The white blood cell count is within normal limits for a postpartum client. 2. The red blood cell count is within normal limits for a postpartum client. 3. The client's hematocrit is well below normal. This value should be reported to the client's healthcare provider. 4. The hemoglobin is within normal limits for a postpartum client. TEST-TAKING TIP: The hematocrit of a postpartum woman is likely to be below the "normal" of 35% to 45%, but a hematocrit of 30% or lower is considered abnormal and should be reported to the client's healthcare provider. It is likely that the client will be prescribed iron supplements.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not." Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

Answer: 3 This diagnosis is inappropriate. There is no indication that this client is suicidal or psychotic. 2. This diagnosis is inappropriate. There is no indication in the scenario that the client had a traumatic delivery. 3. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery. 4. This diagnosis is inappropriate. Nothing in the scenario implies that the client is in spiritual diffi culties. TEST-TAKING TIP: It is essential that nurses discuss postpartum blues with clients. When clients are unfamiliar with the phenomenon, they often feel like they are going crazy or that there is something very wrong with them. Other members of the family, especially the woman's partner, should also be forewarned.

. The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperrefl exia bilaterally.

Answer: 3 This response is incorrect. Clients who have had spinal anesthesia are at high risk for spinal headaches when they are elevated soon after surgery. 2. It is unnecessary to report absent bowel sounds to the client's physician. 3. The woman should turn, cough, and deep breathe every 2 hours. 4. There is no indication in the scenario that this client needs patellar refl ex assessments every 2 hours. TEST-TAKING TIP: Spinal anesthesia is administered directly into the spinal column. As a result, spinal fl uid is able to escape through the puncture wound. When there is a drop in the amount of spinal fl uid, clients often develop severe headaches. It is recommended that clients who have had spinals be elevated only slightly during the early postoperative period. To maintain pulmonary health, however, it is essential that clients perform respiratory exercises frequently during the postoperative period.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

Answer: 4 1. It is inappropriate to advise a breastfeeding mother to switch to the bottle unless there is a specifi c medical reason for her to do so. 2. Massaging the fundus will not relieve the client's discomfort. 3. An alternate position will not relieve the client's discomfort. 4. The nurse should discuss the action of oxytocin. TEST-TAKING TIP: Oxytocin, the hormone of labor, also stimulates the uterus to contract in the postpartum period to reduce blood loss at the placental site. Oxytocin is the same hormone that regulates the milk ejection refl ex. Therefore, whenever a mother breastfeeds, oxytocin stimulates her uterus to contract. In essence, breastfeeding naturally benefi ts the mother by contracting the uterus and preventing excessive bleeding

A bottle-feeding woman, 1½ weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated two pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

Answer: 4 . 1. This response is not appropriate. This client is bleeding heavily and she is not breastfeeding. 2. It is unlikely that this client is menstruating since she is only 1½ weeks postpartum. 3. This response is not appropriate. The client should not bleed heavily, especially so long after delivery. 4. This response is appropriate. The client should be examined to assess her involution. TEST-TAKING TIP: One important piece of information in this question is the fact that the client is bottle feeding her baby. If she were breastfeeding, she could be encouraged to put the baby to breast and see if the bleeding subsided. Since oxytocin is released when babies suckle at the breast, this is a noninvasive method of promoting uterine contraction.

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. ½ cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounces yogurt mixed with 1 medium banana. 3. 12 ounces strawberry milk shake. 4. 1½ cups raw broccoli.

Answer: 4 1. Celery is especially high in vitamin K, but it contains very little iron or vitamin A. Cream cheese is very high in fat. 2. Yogurt is high in calcium but is not high in either iron or vitamin A. Bananas are high in vitamin B 6, potassium, and vitamin C, but they are not high in either iron or vitamin A. 3. Strawberries are very high in vitamin C, but they are not high in either iron or vitamin A. 4. Broccoli is very high in vitamin A and also contains iron. TEST-TAKING TIP: Breastfeeding clients should be advised to consume a wellbalanced diet high in vitamins and minerals. As a result, nurses must be prepared to suggest foods that meet those needs.

A client, G1 P1, who had an epidural has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

Answer: 4 1. Even though this response may be true, the client's feelings are being ignored by the nurse. 2. This response is inappropriate. Even though the baby is well, the client feels disappointed with her performance. 3. Even though this response may be true, the client's feelings are being ignored by the nurse. 4. This response shows that the nurse has an understanding of the client's feelings. TEST-TAKING TIP: When clients express their feelings, nurses must provide acceptance and implicit approval to encourage the clients to continue to express those feelings. Comments like "Don't say that. There are many women who would be ecstatic to have that baby" close down conversation and communicate disapproval.

A G2 P2002 who is postpartum 6 hours from a spontaneous vaginal delivery is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary healthcare provider

Answer: 4 1. Heavy lochia is not a normal finding. Moderate lochia, which is similar in quantity to a heavy menstrual period, is a normal finding. 2. The woman's fundus is firm. There is no need to massage the fundus. 3. The fundus is at the umbilicus and it is fi rm. It is unlikely that her bladder is full. 4. Because of the heavy lochia, the nurse should notify the woman's healthcare provider. TEST-TAKING TIP: The nurse must do some detective work when observing unexpected signs/symptoms. This client is bleeding more heavily than the nurse would expect. When the nurse assesses the two most likely sources of the bleeding—the fundus and the perineal sutures—normal fi ndings are noted. The next most likely source of the bleeding—a laceration in the birth canal—is unobservable to the nurse because performing a postpartum internal examination is not a nursing function. The nurse, therefore, must notify the healthcare practitioner of the problem

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

Answer: 4 1. It is not recommended that breastfeeding mothers go on weight-reduction diets. In addition, it is not necessary for mothers to drink milk to make breast milk. 2. When a breastfeeding woman has a poor diet, the quality of her breast milk changes very little. In fact, if a mother consumes a poor diet, it is her own body that will suffer. 3. Mothers do not need to eat 3,000 calories a day while breastfeeding. 4. Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding. TEST-TAKING TIP: Mothers should be advised to eat a well-balanced diet and drink suffi cient quantities of fl uids while breastfeeding. There is no absolute number of calories that the mother should consume, but if she does go on a restrictive diet, it is likely that her milk supply may dwindle. Babies do take in about 500 calories a day at the breast; therefore, mothers can be advised that breastfeeding alone is a form of dieting.

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother

Answer: 4 1. Nourishment is a need of the client in the taking in phase. 2. Rest is a need of the client in the taking in phase. 3. Assistance with self-care is a need of the client in the taking in phase. 4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby. TEST-TAKING TIP: During the taking hold-phase, clients regain their independence. They care for their own bodies and are very receptive to learning about child care as well as self-care. Primigravidas are especially open to learning about caring for their baby during this phase and are especially vulnerable if they feel incompetent when performing baby-care tasks.

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

Answer: 4 1. The client should ambulate. There is nothing in the scenario indicating that the client must use a bedpan. 2. It is likely that the client needs to urinate. 3. Indwelling catheters are rarely inserted for vaginal deliveries under local anesthesia. 4. This is the appropriate action by the nurse. TEST-TAKING TIP: Because they have elevated clotting factors, postpartum clients are at high risk for thrombus formation. When they need to urinate, they should be encouraged to ambulate to the bathroom to prevent pooling of blood in the dependent blood vessels. Clients should be accompanied to the bathroom during the early postpartum period, however, because they may be lightheaded from the stress and work of labor and delivery.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

Answer: 4 1. The fundus should have descended below the umbilicus and there is no such lochia as "lochia rosa." 2. The fundus should have descended below the umbilicus and the lochia usually does not turn to alba until about 10 days postpartum. 3. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3. 4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3. TEST-TAKING TIP: Although each client's postpartum course is slightly different, on day 3 postpartum, the nurse would expect the fundus of most clients to be 3 cm below the umbilicus and the lochia to have become serosa.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

Answer: 4 1. This action is unsafe. It is unsafe to place anything in the vagina before involution is complete. 2. This response is inappropriate. The amount of discharge does not determine the type of pad that can be used. 3. This response is inappropriate. The client's pain does not determine the type of pad that can be used. 4. This response is correct. It is unsafe to place anything in the vagina before involution is complete. TEST-TAKING TIP: This question examines whether or not the test taker is aware of changes in care that are determined by the situation. Because the cervix is not fully closed and the uterine body is at high risk for infection, it is unsafe to insert anything into the vagina until involution is complete.

A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

Answer: 4 1. This fundal height is within normal limits. Clients who have had cesarean sections often involute at a slightly slower pace than clients who have had vaginal deliveries. 2. This fi nding is normal. Pregnant clients and clients in the early postpartum period have nodular breasts in preparation for lactation. 3. This pulse rate is normal. Once the placenta is delivered, the reservoir for the large blood volume is gone. Clients often develop bradycardia as a result. 4. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notifi ed. TEST-TAKING TIP: Because the placenta is manually removed and the uterine cavity is manually scraped during cesarean deliveries, it is common for postoperative clients to have a scanty lochial fl ow. This client is having a heavy loss. After the fundal assessment is complete, the observations should be reported to the surgeon.

A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpartum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

Answer: 4 1. This response is not accurate. Clients can begin to perform some exercises during the postpartum period. 2. The client can begin Kegel exercises, and little by little she can add other muscle toning exercises during the postpartum period. 3. It is inappropriate to make this statement to a client. Her prepregnancy exercise schedule may be beyond her physical abilities at this time. 4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on. TEST-TAKING TIP: It is important for the postpartum client to begin muscle toning early in the postpartum period. However, she should not do any weight lifting or high-impact or stressful aerobic exercising until after her 6-week postpartum check.

A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles.

Answer: 4 This action is appropriate. This client's respiratory rate is below normal. 2. A complaint of thirst is within normal. There is no need to notify the physician. 3. This urinary output is normal for a postpartum client. There is no need to notify the physician. 4. Clients who have received epidurals will have numbness of their feet and ankles until the medication has metabolized. There is no need to notify the physician. TEST-TAKING TIP: One of the serious complications of narcotic administration is respiratory depression. This client's respiratory rate is well below expected. The nurse should continue to monitor the client carefully and notify the anesthesiologist of the complication.

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fi elds to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

Answer: 4 This response is accurate, but the nurse is exhibiting a lack of caring. 2. This response is inappropriate. Even if the lung fields are clear, the client should perform respiratory exercises. 3. This response is inappropriate. Simply breathing deeply may not be as effective as coughing. 4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of postsurgical coughing. TEST-TAKING TIP: Clients with abdominal incisions experience signifi cant postoperative pain. And because their abdominal muscles have been incised, the pain is increased when the clients breathe in and cough. Bracing the abdominal muscles with a pillow or a blanket helps to reduce the discomfort.

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

Answer: 4 1. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client needs acetaminophen. 2. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client is infected. 3. A temperature of 100.2°F is not a febrile temperature. It is unlikely that this client needs cool compresses 4. It is likely that this client is dehydrated. She should be advised to drink fluids. TEST-TAKING TIP: In the early postpartum period, up to 24 hours after delivery, the most common reason for clients to have slight temperature elevations is dehydration. During labor, clients work very hard, often utilizing breathing techniques as a form of pain control. As a result, the clients lose fl uids through insensible loss via the respiratory system.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

Answer: 4 and 5 are correct. 1. It is unnecessary for a bottle-feeding mother to increase her fluid intake. 2. It is inadvisable for a bottle-feeding mother to massage her breasts. 3. It is inadvisable for a bottle-feeding mother to apply heat to her breasts. 4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. 5. The mother should be advised to stand with her back toward the warm shower water. TEST-TAKING TIP: The postpartum body naturally prepares to breastfeed a baby. To suppress the milk production, the mother should refrain from stimulating her breasts. Both massage and heat stimulate the breasts to produce milk. Mothers, therefore, should be encouraged to refrain from touching their breasts and when showering to direct the warm water toward their backs rather than toward their breasts. A supportive bra will help to minimize any engorgement that the client may experience.

The surgeon has removed the surgical cesarean section dressing from a postop day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision and assess for pain.1

Answer:2 1. Cesarean section incisions do not routinely need to be irrigated. 2. This is appropriate. The nurse should assess for all signs on the REEDA scale. 3. The incision is held together with sutures or staples. It is unnecessary to apply steristrips at this time. 4. It is inappropriate for the nurse to palpate the suture line. TEST-TAKING TIP: Once the dressing has been removed, the nurse on each shift should monitor the incision line for all signs on the REEDA scale—redness, edema, ecchymosis, discharge, and approximation.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

Answer:2 1. Estrogen drops precipitously after the placenta is delivered. 2. Prolactin will elevate sharply in the client's bloodstream. 3. Human placental lactogen drops precipitously after the placenta is delivered. 4. Human chorionic gonadotropin is produced by the fertilized ovum. TEST-TAKING TIP: To answer this question correctly, it is important for the test taker to know what happens at the end of the third stage of labor—that is, the delivery of the placenta. Because the hormones of pregnancy produced by the placenta— progesterone and estrogen—drop precipitously at this time, prolactin is no longer inhibited and, therefore, rises. The way the woman intends to feed her baby is irrelevant.

A nurse is caring for a postpartum client who has stated that she is putting her newborn son up for adoption. The client asks the nurse to help her breastfeed her baby. Which of the following responses by the nurse is appropriate? 1. "Are you sure you want to try breastfeeding? You won't be able to do it once you give your baby away." 2. "You want to place your baby on a lap pillow and have your baby face you. Then wait for the baby to open his mouth before moving the baby toward your breast." 3. "If you stimulate your breasts to produce milk by having the baby breastfeed, you may become engorged when your baby leaves you." 4. "You should be forewarned that breastfeeding is such an intimate experience that if you start feeding your baby that way, you won't want to give him up."

Answer:2 1. Even though this statement is accurate, it is an inappropriate nursing response. 2. The nurse should accurately respond to the client's request. 3. Even though this statement may be true, it is an inappropriate nursing response. 4. Even though this statement may be true, it is an inappropriate nursing response. TEST-TAKING TIP: After much thought, some pregnant women decide that the best decision for themselves and their baby is to place the baby up for adoption. While in hospital, however, the woman is the baby's mother and may care for the baby herself including, if she should desire, to breastfeed the baby. In some instances, women then decide to keep the baby rather than surrendering the baby to adoptive parents.

A Muslim woman requests something to eat after the delivery of her baby. Which of the following meals would be most appropriate for the nurse to give her? 1. Ham sandwich. 2. Bacon and eggs. 3. Spaghetti with sausage. 4. Chicken and dumplings.

Answer:4 1. This is inappropriate. Pork products are prohibited foods for Muslims. 2. This is inappropriate. Pork products are prohibited foods for Muslims. 3. This is inappropriate. Pork products are prohibited foods for Muslims. 4. Although this is not a traditional Muslim dish, the foods are allowable by Muslim tradition. TEST-TAKING TIP: Clients in the immediate post delivery period are in need of nourishment. It is very important that the nurse be aware of cultural differences and provide foods that are acceptable to the clients. Most Muslim clients adhere to religious dietary restrictions, called halal

A postpartum nurse is caring for a client who received epidural anesthesia during her labor and delivery. The nurse should advise the woman that she may experience which of the following side effects of the medication during the postpartum period? 1. Backache. 2. Light-headedness. 3. Hypertension. 4. Footdrop.

Answers: 1 1. Many clients who have received epidurals during labor complain of a backache during the postpartum period. 2. Light-headedness is rarely a complaint of clients postepidural. 3. Hypertension is not a complication seen in clients postepidural. 4. Footdrop is very rarely a complication of epidural anesthesia. TEST-TAKING TIP: Although rarely a serious complication or a long-lasting side effect of epidural anesthesia, clients who received epidurals during their labor and delivery frequently complain of backache. The clients should be counseled that the backaches usually resolve in a few weeks and that heat and over-the-counter analgesics are often effective in relieving the discomfort.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

Aswer: 1 1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the post-anesthesia care unit. 2. This answer is inappropriate. The client had an indwelling catheter inserted for the surgery. And even if the catheter were removed immediately after the operation, she is paralyzed from the spinal anesthesia and unable to void. 3. This answer is inappropriate. The client has had major surgery. She will be consuming clear fl uids, at the most, immediately after the cesarean section. 4. This answer is inappropriate. Immediately after surgery, the incision is covered by a dressing. Plus, it is too early for an infection to have appeared. TEST-TAKING TIP: The key to answering this question is the fact that the client has just moved from the operating room. The nurse in the post-anesthesia care unit(PACU) is concerned with monitoring for immediate postoperative and postpartum complications and the client's recovery from the anesthesia.

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness

Aswers:1, 2, and 5 are correct. 1. The nurse would assess for pain. 2. The nurse would assess for warmth. 3. The nurse would not be assessing for discharge. 4. The nurse would not be assessing for ecchymosis. 5. The nurse would assess for redness. TEST-TAKING TIP: Postpartum clients are at high risk for deep vein thrombosis (DVT). At each postpartum assessment the nurse assesses the calves for signs of the complication, that is, those seen in any infl ammatory response: pain, warmth, redness, and edema. If the signs/ symptoms are noted, the nurse should request an order from the primary healthcare practitioner for diagnostic tests to be performed, such as a Doppler series.

The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6°F, 82, 18; fundus firm at umbilicus; moderate lochia rubra; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience

aNSWER: 4 1. This client's lochia fl ow and vital signs are normal. She is exhibiting no signs of fl uid volume defi cit. 2. This client has had no episiotomy or perineal laceration. She is exhibiting no signs of impaired skin integrity. 3. This client is voiding as expected — approximately every 2 hours. She is exhibiting no signs of impaired urinary elimination. 4. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding newborn care as well as self-care. TEST-TAKING TIP: This is a diffi cult analysis level question. The test taker must determine, based on the facts given, which nursing diagnosis is appropriate. This question, however, should be approached the same way that all other questions are approached: (1) determine what is being asked; (2) develop possible answers to the question BEFORE reading the given responses; (3) read the responses and compare them with the list of possible answers; and (4) choose the one response that best compares with the list of possible answers.