Ch 17: Nursing Care of a Postpartal Family
d) Cannot be palpated Pg. 403 By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
1. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? a) 6 cm below the umbilicus b) 2 cm below the umbilicus c) 10 cm below the umbilicus d) Cannot be palpated
c) Increased heart rate Pg. 407
10. The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? a) Increased cardiac output b) Increased blood pressure c) Increased heart rate d) Increased hematocrit level
c) Ask the client when she last changed her perineal pad Pg. 398 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.
11. 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) Immediately call the primary care provider b) Vigorously massage the fundus c) Ask the client when she last changed her perineal pad d) Have the charge nurse review the assessment
b) At risk for postpartum depression due to inadequate rest Pg. 414 This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.
12. 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 (dilatation) 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: a) At risk for safety due to low hemoglobin b) At risk for postpartum depression due to inadequate rest c) At risk for inadequate healing due to decreased nutrition d) At risk for interruption of tissue integrity
d) Ensure early and frequent parent-newborn interactions Pg. 400-401 Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and their partners to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. Eye contact and interacting with the newborn during feeding helps to promote attachment and bonding.
13. A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan? a) Urge parents to talk to each other when holding the baby b) Encourage contact between the newborn's skin and parental clothing c) Have the parents participate in newborn care once a day d) Ensure early and frequent parent-newborn interactions
d) "Apply ice packs to your breasts to reduce the amount of milk being produced" Pg. 416 For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.
14. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? a) "Take several warm showers daily to stimulate the milk let-down reflex" b) "Express some milk from your breasts every so often to relieve the distention" c) "Remove your bra to relieve the pressure on your sensitive nipples and breasts" d) "Apply ice packs to your breasts to reduce the amount of milk being produced"
d) Hemorrhage Pg. 397 If a client is going to hemorrhage, they are most likely to do so within the first postpartum hour. The nurse must assess a postpartum client every 15 minutes for the first hour. Infection, dehydration, and bladder distention are all assessment parameters but do not take precedence over hemorrhage in the first postpartum hour.
15. The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize? a) Bladder distention b) Dehydration c) Infection d) Hemorrhage
b) Urinary Pg. 405 The urinary system must handle an increased workload in the early postpartum period and the renal system is altered by hydronephrosis, a normal change with pregnancy. The hydronephrosis and urinary stasis often lead to urinary tract infections.
16. Which body system is most vulnerable to infection during the postpartum period? a) Breasts b) Urinary c) Respiratory d) Gastrointestinal
b) Two fingerbreadths below the umbilicus Pg. 403 Immediately after delivery, the uterine fundus should be at the level of the umbilicus. One day postpartum, the height is one fingerbreadth below the umbilicus and by day 2, the fundal height is two fingerbreadths below the umbilicus.
17. Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? a) At the pubic bone b) Two fingerbreadths below the umbilicus c) One fingerbreadth below the umbilicus d) Level with the umbilicus
d) Slit-like Pg. 404 After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."
18. A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: a) Triangular b) Shapeless c) Circular d) Slit-like
d) "If you are breastfeeding, that will help make your uterus contract and get smaller" Pg. 403 There are several things that a new mother can do to assist in uterine involution. The most well-known one is breastfeeding the infant. Whenever a new mother breastfeeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.
19. A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be: a) "I would recommend that you rest for a few days to allow your body to heal and get back to normal" b) "There is really nothing you can do to speed along the progress, so just be patient" c) "Eating a large amount of protein and carbohydrates will help make the uterus contract" d) "If you are breastfeeding, that will help make your uterus contract and get smaller"
c) Docusate Pg. 415 A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
2. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? a) Methylergonovine b) Ferrous sulfate c) Docusate d) Bromocriptine
d) Have the client void, and then massage the fundus until it is firm Pg. 411 The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.
20. A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? a) Check and inspect the lochia, and document all findings b) Notify the primary care provider, and document the findings c) Assess a full set of vital signs d) Have the client void, and then massage the fundus until it is firm
a) Ensure the baby empties the breasts at each feeding Pg. 416 Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
21. A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? a) Ensure the baby empties the breasts at each feeding b) Restrict fluid intake to 2 L each day c) Wear a tight fitting bra at all times d) Apply ice packs before a feeding
d) Developing Rh sensitivity Pg. 421 The woman who is Rh-negative and whose infant is Rh-positive should be given Rho(D) immune globulin within 72 hours after birth to prevent sensitization.
22. The nurse administers Rho(D) immune globulin to an Rh-negative client after birth of an Rh-positive newborn based on the understanding that this drug will prevent her from: a) Developing AB antigens in her blood b) Becoming Rh positive c) Becoming pregnant with an Rh-positive fetus d) Developing Rh sensitivity
d) Continue to monitor the woman's temperature every 4 hours; this finding is normal Pg. 406 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.
23. 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) Inspect the perineum for hematoma formation 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
a) Lack of social support b) Feeling overwhelmed and out of control c) Low self-esteem d) Low socioeconomic status Pg. 666 Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.
24. The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. a) Lack of social support b) Feeling overwhelmed and out of control c) Low self-esteem d) Low socioeconomic status e) Involving family in infant care
b) Postpartum depression Pg. The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
25. The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? a) Anxiety disorders b) Postpartum depression c) Postpartum blues d) Postpartum psychosis
b) Body secreting the excess fluids from pregnancy Pg. 405 Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.
26. A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? a) Change in pregnancy hormone b) Body secreting the excess fluids from pregnancy c) The body is trying to get rid of the extra blood made during pregnancy d) The patient may be drinking too much fluid
c) The urinary output is normal Pg. 415 Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void.
27. In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? a) The urinary output is inadequate suggestive of urinary retention b) The urinary output is inadequate and the mother needs to drinks more fluids c) The urinary output is normal d) The urinary output is above expected levels
c) Risk for injury: postpartum hemorrhage related to uterine atony Pg. 397 The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.
28. The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize? a) Acute pain related to afterpains or episiotomy discomfort b) Risk for infection related to multiple portals of entry for pathogens c) Risk for injury: postpartum hemorrhage related to uterine atony d) Risk for injury: falls related to postural hypotension and fainting
a) Oxytocin Pg. 404 Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.
29. A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? a) Oxytocin b) Prolactin c) Progesterone d) Estrogen
a) Uterine atony Pg. 412 Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.
3. A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? a) Uterine atony b) Iron deficiency c) Hemorrhoid d) Diuresis
b) 1500 Pg. The woman is in her second hour postpartum. Typically, the nurse would assess the woman every 30 minutes. In this case, this would be 1500. During the first hour, assessments are usually completed every 15 minutes. After the second hour, assessments would be made every 4 hours for the first 24 hours and then every 8 hours.
30. A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? a) 1530 b) 1500 c) 1445 d) 1830
b) Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby Pg. 402 Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.
31. A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement? a) Recommend that she talk to the unit social worker to get the mother some counseling prior to discharge b) Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby c) Recommend rooming-in to foster attachment and confidence by the mother d) Dismiss the mother's concerns by telling her that you are sure she doesn't really mean it
c) Demonstrating how to do cord care on the newborn Pg. 399 When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.
32. A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? a) Telling the mother to feed the baby when it cries b) Correcting the mother when she holds the newborn incorrectly c) Demonstrating how to do cord care on the newborn d) Changing the infant's diapers for the mother
b) The fundus is located 2 fingerbreadths above the umbilicus Pg. 635 The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.
33. The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? a) The client is afebrile b) The fundus is located 2 fingerbreadths above the umbilicus c) Bowel sounds are active d) The client is having a moderate amount of rubra lochia e) The client requires assistance to ambulate in the hallway
a) "Ending the adoption process is a big decision and there are many factors to consider as you decide" Pg. 427 The woman is experiencing many emotions during the initial postpartum time and emotional support should be offered in a nonjudgmental approach. The nurse should avoid giving advice or sharing personal advice as the woman is vulnerable during this time.
34. The nurse is caring for a woman who gave birth 4 hours prior. The woman had planned to pursue adoption through an agency she was working with during her pregnancy. The woman now expresses a desire to end the adoption process. How should the nurse respond to the woman? a) "Ending the adoption process is a big decision and there are many factors to consider as you decide" b) "I would encourage you to move forward with the adoption since the adoptive parents will be disappointed" c) "I adopted my child and he has had a good life. His birth mother is a part of his life and she is happy" d) "You will want to really think on this...the adoptive family may allow you to be part of his life as he grows up"
b) "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Pg. 401 Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.
35. A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request? a) "Your baby is so vulnerable to infections right now that it would be better to wait until you are at home to introduce her to her siblings" b) "As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" c) "I recommend that you introduce the new baby to her siblings once you are back at home. Right now you need to rest and recover" d) "That's a great idea! They can also take the baby out into the hall and walk with it for a while to give you a break"
b) Normal reaction to accepting a new child Pg. Many new mothers approach a newborn tentatively as part of the bonding process, so this is typical behavior for a second postpartum day. It is unlikely this would be an indication of disappointment in the sex of the child. It is also not an indication of her waiting for the nurse to provide instruction. The nurse should be observant and offer advice and instruction as it is deemed appropriate. There are many cultural practices, but avoiding the child is not one of them.
36. While caring for a new mother on her second day postpartum, the nurse notes the new mother handles her newborn tentatively, not kissing her child but appears afraid to interact with her baby. Which situation would the nurse suspect as the probable reason for this? a) Responding with cultural customs of avoiding interaction b) Normal reaction to accepting a new child c) Waiting for instruction from the nurse d) Disappointment in the child's sex
a) Taking-in, taking-hold, letting-go Pg. 398 The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
37. Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: a) Taking-in, taking-hold, letting-go b) Taking, holding-on, letting-go c) Taking-in, taking-on, letting-go d) Taking-in, holding-on, letting-go
a) Supine Pg. 407 The best position for a complete assessment of the uterus is lying flat, supine. The other positions will not allow for a true assessment of the location of the uterus in relation to the umbilicus.
38. The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus? a) Supine b) High Fowler c) Semi-Fowler d) Left-lateral side lying
c) Accept the mother's statement and perform discharge teaching accordingly Pg. 399 In some cultures, new mothers are not allowed to leave the home for at least 1 month to allow her opportunity to rest and keep her healthy. Because the client's mother informed the nurse that this is the family's cultural custom, the nurse should not try to talk the client or her mother out of their beliefs on caring for both the client and the newborn. Asking the client's mother why she is putting restrictions on her daughter is challenging and unprofessional.
39. After the birth of the newborn, the mother is ready to be discharged home. The client's mother is present and will remain with her for 1 month. The client's mother tells the nurse that her daughter will not be allowed to leave the house for the first month after the birth, based on the family's cultural customs. How should the nurse respond to this statement? a) Remind the client's mother that the woman needs to get out and get fresh air over the next month b) Ask the client's mother why she is putting such restrictions on her daughter c) Accept the mother's statement and perform discharge teaching accordingly d) Explain to the client's mother that her daughter may have to go places in caring for the newborn
b) "The baby's sucking releases a hormone that causes the uterus to contract" Pg. 404 The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.
4. A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? a) "Let me check your vaginal discharge just to make sure everything is fine" b) "The baby's sucking releases a hormone that causes the uterus to contract" c) "Your body is responding to the events of labor, just like after a tough workout" d) "Your uterus is still shrinking in size; that's why you're feeling this pain"
d) Ensure the baby empties the breasts at each feeding Pg. 416 Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
40. A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? a) Wear a tight fitting bra at all times b) Apply ice packs before a feeding c) Restrict fluid intake to 2 L each day d) Ensure the baby empties the breasts at each feeding
a) Discomfort due to hemorrhoids Pg. 415 The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation.
41. The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor? a) Discomfort due to hemorrhoids b) Distention of abdominal muscles c) Relaxation of abdominal muscles d) Separation of rectus muscles
a) Taking-in phase Pg. 398 The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period.
42. A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? a) Taking-in phase b) Rooming-in phase c) Taking-hold phase d) Letting-go phase
c) Venous duplex ultrasound of the right leg Pg. 416 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.
5. 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) Transthoracic echocardiogram c) Venous duplex ultrasound of the right leg d) Noninvasive arterial studies of the right leg
c) Ask her questions and observe her caring for the baby Pg. 397 The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.
6. The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics? a) Since she has had a previous child, she should already know how to do most everything b) Have her fill out a questionnaire on the subject c) Ask her questions and observe her caring for the baby d) Have her demonstrate how to do all the baby care tasks as well as her self-care tasks
a) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min Pg. 406-407 The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.
7. A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize? a) BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min b) Blood loss of 250 mL and WBC 25,000 cells/mL c) Shaking chills with a fever of 99° F (37.2° C) d) Heart rate 70 bpm and excessive, soaking diaphoresis
d) Decreased progesterone levels Pg. Decreased progesterone and estrogen levels are believed to cause postpartum blues in which the client might cry without reason and have some difficulty sleeping. Decreased thyroid hormone levels have been noted to be related with postpartum depression. Decreased hemoglobin levels are related to anemia.
8. A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to? a) Increased estrogen levels b) Increased thyroid hormone levels c) Decreased hemoglobin levels d) Decreased progesterone levels
c) Bleeding Pg. 407 Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
9. A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? a) Infection b) Diabetes c) Bleeding d) Postpartum gestational hypertension
