Maternal Newborn Postpartum

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

"If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider."

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply.

Retained placental fragments from delivery Uterine infection

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction?

The mother requests that the nurse feed the newborn because she is feeling fatigued.

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock?

An increased pulse rate of 80 to 120 beats/min

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and the parents?

Encourage the parents to touch their newborn.

The nurse is monitoring a newborn born to a client who abuses alcohol. Which finding should the nurse expect to note when assessing this newborn?

Irritability

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation?

The client is experiencing normal lochia discharge.

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply.

Report a foul-smelling discharge. Take a warm sitz baths 3 times a day. Use warm water to rinse the perineum after elimination. Wipe the perineum from front to back after voiding and defecation.

The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which finding in the newborn should alert the nurse to the possibility of this syndrome?

Tachypnea and retractions

A just-delivered newborn is dried immediately by the nurse in the delivery area. The nurse thoroughly dries the newborn to prevent heat loss by which mechanism?

Evaporation

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor?

Postpartum infection

The nurse determines the apical heart rate of a 2-day-old newborn to be 140 beats/minute. Which intervention is most appropriate related to this finding?

Document the finding in the electronic health record.

The nurse checks the respirations of a newborn who was just delivered. The respiratory rate is 40 breaths/minute. Which intervention is most appropriate related to this finding?

Document the findings in the electronic health record.

The nurse has determined that a postpartum client has uterine atony. The nurse should take actions in which priority order? Arrange the actions in the priority order that they should be done. All options must be used.

1 - Massage the uterus attempting to achieve firmness. 2 - Contact the primary health care provider. 3 - Monitor vital signs. 4 - Check the amount of drainage on the peripad.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?

Cover the client with a warm blanket.

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa?

Hemorrhage

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.

Massaging the uterus Assisting the woman to urinate Checking for a distended bladder

The nurse is performing an assessment on a newborn and is preparing to measure the head circumference of the newborn. Which item is essential to perform this assessment?

Tape measure

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression?

The client constantly complains of tiredness and fatigue.

The nurse is planning to administer an intramuscular injection of vitamin K to a newborn. To administer the injection, which site should the nurse select?

The lateral aspect of the middle third of the vastus lateralis muscle

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction?

"I need to isolate the infant for 48 hours after beginning the antibiotics."

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction?

"I need to stop breast-feeding until this condition resolves."

A postpartum client develops a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statements, if made by the mother, would indicate a need for further instruction? Select all that apply.

"I need to try to hold my urine as long as I can and urinate 3 to 4 times a day." "The prescribed medication needs to be taken until I feel better."

The nurse has a routine prescription to instill erythromycin ointment into the eyes of a newborn. Which statement, if made by the mother, demonstrates understanding of why this medication is used?

"The medication will help protect my baby's eyes from certain infections transmitted during the labor and delivery process."

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

"You need this vaccine because you are not immune to the rubella virus." "You should not become pregnant for 1 to 3 months after the administration of the vaccine."

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?

3 days postpartum

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

4

Which newborn is most at risk for a brachial plexus injury?

A large for gestational age infant with a history of shoulder dystocia at delivery

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis?

Ambulate frequently.

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?

An adolescent experiencing an emergency cesarean delivery for fetal distress

Methylergonovine has been prescribed for a woman who is at risk for postpartum bleeding in the immediate postpartum period. The nurse preparing to administer the medication ensures that which priority item is at the bedside?

Blood pressure cuff

A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure?

Breast-feed from the left breast and gently pump the right breast.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time?

Concern about the loss of the baby and personal health

The nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6º F (38.1º C) and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action?

Contact the primary health care provider (PHCP).

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

Gently massage the uterine fundus.

The nurse is providing instructions to the mother of a breast-fed newborn who has hyperbilirubinemia. Which instruction should the nurse provide to the mother?

Increase the frequency of the breast-feeding.

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action?

Palpating the uterine fundus

The nurse has provided instructions to a client on how to bathe her newborn. The nurse demonstrates the procedure to the client and on the following day asks the client to perform the procedure. Which observation, if made by the nurse, indicates that the client is performing the procedure correctly?

The client begins to wash the newborn by starting with the eyes and face.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant?

The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?

Wear a supportive brassiere continuously for 72 hours.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal?

The saturation of more than 1 peripad per hour

A newborn is delivered via spontaneous vaginal delivery. On reception of the crying newborn, the nurse's highest priority at this time is to perform which action?

Thoroughly dry the newborn.

A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection?

Urinate frequently throughout the day.

At 10 days postpartum, a breast-feeding mother develops mastitis in her right breast. The nurse plans to instruct the client on which interventions? Select all that apply.

Using ice packs Using analgesics Wearing proper breast support Completing the full course of prescribed antibiotics

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa?

he placenta is implanted in the lower uterine segment.

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.

1 - A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2 - A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen. 3 - An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR). 4 - A 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener.

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs?

15 minutes during the first hour and then every 30 minutes for the next 2 hours

The nurse is checking a newborn's 1-minute Apgar score based on the following assessment. The heart rate is 160 beats/minute; he has positive respiratory effort with a vigorous cry; his muscle tone is active and well flexed; he has a strong gag reflex and cries with stimulus to the soles of his feet; his body is pink, with his hands and feet cyanotic. Which is the newborn's 1-minute Apgar score?

9

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders?

A 39-year-old woman who reports that she smokes

The nurse is preparing to care for 4 assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply.

Anterior fontanelle measuring 5 cm Bluish discoloration of hands and feet Presence of vernix caseosa

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis?

Ask the client about pain in the calf area.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty her bladder.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?

Assess for hypovolemia and notify the primary health care provider (PHCP).

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client?

Assess her blood glucose before administering any glucose-lowering medications

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action?

Assist in healing and provide comfort.

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?

Peanut butter and jelly sandwich and glass of 2% milk

The staff nurse in a neonatal intensive care unit is aware that red electrical outlets denote emergency power and will function in the event of an outage. There are only 2 red outlets in the room of a 4-day-old male newborn being treated for physiological jaundice and to rule out sepsis from group B streptococcal exposure. Which pieces of equipment requiring power would the nurse select to be plugged into the red outlets in case of a power outage? Select all that apply.

Phototherapy lights Intravenous (IV) pump

The rubella vaccine is prescribed to be administered to a client 2 days after delivery of her child. The nurse preparing to administer the vaccine develops a list of the potential risks associated with this vaccine. The nurse reviews the list with the client and cautions the client to avoid which situation?

Pregnancy for 2 to 3 months after the vaccination

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and also notes that this is the client's first child. Which nursing interventions are most appropriate in assisting the promotion of mother-infant interaction and bonding? Select all that apply.

Accepting the client's feelings Acknowledging the client's apprehension Assisting the client with giving the baths to allow her to become more at ease

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the primary health care provider (PHCP), what is the nurse's next action?

Prepare the client for surgery.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client?

"You should not become pregnant for 2 to 3 months after administration of the vaccine."

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Breast-feeding

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client?

Maternal overexertion

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply.

"I am going to need to bottle-feed my baby." "I need to wash my hands before and after bathroom use." "I can transmit the infection to my baby when I breast-feed." "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home."

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates an understanding of the instructions?

"I can use ice packs to assist in alleviating some of the discomfort."

A client who is a gravida 3, para 3 had a cesarean section 1 day ago. She is being treated prophylactically for endometritis. She is complaining of abdominal cramping at a 6 on a pain level scale of 1 to 10 (with 10 being the greatest amount of pain) and fears having her first bowel movement. These medications are prescribed and due to be administered now. Based on priority, in which order should the nurse administer the medications? Arrange the medications in the order that they should be administered. All options must be used.

1 - Ketorolac 30 mg by intravenous (IV) push over 3 minutes 2 - Ampicillin sodium 1 g IV piggyback over 60 minutes 3 - Docusate sodium 100 mg orally daily 4 - Prenatal vitamin 1 tablet orally daily

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

Encourage the client to take pain medication as prescribed.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs?

Retained placental fragments from delivery

The nurse is checking the reflexes of a newborn. Which action should the nurse perform in eliciting the rooting reflex?

Stimulate the perioral cavity with a finger.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?

"A fever on and off is expected and is nothing to worry about."

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

"I need to breast-feed, especially for the first 6 weeks postpartum." "My baby has no symptoms so it is not likely that he has gotten the infection from me."

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?

"I should apply my antiembolism stockings after breakfast."

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment, the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response?

"Mastitis can occur at any time during breast-feeding."

After surgical evacuation and repair of a paravaginal hematoma, a client is discharged 3 days postpartum. The nurse determines that the client needs further discharge instructions when the client makes which statement?

"The only medications I will take are prenatal vitamins and stool softeners."

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?"

The nurse is providing nutritional counseling to a new mother who is breast-feeding her newborn. The nurse should instruct the client that her calorie needs should increase by approximately how many calories a day?

500

The postpartum unit nurse is creating a plan of care for a first-time mother and identifies the need for measures that will promote parent-infant bonding. Which measure should the nurse include in the plan?

Encourage the mother to hold the infant when the infant cries.

The nurse suspects the presence of uterine atony and massages the uterus, but this action does not assist in controlling blood loss. Which is the next nursing action?

Contact the primary health care provider (PHCP).

The nurse is performing an initial assessment on a newborn. On assessment, which finding could be indicative of a congenital defect?

Low-set ears

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurses.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression?

The mother constantly complains of tiredness and fatigue.

The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.

Wear a supportive bra between feedings. Apply moist heat to both breasts for about 20 minutes before a feeding. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Massage the breasts gently during a feeding, from the outer areas to the nipples.