Chapter 29 (Postpartum) & 30 (Postpartum Complications)

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clot and notes that they are larger than 1 cm. Which nursing action is most appropriate? 1. Document findings 2. Reassess client in 2 hours 3. Notify HCP 4. Encourage increased oral intake of fluids

3

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vitals 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of tearing sensation

1

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum

1

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? 1. Elevate the client's legs 2. Massage the fundus until it is firm 3. Ask the client to turn on her left side 4. Push on the uterus to assist in expressing clots

2

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breastfeeding her newborn. Which statement would indicate the need for further instruction? 1. "I should breastfeed every 2-3 hours" 2. "I should change the breast pads frequently" 3. "I should wash my hands well before BF" 4. "I should wash my nipples daily with soap and water"

4

The nurse has provided discharge instructions to a client who delivered a healthy newborn by c-section. Which statement by the client indicates a need for further instruction? 1. "I will begin abdominal exercises immediately" 2. "I will notify the HCP if I develop a fever" 3. "I will turn on my side and push with my arms to get out of bed" 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks"

1

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume

1

The nurse is teaching a postpartum client about breastfeeding. Which instruction should the nurse include? 1. The diet should include additional fluids 2. Prenatal vitamins should be discontinued 3. Soap should be used to cleanse the breasts 4. Birth control measures are unnecessary while BF

1

The nurse is assessing a client in the fourth stage of labor and notes the fundus is firm, but the bleeding is excessive. Which should bee the initial nursing action? 1. Record the findings 2. Massage the fundus 3. Notify HCP 4. Place client in Trendelenburg

3

The nurse is preparing a list of self care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Wear a supportive bra 2. Rest during the active phase 3. Maintain a fluid intake of at least 3000 mL/day 4. Continue to breastfeed if the breasts are not sore 5. Take the prescribed antibiotics until the soreness subsides 6. Avoid decompression of the breasts by breastfeeding or breast pump

1, 2, 3, 4

A client in postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardia and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Start an IV line 2. Assess the client's BP 3. Prepare to administer morphine sulfate 4. Administer oxygen 8-10 L/minute by face mask

4

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should be taking which initial action? 1. Document the findings 2. Elevate the client's legs 3. Massage the fundus until it is firm 4. Push on the uterus to assist in expressing clots

3

The nurse is assessing a client who is 6 hours postpartum after delivering a full term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? 1. Raise the head of the client's bed 2. Obtain Hgb and Hct levels 3. Instruct the client to request help when getting out of bed 4. Inform nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided

3

The nurse is preparing to care for four assigned clients. Which client is most at risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A primiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia

3

The postpartum nurse is assessing a client who delivered a healthy infant by c-section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses

3

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage hourly ambulation 2. Assess vitals every 4 hours 3. Measure fundal height every 4 hours 4. Prepare an icepack for application to the area

4

The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1. Document the finding 2. Encourage the client to ambulate 3. Encourage the client to increase fluid intae 4. Contact HCP and inform of the finding

4

The nurse is providing postpartum instructions for a client who will be breast feeding her newborn. The nurse determines that the client understands the instructions if she makes which statement? Select all that apply. 1. "I should wear a bra that provides support" 2. "Drinking alcohol can affect my milk supply" 3. "The use of caffeine can decrease my milk supply" 4. "I will start my estrogen birth control pills again as soon as I get home" 5. "I know if my breasts get engorged, I will limit my BF and supplement the baby" 5. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily"

1, 2, 3, 6

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring Hcg and Hct levels

2

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? 1. Encourage the mother to BF soon after birth 2. Support the mother in her reaction to the newborn infant 3. Tell the mother that it is important to hold the newborn infant 4. Document a complete account of the mother's reaction on the birth record

2

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4 F (38 C) 2. A increase in pulse rate from 88 to 102 bpm 3. A BP change from 130/88 to 124/80 mmHg 4. An increase in the respiratory rate from 18 to 22 BPM

2

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 bpm 3. The client with colostrum discharge form both breasts 4. The client with lochia that is red and has a foul smelling odor

4

The postpartum nurse is taking the vitals of client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2 F. What is the priority nursing action? 1. Document the findings 2. Retake the temperature in 15 mintues 3. Notify HCP 4. Increase hydration by encouraging oral fluids

4