CH 16 OB Combined

Ace your homework & exams now with Quizwiz!

A nurse is instructing a patient who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is best described as which of the following? a) creamy yellow b) gray liquid c) bluish white d) milky white

creamy yellow

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color?

creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

A nurse is instructing a patient who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is best described as which of the following? a) milky white b) bluish white c) creamy yellow d) gray liquid

creamy yellow Correct Explanation: If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

After teaching a postpartum woman about postpartum blues, which statement indicates effective teaching? a) "If the symptoms last more than a few days, I need to call my doctor." b) "I'll need to take medication to treat the anxiety and sadness." c) "I should call this support line only if I hear voices." d) "I might feel like laughing one minute and crying the next."

"I might feel like laughing one minute and crying the next."

A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobulin be injected in the mother? a) 80 b) 72 c) 78 d) 75

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following? a) atony b) normal involution c) hemorrhage d) infection

atony

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following? a) normal involution b) infection c) atony d) hemorrhage

atony Correct Explanation: The uterus in a postpartum patient should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which of the following? a) bonding b) attachment c) being spoiled d) none of the above

attachment

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by:

bringing the newborn into the room. Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? a) proximity b) reciprocity c) commitment d) all of the above

reciprocity

Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection? a) Labor of 12 hours b) Multiparity c) Placenta removed via manual extraction d) Hemoglobin of 11.5 mg/dL

Placenta removed via manual extraction

Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection? a) Hemoglobin of 11.5 mg/dL b) Placenta removed via manual extraction c) Labor of 12 hours d) Multiparity

Placenta removed via manual extraction Correct Explanation: Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum hemorrhage.

When palpating for fundal height on a postpartal woman, which technique is preferable? a) Placing one hand on the fundus, one on the perineum b) Resting both hands on the fundus c) Placing one hand at the base of the uterus, one on the fundus d) Palpating the fundus with only fingertip pressure

Placing one hand at the base of the uterus, one on the fundus Correct Explanation: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. Punishing the older child for bedwetting behavior b. Sending the sibling to the grandparents' house c. Planning a daily "special time" for the older sibling d. Allowing the sibling to share a room with the infant

Planning a daily "special time" for the older sibling

A patient delivered 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the patient was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the physician and the nurse-midwife to her concern that the patient may be experiencing a) Mitral valve collapse b) Upper respiratory infection c) Pulmonary embolism d) Thrombophlebitis

Pulmonary embolism

A postpartal woman has a history of thrombophlebitis. Which of the following would help you to determine if she is developing this postpartally? a) Ask her if she feels any warmth in her legs. b) Assess for calf redness and edema. c) Take her temperature every 4 hours. d) Palpate her feet for tingling or numbness.

Assess for calf redness and edema.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a) Temperature b) Drainage c) Redness d) Edema

Temperature

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a) Temperature b) Edema c) Redness d) Drainage

Temperature Correct Explanation: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

Which of the following would the nurse assess as indicating positive bonding between the parents and their newborn? a. Holding the infant close to the body b. Having visitors hold the infant c. Buying expensive infant clothes d. Requesting that the nurses care for the infant

Holding the infant close to the body

Which factor puts a client on her first postpartum day at risk for hemorrhage? a) Thrombophlebitis b) Uterine atony c) Moderate amount of lochia rubra d) Hemoglobin level of 12 g/dl

Uterine atony

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by a) Bringing the newborn into the room b) Talking about how the nurse held her own newborn while on the delivery table c) Showing a video of parents feeding their babies d) Allowing the mother to pick the best time to hold her newborn

Bringing the newborn into the room

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a) At the level of the umbilicus b) Below the symphysis pubis c) One fingerbreadth above the umbilicus d) One fingerbreadth below the umbilicus

One fingerbreadth below the umbilicus

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a) One fingerbreadth above the umbilicus b) One fingerbreadth below the umbilicus c) Below the symphysis pubis d) At the level of the umbilicus

One fingerbreadth below the umbilicus

Which of the following would the nurse include when teaching the parents of a newborn who have a 2-year-old boy at home? a) "Expect to see your 2-year-old become more independent when the baby gets home." b) "Have your 2-year-old stay at home while you're here in the hospital." c) "Talk to your 2-year-old about the baby when you're driving him to day care." d) "Ask your 2-year-old to pick out a special toy for his sister."

"Ask your 2-year-old to pick out a special toy for his sister."

After teaching a postpartum woman about postpartum blues, which statement indicates effective teaching? a) "I should call this support line only if I hear voices." b) "I might feel like laughing one minute and crying the next." c) "I'll need to take medication to treat the anxiety and sadness." d) "If the symptoms last more than a few days, I need to call my doctor."

"I might feel like laughing one minute and crying the next." Correct Explanation: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: a) "RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." b) "RhoGAM suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." c) "RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." d) "RhoGAM suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood."

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful? a) "Let me contact our lactation specialist and together maybe we can work through this." b) "Some babies latch on and catch on quickly; others take a little more time." c) "Breast-feeding takes time. Let's see what's happening." d) "Some women just can't breast-feed. Maybe you're one of these women."

"Some women just can't breast-feed. Maybe you're one of these women."

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

"You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?

2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal delivery. Which of the following interventions should the nurse perform to ensure that the client gets the optimum benefits of the procedure? a) Apply ice packs for 40 minutes continuously. b) Apply ice packs directly to the perineal are c) Ensure ice pack is changed frequently. d) Use ice packs for a week after delivery.

Ensure ice pack is changed frequently.

Fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. Which of the following classifications will the nurse use to describe the laceration? a) First-degree laceration b) Third-degree laceration c) Fourth-degree laceration d) Second-degree laceration

Fourth-degree laceration

Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply. a) Fundus one fingerbreadth above umbilicus b) Moderate saturation of peripad every 3 hours c) Inverted nipples following breastfeeding d) Urination of 50 mL every hour e) Hypotonic bowel sounds

Fundus one fingerbreadth above umbilicus Moderate saturation of peripad every 3 hours

When doing a health assessment, at which of the following locations would you expect to palpate the fundus in a woman on the second postpartal day and how should it feel? a) Fundus height 4 cm below umbilicus and midline b) Fundus two fingerbreadths below umbilicus and firm c) Fundus two fingerbreadths above symphysis pubis and hard d) Fundus 4 cm above symphysis pubis and firm

Fundus two fingerbreadths below umbilicus and firm

A woman yesterday delivered a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at delivery. The nurse's priority is to assist the mother to a) Review causes of a cleft palate b) Care for herself c) Visit the child in the nursery d) Grieve for the loss of the perfect baby

Grieve for the loss of the perfect baby

Which of the following exercises should a nurse suggest to the client during the first day of postpartum? a) Thigh-toning exercises b) Abdominal exercises c) Kegel exercises d) Buttock exercises

Kegel exercises

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which actions would the nurse include in her discussion as possible strategies for the new mothers to do? Select all that apply.

Kegel exercises avoid smoking lose weight if obese Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoid smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 mL to 2,000 mL.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following? a) diabetes b) long-term obesity c) feelings of increased self-esteem d) increased sex drive

Long-term obesity Correct Explanation: Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

A nurse assessing a postpartum patient notices excessive bleeding. What should be the nurse's first action? a) Call the physician. b) Massage the boggy fundus until it is firm. c) Document the findings. d) Nothing--excessive postpartum blood loss is normal.

Massage the boggy fundus until it is firm.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm. The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

Inspection of a woman's perineal pad reveals a 5-inch stain. The nurse documents this amount as which of the following? a) Light b) Heavy c) Scant d) Moderate

Moderate

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

active bowel sounds passing gas nondistended abdome Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.

Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a) change in the temperature from the delivery room b) dehydration c) fluid volume overload d) infection

dehydration

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a) fluid volume overload b) dehydration c) infection d) change in the temperature from the delivery room

dehydration Explanation: Many women experience a slight fever (100.4 degrees F) during the first 24 hours after delivery. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after birth make a woman more susceptible to infection? Select all that apply

urinary stasis denuded endometrial arteries episiotomy The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation.

venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A mother just delivered 3 hours ago. The nurse enters the room to continue hourly assessments and finds the patient on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? a) "I need to assess your fundus now." b) "If you plan to breastfeed, you need to calm down." c) "You have a beautiful baby, why worry about that now?" d) "It sounded like you had quite a time getting here. Would you like to continue your story?"

"It sounded like you had quite a time getting here. Would you like to continue your story?"

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "I'll contact your physician." b) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." c) "If you don't attempt to void, I'll need to catheterize you." d) "I'll check on you in a few hours."

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

A nursing instructor teaching students how to check the patient's uterus postpartum realizes that further instruction is needed when one of the students says: a) "Six to twelve hours after birth the fundus is typically at the level of the umbilicus." b) "One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis." c) "Normally the fundus progresses downward at a rate of 1 fingerbreadth per day after birth." d) "One to two hours after birth the fundus is typically at the level of the umbilicus."

"One to two hours after birth the fundus is typically at the level of the umbilicus."

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

Which finding would the nurse describe as "light" or "small" lochia? a) 4- to 6-inch stain with an estimated loss of 25 to 50 ml b) 4-inch stain or a 1 to 25 ml loss c) 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss d) pad is saturated within 1 hour after changing it

4-inch stain or a 1 to 25 ml loss Explanation: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it.

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 1 to 25 ml loss Typically the amount of lochia is described as follows: scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; light or small: 4-inch stain or a 10 to 25 ml loss; moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; large or heavy: a pad is saturated within 1 hour after changing it

Which finding would the nurse describe as "light" or "small" lochia? a) pad is saturated within 1 hour after changing it b) 4-inch stain or a 1 to 25 ml loss c) 4- to 6-inch stain with an estimated loss of 25 to 50 ml d) 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss

4-inch stain or a 1 to 25 ml loss Explanation: Typically the amount of lochia is described as follows: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day?

650 Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

Which of the following findings would lead you to suspect that a woman is developing a postpartum complication? a) Red-colored lochia for the first 24 hours b) An absence of lochia c) Lochia that is the color of menstrual blood d) Lochia appearing pinkish-brown on the fourth day

An absence of lochia

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant. "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after delivery? a) After 45 minutes b) After 60 minutes c) Every 30 minutes d) Every 15 minutes

Every 15 minutes

A nurse, assigned to check the pulse, discerns tachycardia in a postpartum client. Which of the following does it suggest? a) Pulmonary embolism b) Excessive blood loss c) Atelectasis d) Pulmonary edema

Excessive blood loss

When doing a health assessment, at which of the following locations would you expect to palpate the fundus in a woman on the second postpartal day and how should it feel? a) Fundus two fingerbreadths below umbilicus and firm b) Fundus two fingerbreadths above symphysis pubis and hard c) Fundus height 4 cm below umbilicus and midline d) Fundus 4 cm above symphysis pubis and firm

Fundus two fingerbreadths below umbilicus and firm Correct Explanation: A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

A nurse is assessing a postpartum client. Which of the following measures is appropriate? a) Wear sterile gloves when assessing the pad and perineum. b) Perform the examination as quickly as possible. c) Instruct the client to empty her bladder before the examination. d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus.

Instruct the client to empty her bladder before the examination. Correct Explanation: An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after delivery.

Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT a) List signs of infection that she will report to her health care provider b) Maintain previous household routines to prevent infection c) The patient will show no signs of infection d) Discuss methods that the woman will use to prevent infection

Maintain previous household routines to prevent infection Correct Explanation: The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

A nurse assessing a postpartum patient notices excessive bleeding. What should be the nurse's first action? a) Massage the boggy fundus until it is firm. b) Nothing--excessive postpartum blood loss is normal. c) Document the findings. d) Call the physician.

Massage the boggy fundus until it is firm. Correct Explanation: The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take?

Notify the health care provider about this elevation; this finding reflects infection. A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A hematoma would not necessarily be a cause for an elevated temperature. Cultures may be warranted after notifying the health care provider. A temperature of 100.4° F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor.

A client who has a breastfeeding newborn complains of sore nipples. Which of the following interventions can the nurse suggest to alleviate the client's condition? a) Encourage use of breast pads with plastic liners. b) Fasten nursing bra flaps immediately after feeding. c) Recommend a moisturizing soap to clean the nipples. d) Offer suggestions based on observation to correct positioning or latching.

Offer suggestions based on observation to correct positioning or latching.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a) One fingerbreadth above the umbilicus b) One fingerbreadth below the umbilicus c) At the level of the umbilicus d) Below the symphysis pubis

One fingerbreadth below the umbilicus Explanation: After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops. The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives.

The nurse observes a 2-in lochia stain on the perineal pad of a postpartum client. Which of the following terms should the nurse use to describe the amount of lochia present? a) Moderate b) Light c) Large d) Scant

Scant

attachment Correct Explanation: Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used.

commmitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.

A nurse is instructing students on how to check an episiotomy and perineum of a woman after Which of the following are normal in the early postpartum period? (Select all that apply.) a) discharge b) edema c) slight bruising d) redness

edema slight bruising

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a Japanese-American postpartum woman, which action would be a priority?

ensuring that the newborn receives a daily bath In the Japanese-America culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? a) nothing--it is normal b) hematoma c) DVT d) infection

hematoma

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? a) DVT b) hematoma c) nothing--it is normal d) infection

hematoma Explanation: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the physician immediately.

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing? a) depression b) pulmonary emboli c) infection d) hemorrhage

infection

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing? a) hemorrhage b) depression c) pulmonary emboli d) infection

infection Correct Explanation: There are many risk factors for developing a postpartum infection: operative procedures(eg, forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing? a) pulmonary emboli b) depression c) infection d) hemorrhage

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following? a) feelings of increased self-esteem b) long-term obesity c) diabetes d) increased sex drive

long-term obesity

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? a) an improperly positioned baby during feedings b) mastitis c) normal findings in breastfeeding mothers d) too much milk being retained

mastitis Correct Explanation: Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which of the following? a) negative attachment b) positive bonding c) positive attachment d) negative bonding

negative attachment

A nurse is auscultating the lungs of a postpartum patient and notices crackles and some dyspnea. The patient's respiratory rate is 12 breaths/min; she appears in some distress. What complication should the nurse suspect based on these data? a) pulmonary edema b) infection c) hemorrhage d) fluid volume deficit

pulmonary edema

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus If the bladder is distended, the nurse would most likely palpate a rounded mass at the the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 2-inch lochia stain. This amount should be documented as which type?

scant Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action?

talks to company and ignores the baby lying next to her Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending to her child. Ignoring the infant while talking to visitors is not an example of proper bonding.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at:

the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

third-degree laceration A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted.

A nurse is assessing a client during the postpartum period. Which of the following indicate normal postpartum adjustment? Select all that apply. a) Active bowel sounds b) Nondistended abdomen c) Abdominal pain d) Passing gas e) Tender abdomen

• Active bowel sounds • Passing gas • Nondistended abdomen

Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? a) Infant formula selection b) Activity c) Resumption of prepregnancy diet d) Resumption of intercourse e) Signs and symptoms of infection

• Activity • Resumption of intercourse • Signs and symptoms of infection

Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply. a) Inverted nipples following breastfeeding b) Fundus one fingerbreadth above umbilicus c) Urination of 50 mL every hour d) Hypotonic bowel sounds e) Moderate saturation of peripad every 3 hours

• Fundus one fingerbreadth above umbilicus • Moderate saturation of peripad every 3 hours

A newly delivered mother has difficulty sleeping despite her exhaustion from labor. This inability to rest is due to Select all that apply. a) Bottle feeding b) Excess fatigue and overstimulation by visitors c) Frequent trips to the bathroom due to diuresis d) The baby's crying e) Inability to get adequate pain relief

• The baby's crying • Inability to get adequate pain relief • Frequent trips to the bathroom due to diuresis • Excess fatigue and overstimulation by visitors Explanation: The period before labor and delivery can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.

Which of the following would lead the nurse to suspect that a postpartum woman was developing a complication? a. Fatigue and irritability b. Perineal discomfort and pink discharge c. Pulse rate of 60 bpm d. Swollen, tender, hot area on breast

Swollen, tender, hot area on breast

Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT a) List signs of infection that she will report to her health care provider b) The patient will show no signs of infection c) Maintain previous household routines to prevent infection d) Discuss methods that the woman will use to prevent infection

Maintain previous household routines to prevent infection

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a) Venogram of the right leg b) Noninvasive arterial studies of the right leg c) Transthoracic echocardiogram d) Venous duplex ultrasound of the right leg

Venous duplex ultrasound of the right leg

A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action?

Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?

placenta removed via manual extraction Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum infection.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?

places a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus

Which of the following findings would lead you to suspect that a woman is developing a postpartum complication? a) Red-colored lochia for the first 24 hours b) Lochia that is the color of menstrual blood c) Lochia appearing pinkish-brown on the fourth day d) An absence of lochia

An absence of lochia Correct Explanation: Women should have a lochia flow following childbirth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

During assessment of the mother during the postpartum period, what would alert the nurse that the client is likely experiencing uterine atony? a) Boggy or relaxed uterus b) Fundus feels firm c) Foul-smelling urine d) Purulent vaginal drainage

Boggy or relaxed uterus

A postpartal woman has a history of thrombophlebitis. Which of the following would help you to determine if she is developing this postpartally? a) Take her temperature every 4 hours. b) Assess for calf redness and edema. c) Ask her if she feels any warmth in her legs. d) Palpate her feet for tingling or numbness.

Assess for calf redness and edema. Correct Explanation: Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. a) Breasts are hard. b) Breasts are tender. c) Nipples are cracke d) Breasts are soft. e) Nipples are fissured.

Breasts are hard. Breasts are tender.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment by a) Allowing the mother to pick the best time to hold her newborn b) Showing a video of parents feeding their babies c) Talking about how the nurse held her own newborn while on the delivery table d) Bringing the newborn into the room

Bringing the newborn into the room Correct Explanation: Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by a) Allowing the mother to pick the best time to hold her newborn b) Talking about how the nurse held her own newborn while on the delivery table c) Showing a video of parents feeding their babies d) Bringing the newborn into the room

After teaching a group of breast-feeding women about nutritional needs, the nurse determines that the teaching was successful when the women state that they need to increase their intake of which nutrients? a. Carbohydrates and fiber b. Fats and vitamins c. Calories and protein d. Iron-rich foods and minerals

Calories and protein

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? a) Ask the woman what she has had to eat today. b) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. c) Do nothing, this is normal. d) Advise that the woman not get out of bed until the nurse returns with assistance.

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? a) Advise that the woman not get out of bed until the nurse returns with assistance. b) Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. c) Ask the woman what she has had to eat today. d) Do nothing, this is normal.

Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit. Correct Explanation: During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. Be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits? a) Her uterus is soft to your touch. b) The flow contains large clots. c) The flow is over 500 mL. d) The color of the flow is red.

The color of the flow is red.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m. If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a) Ask the client when she last changed her perineal pad. b) Have the charge nurse review the assessment. c) Vigorously massage the fundus. d) Immediately call the primary care provider.

Ask the client when she last changed her perineal pad.

Which of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman? a) Screening for bacteriuria in the urine. b) Increasing oral fluid intake. c) Encouraging the woman to empty her bladder completely every 2 to 4 hours. d) Increasing intravenous fluids.

Encouraging the woman to empty her bladder completely every 2 to 4 hours. Explanation: The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a physician's order and is not necessary as a prevention measure.

The major purpose of the first postpartum homecare visit is to: a. Identify complications that require interventions b. Obtain a blood specimen for PKU testing c. Complete the official birth certificate d. Support the new parents in their parenting roles

Identify complications that require interventions

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications? a) Ruptured bladder b) Fluid volume overload c) Increased lochia drainage d) Permanent urinary incontinence

Increased lochia drainage

Inspection of a woman's perineal pad reveals a 5-inch stain. The nurse documents this amount as which of the following? a) Moderate b) Heavy c) Scant d) Light

Moderate Correct Explanation: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

Which of the following would you emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths? a) Sitz baths cause perineal vasoconstriction and decreased bleeding. b) The longer a sitz bath is continued, the more therapeutic it becomes. c) Sitz baths increase the blood supply to the perineal area. d) Sitz baths may lead to increased postpartal infection.

Sitz baths increase the blood supply to the perineal area.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

The nurse working on a postpartum must check lochia in terms of amount, color, change with activity and time, and: a) pH b) specific gravity c) consistency d) odor

odor

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

A nursing student learns that a certain condition in 1 in every 2,000 pregnancies is a major cause of death. What is this condition? a) pulmonary embolism b) infection c) hypertension d) hemorrhage

pulmonary embolism

Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply. a) Fundus one fingerbreadth above umbilicus b) Hypotonic bowel sounds c) Urination of 50 mL every hour d) Moderate saturation of peripad every 3 hours e) Inverted nipples following breastfeeding

• Fundus one fingerbreadth above umbilicus • Moderate saturation of peripad every 3 hours Correct Explanation: A fundus can rise to slightly above or below the umbilicus in the first 24 hours, and moderate saturation of 2/3 of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and 50 mL urine is inadequate given the occurrence of diuresis.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. a) Show mothers how to initiate breastfeeding within 30 minutes of birth. b) Encourage breastfeeding of the newborn infant on demand. c) Give newborns water and other foods to balance nutritional needs. d) Provide breastfeeding newborns with pacifiers. e) Place baby in uninterrupted skin-to-skin contact with the mother.

• Show mothers how to initiate breastfeeding within 30 minutes of birth. • Encourage breastfeeding of the newborn infant on demand. • Place baby in uninterrupted skin-to-skin contact with the mother.

A newly delivered mother has difficulty sleeping despite her exhaustion from labor. This inability to rest is due to Select all that apply. a) The baby's crying b) Frequent trips to the bathroom due to diuresis c) Inability to get adequate pain relief d) Bottle feeding e) Excess fatigue and overstimulation by visitors

• The baby's crying • Frequent trips to the bathroom due to diuresis • Inability to get adequate pain relief • Excess fatigue and overstimulation by visitors

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the healthcare provider is not necessary, and this statement could add to the client's currrent concern.

A mother just delivered 3 hours ago. The nurse enters the room to continue hourly assessments and finds the patient on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? a) "If you plan to breastfeed, you need to calm down." b) "You have a beautiful baby, why worry about that now?" c) "I need to assess your fundus now." d) "It sounded like you had quite a time getting here. Would you like to continue your story?"

"It sounded like you had quite a time getting here. Would you like to continue your story?" Correct Explanation: The mother is going through the taking-in phase of relating events during her pregnancy and delivery. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.

A nursing instructor teaching students how to check the patient's uterus postpartum realizes that further instruction is needed when one of the students says: a) "Normally the fundus progresses downward at a rate of 1 fingerbreadth per day after birth." b) "One to two hours after birth the fundus is typically at the level of the umbilicus." c) "Six to twelve hours after birth the fundus is typically at the level of the umbilicus." d) "One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis."

"One to two hours after birth the fundus is typically at the level of the umbilicus." Explanation: One to two hours after birth the fundus is typically between the umbilicus and symphysis pubis. At 6ix to 12 hours after birth the fundus usually is at the level of the umbilicus. Normally the fundus progresses downward at at rate of one fingerbreadth per day after birth.

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Correct Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. RhoGAM is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful? a) "Some babies latch on and catch on quickly; others take a little more time." b) "Some women just can't breast-feed. Maybe you're one of these women." c) "Breast-feeding takes time. Let's see what's happening." d) "Let me contact our lactation specialist and together maybe we can work through this."

"Some women just can't breast-feed. Maybe you're one of these women." Correct Explanation: This response ignores the woman's feelings and displays a negative attitude, indicating that the woman is at fault for the current situation. The woman needs reassurance that she can breast-feed and accomplish the task. She needs to understand that although breast-feeding is a natural process, it takes time and practice. By offering to observe her breast-feeding, the nurse offers support and can provide the woman with some practical suggestions as necessary. The statement that some babies need more time would reduce her frustration and uncertainty about her ability to breast-feed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation

Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to a) Assess and massage the fundus b) Increase the flow of an IV c) Call the physician or the nurse-midwife d) Inspect the perineum for lacerations

Assess and massage the fundus Correct Explanation: This woman is a multigravida who delivered a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Apply an ice pack to the perineal area. Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a) Have the charge nurse review the assessment. b) Immediately call the primary care provider. c) Vigorously massage the fundus. d) Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad. Correct Explanation: If the morning assessment is done relatively yearly, it's possible that the client hasn't yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, wouldn't be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse wouldn't want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status

Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to a) Inspect the perineum for lacerations b) Assess and massage the fundus c) Increase the flow of an IV d) Call the physician or the nurse-midwife

Assess and massage the fundus

When caring for a postpartum woman who is Muslim, which of the following would be a priority? a) Assigning a female nurse to care for her b) Ensuring that the newborn's daily bath is performed by the nurses c) Allowing time for the numerous visitors who come to see the woman and newborn d) Providing time for prayers to be performed at the bedside

Assigning a female nurse to care for her

When caring for a postpartum woman who is Muslim, which of the following would be a priority? a) Ensuring that the newborn's daily bath is performed by the nurses b) Allowing time for the numerous visitors who come to see the woman and newborn c) Providing time for prayers to be performed at the bedside d) Assigning a female nurse to care for her

Assigning a female nurse to care for her Correct Explanation: Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A G1 P1001 mother is just home after delivering her first child 5 days ago. Her delivery was complicated by an emergency cesarean delivery resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this patient care issue is a) At risk for interruption of tissue integrity b) At risk for inadequate healing due to decreased nutrition c) At risk for safety due to low hemoglobin d) At risk for postpartum depression due to inadequate rest

At risk for postpartum depression due to inadequate rest

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is:

At risk for postpartum depression due to inadequate rest. This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.

Which of the following suggestions would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. Increase fluid intake and acid-producing foods in her diet. b. Avoid empty-calorie foods and increase exercise. c. Start a high-protein diet and restrict fluids. d. Eat no snacks or carbohydrates.

Avoid empty-calorie foods and increase exercise.

Which of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman? a) Increasing oral fluid intake. b) Encouraging the woman to empty her bladder completely every 2 to 4 hours. c) Increasing intravenous fluids. d) Screening for bacteriuria in the urine.

Encouraging the woman to empty her bladder completely every 2 to 4 hours.

A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100°F (37.8°C). Which action would be most appropriate? a) Notify the health care provider about this elevation; this finding reflects infection. b) Obtain a urine culture; the woman most likely has a urinary tract infection. c) Inspect the perineum for hematoma formation. d) Continue to monitor the woman's temperature every 4 hours; this finding is normal.

Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal. A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.

A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100 degrees F. Which action would be most appropriate? a) Inspect the perineum for hematoma formation. b) Notify the health care provider about this elevation; this finding reflects infection. c) Obtain a urine culture; the woman most likely has a urinary tract infection. d) Continue to monitor the woman's temperature every 4 hours; this finding is normal.

Continue to monitor the woman's temperature every 4 hours; this finding is normal. Correct Explanation: A temperature of 100.4 degrees F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the physician, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum), because this finding is normal.

Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a) During the first 24 hours after delivery owing to dehydration from exertion b) When the elevated temperature exceeds 100.4° F c) When the white blood cell count is less than 10,000/mm³ d) After any period of decreased intake

During the first 24 hours after delivery owing to dehydration from exertion

Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a) After any period of decreased intake b) When the white blood cell count is less than 10,000/mm³ c) When the elevated temperature exceeds 100.4° F d) During the first 24 hours after delivery owing to dehydration from exertion

During the first 24 hours after delivery owing to dehydration from exertion Correct Explanation: Rapid breathing during labor and delivery and limited oral intake can cause a self-limited period of dehydration that is resolved after delivery by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

Which of these activities would best help the postpartum nurse to provide culturally sensitive care for the childbearing family? a. Taking a transcultural course b. Caring for only families of his or her cultural origin c. Teaching Western beliefs to culturally diverse families d. Educating himself or herself about diverse cultural practices

Educating himself or herself about diverse cultural practices

A client who gave birth by cesarean delivery 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: a) Encouraging the client to wear a supportive bra. b) Informing the physician that the client is showing early signs of breast infection. c) Using a breast pump to facilitate removal of stagnant breast milk. d) Having the client stand facing in a warm shower.

Encouraging the client to wear a supportive bra.

A client who gave birth by cesarean delivery 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: a) Using a breast pump to facilitate removal of stagnant breast milk. b) Having the client stand facing in a warm shower. c) Informing the physician that the client is showing early signs of breast infection. d) Encouraging the client to wear a supportive bra.

Encouraging the client to wear a supportive bra. Explanation: These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and don't indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient? a) The patient needs to walk to the bathroom more often. b) Increased intake will increase the patient's output and therefore will provide an opportunity for more frequent perineal self-care. c) Increased intake will rehydrate the patient and decrease her skin temperature. d) The patient will have to call for the nurse's help more often.

Increased intake will rehydrate the patient and decrease her skin temperature.

A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient? a) Increased intake will rehydrate the patient and decrease her skin temperature. b) Increased intake will increase the patient's output and therefore will provide an opportunity for more frequent perineal self-care. c) The patient needs to walk to the bathroom more often. d) The patient will have to call for the nurse's help more often.

Increased intake will rehydrate the patient and decrease her skin temperature. Correct Explanation: The perception of increased skin temperature a short time post delivery is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature. Information is insufficient to suggest the presence of infection. Goals of more frequent perineal care and ambulation, as well as reinforcement of patient teaching, are not appropriate in this situation.

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications? a) Increased lochia drainage b) Ruptured bladder c) Fluid volume overload d) Permanent urinary incontinence

Increased lochia drainage Correct Explanation: If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.

A nurse is assessing a postpartum client. Which of the following measures is appropriate? a) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. b) Perform the examination as quickly as possible. c) Instruct the client to empty her bladder before the examination. d) Wear sterile gloves when assessing the pad and perineum.

Instruct the client to empty her bladder before the examination.

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

Question: Postpartum bleeding must be assessed carefully during the first 24 hours after delivery. Prioritize the actions taken upon detection of increased vaginal bleeding in a patient who delivered within the last 24 hours. 1 Palpate the fundus 2 Massage the fundus if boggy 3 Notify the physician or the nurse-midwife of excessive bleeding 4 Increase IV pitocin or breastfeed the newborn 5 Assess blood pressure 6 Assist the patient to empty her bladder in the bathroom

Postpartum bleeding must be assessed carefully during the first 24 hours after delivery. Prioritize the actions taken upon detection of increased vaginal bleeding in a patient who delivered within the last 24 hours. Palpate the fundus Massage the fundus if boggy Notify the physician or the nurse-midwife of excessive bleeding Increase IV pitocin or breastfeed the newborn Assess blood pressure Assist the patient to empty her bladder in the bathroom

Palpate the fundus Massage the fundus if boggy Notify the physician or the nurse-midwife of excessive bleeding Increase IV pitocin or breastfeed the newborn Assess blood pressure Assist the patient to empty her bladder in the bathroom Explanation: Determining the site of bleeding is the first assessment. Palpate the fundus. If the fundus is boggy, take steps to stimulate contractions by massaging. Notify the health care provider, and continue with the assessment. Stimulate contractions. Assess blood pressure and assess for safety to ambulate. A likely reason for a boggy uterus is dislocation by a full bladder.

Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? a) Bladder is nonpalpable b) Lochia is less than usual c) Percussion reveals dullness d) Uterus is firm

Percussion reveals dullness

Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? a) Percussion reveals dullness b) Uterus is firm c) Bladder is nonpalpable d) Lochia is less than usual

Percussion reveals dullness Correct Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

When assessing a postpartum woman, which of the following would lead the nurse to suspect postpartum blues? a. Panic attacks and suicidal thoughts b. Anger toward self and infant c. Periodic crying and insomnia d. Obsessive thoughts and hallucinations

Periodic crying and insomnia

Placenta removed via manual extraction

Pulmonary embolism Correct Explanation: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

Not all mothers express joy at seeing their newborn upon delivery and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is a) Giving the child an uncommon name b) Referring to a facial feature as "ugly" c) Bottle feeding d) Dressing the child in old clothes

Referring to a facial feature as "ugly"

Not all mothers express joy at seeing their newborn upon delivery and during their hospitalization. A behavior that indicates impaired attachment of the mother to the newborn is a) Referring to a facial feature as "ugly" b) Dressing the child in old clothes c) Giving the child an uncommon name d) Bottle feeding

Referring to a facial feature as "ugly" Correct Explanation: Making negative comments about a newborn's features is a warning sign of impending attachment difficulties. The other options may be culturally rooted.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth? a) Use oral contraceptives for contraception. b) Avoid performing pelvic floor exercises. c) Avoid use of water-based gel lubricants. d) Resume intercourse if bright-red bleeding stops.

Resume intercourse if bright-red bleeding stops.

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" a) Saturating 1 pad in 1 hour b) Saturating 1 pad in 8 hours c) Saturating 1 pad in 3 hours d) Saturating 1 pad in 6 hours

Saturating 1 pad in 1 hour

When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" a) Saturating 1 pad in 6 hours b) Saturating 1 pad in 1 hour c) Saturating 1 pad in 8 hours d) Saturating 1 pad in 3 hours

Saturating 1 pad in 1 hour Correct Explanation: Bleeding is considered heavy when a woman saturates a sanitary pad in 1 hour. Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes. Moderate bleeding occurs when the bleeding saturates less than 15 cm of a pad in 1 hour.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

Sitz baths increase the blood supply to the perineal area. Correct Explanation: Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

A patient who has just delivered a baby girl demonstrates behavior not indicative of bonding when she does which of the following? a) Talks to company and ignores the baby lying next to her b) Strokes the infants' head c) Holds and smiles at the infant d) Kisses the infant on her cheek

Talks to company and ignores the baby lying next to her

A patient who has just delivered a baby girl demonstrates behavior not indicative of bonding when she does which of the following? a) Strokes the infants' head b) Holds and smiles at the infant c) Talks to company and ignores the baby lying next to her d) Kisses the infant on her cheek

Talks to company and ignores the baby lying next to her Correct Explanation: Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending to her child. Ignoring the infant while talking to visitors is not an example of proper bonding.

You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits? a) The flow is over 500 mL. b) The flow contains large clots. c) The color of the flow is red. d) Her uterus is soft to your touch.

The color of the flow is red. Correct Explanation: A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: a) The level of the umbilicus b) 2 cm below the umbilicus c) Between the umbilicus and symphysis pubis d) 1 cm below the umbilicus

The level of the umbilicus

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: a) Between the umbilicus and symphysis pubis b) The level of the umbilicus c) 2 cm below the umbilicus d) 1 cm below the umbilicus

The level of the umbilicus Correct Explanation: Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this as which of the following? a) Third-degree laceration b) Second-degree laceration c) First-degree laceration d) Fourth-degree laceration

Third-degree laceration

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this as which of the following? a) First-degree laceration b) Fourth-degree laceration c) Second-degree laceration d) Third-degree laceration

Third-degree laceration Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth. a) True b) False

True

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth. a) True b) False

True Explanation: Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same.

Which factor puts a client on her first postpartum day at risk for hemorrhage? a) Uterine atony b) Hemoglobin level of 12 g/dl c) Moderate amount of lochia rubra d) Thrombophlebitis

Uterine atony Correct Explanation: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a) Transthoracic echocardiogram b) Venogram of the right leg c) Venous duplex ultrasound of the right leg d) Noninvasive arterial studies of the right leg

Venous duplex ultrasound of the right leg Correct Explanation: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and wouldn't be the first choice. Transthoracic echocardiography looks at cardiac structures and isn't indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A woman states that she still feels exhausted on her second postpartal day. Your best advice for her would be to do which of the following? a) Walk the length of the hallway to regain her strength. b) Avoid elevating her feet when she rests in a chair. c) Avoid getting out of bed for another 2 days. d) Walk with you the length of her room.

Walk with you the length of her room.

A woman states that she still feels exhausted on her second postpartal day. Your best advice for her would be to do which of the following? a) Walk with you the length of her room. b) Avoid getting out of bed for another 2 days. c) Walk the length of the hallway to regain her strength. d) Avoid elevating her feet when she rests in a chair.

Walk with you the length of her room. Correct Explanation: Most women report feeling exhausted following childbirth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

A postpartal woman asks you about perineal care. Which of the following recommendations would you give? a) Refrain from washing lochia from the suture line. b) Use an alcohol wipe to wash her suture line. c) Wash her perineum with her daily shower. d) Avoid using soap in her perineal care.

Wash her perineum with her daily shower.

A postpartal woman asks you about perineal care. Which of the following recommendations would you give? a) Wash her perineum with her daily shower. b) Use an alcohol wipe to wash her suture line. c) Avoid using soap in her perineal care. d) Refrain from washing lochia from the suture line.

Wash her perineum with her daily shower. Explanation: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.

A client has been discharged from the hospital after a cesarean birth. Which of the following is the most appropriate time for scheduling a follow-up appointment for the client? a) Within 2 weeks of hospital discharge b) Within 1 week of hospital discharge c) Between 4 and 6 weeks after hospital discharge d) Within 3 weeks of hospital discharge

Within 2 weeks of hospital discharge

A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening? a) infection b) pulmonary emboli c) fluid volume overload d) hemorrhage

hemorrhage

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening? a) fluid volume overload b) pulmonary emboli c) infection d) hemorrhage

hemorrhage Correct Explanation: Some risk factors for developing hemorrhage after delivery include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? a) mastitis b) too much milk being retained c) an improperly positioned baby during feedings d) normal findings in breastfeeding mothers

mastitis

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which of the following? a) negative bonding b) negative attachment c) positive attachment d) positive bonding

negative attachment Correct Explanation: Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.

The nurse working on a postpartum must check lochia in terms of amount, color, change with activity and time, and: a) odor b) pH c) consistency d) specific gravity

odor Correct Explanation: The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor. The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus

one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C) A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply.

previous oral contraceptive use severe varicose veins preeclampsia Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.

A nurse is auscultating the lungs of a postpartum patient and notices crackles and some dyspnea. The patient's respiratory rate is 12 breaths/min; she appears in some distress. What complication should the nurse suspect based on these data? a) fluid volume deficit b) infection c) hemorrhage d) pulmonary edema

pulmonary edema Correct Explanation: Any change in the respiratory rate of a postpartum woman might indicate pulmonary edema, atelectasis, or pulmonary embolism and must be reported. Lungs should be clear upon auscultation

A nursing student learns that a certain condition in 1 in every 2,000 pregnancies is a major cause of death. What is this condition? a) hemorrhage b) infection c) hypertension d) pulmonary embolism

pulmonary embolism Explanation: Pulmonary embolism occurs in 1 in 2,000 pregnancies and is a major cause of maternal mortality.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism. These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

A woman who had a cesarean delivery of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect? a) fluid volume overload b) pulmonay emboli c) infection d) hemorrhage

pulmonay emboli

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment?

reciprocity Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? a) proximity b) reciprocity c) commitment d) all of the above

reciprocity Correct Explanation: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (ie, the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.

Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? a) Infant formula selection b) Signs and symptoms of infection c) Activity d) Resumption of prepregnancy diet e) Resumption of intercourse

• Signs and symptoms of infection • Activity • Resumption of intercourse Correct Explanation: The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her prepregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after delivery make a woman more susceptible to infection? Select all that apply. a) Episiotomy b) White blood cell count 25,000/mm³ c) Urinary stasis d) Denuded endometrial arteries

• Urinary stasis • Denuded endometrial arteries • Episiotomy

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after delivery make a woman more susceptible to infection? Select all that apply. a) Urinary stasis b) White blood cell count 25,000/mm³ c) Episiotomy d) Denuded endometrial arteries

• Urinary stasis • Denuded endometrial arteries • Episiotomy Explanation: The urinary system after delivery is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation.

A nursing student is studying postpartal complications. Thromboembolic conditions have which of the following risk factors? (Select all that apply.) a) obesity b) anemia c) multiparity d) cigarette smoking e) irritable bowel f) diabetes

• anemia • diabetes • cigarette smoking • obesity • multiparity

A nursing student is studying postpartal complications. Thromboembolic conditions have which of the following risk factors? (Select all that apply.) a) cigarette smoking b) diabetes c) multiparity d) irritable bowel e) anemia f) obesity

• anemia • diabetes • cigarette smoking • obesity • multiparity Explanation: Risk factors for developing thromboembolic conditions include anemia, diabetes, cigarette smoking, obesity, preeclampsia, hypertension, varicose veins, pregnancy, cesarean section, multiparity, inactivity, and advanced maternal age.

The nurse who works on a post-partum floor is mentoring a new graduate. She informs the new nurse that a post-partum assessment of the mother includes which of the following? (check all that apply) a) head-to-toe assessment b) pain level c) head-to-toe assessment of newborn d) newborn's vital signs e) vital signs of mother

• head-to-toe assessment • pain level • vital signs of mother Correct Explanation: Post-partum assessment of the mother usually includes vital signs, pain level and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.

Hypercoagulability during pregnancy protects the mother against excessive blood loss during childbirth. It also can increase a woman's risk of developing a blood clot. It does this by which of the following ways? (Select all that apply.) a) localized vascular damage b) decline in WBCs c) altered coagulation d) stasis e) decline in HGB

• stasis • altered coagulation • localized vascular damage

The nurse who works on a post-partum floor is mentoring a new graduate. She informs the new nurse that a post-partum assessment of the mother includes which of the following? (check all that apply) a) vital signs of mother b) head-to-toe assessment of newborn c) pain level d) head-to-toe assessment e) newborn's vital signs

CH 16 OB Combined

Related study sets

The t Distributions

PS 104 Exam 1

micro final

Pharmacology Made Easy 4.0 Gastrointestinal System

Chapter 2

RN Maternal Newborn A

APES Chapter 8 Vocab

Electoral College and the Executive Branch

Module 1: Experimental Psychology and the Scientific Method

Biology

Sport in American Society Final

Narrative of the Life of Frederick Douglass Study Guide Questions

Week 6 #2

Psych 200 -Final

Unit 9: Ecology (Mohamed Elarag)

Acute Coronary Syndrome

Psy 1010 Ch 1

AP World History - Ming and Qing Dynasties

Cognitive Psych Test 2

vSIMS #6 Questions