Maternity Ch. 15
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?
"After birth it is easier to develop an infection in the urinary system; we need to see you today."
A nurse on the postpartum floor is conducting a class on danger signs for postpartum women after discharge. The nurse recognizes that further teaching is needed when a new mother makes which statement?
"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
"Ovulation may return as soon as 3 weeks after birth."
A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort."
A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."
A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?
"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color."
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women?
85%
The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding?
A process of developing an attachment and becoming acquainted with each other
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?
Accept the mother's statement and perform discharge teaching accordingly.
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?
Apply ice.
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Bladder distention
A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy
A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client?
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have.
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?
Harm to self
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours.
A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?
Have the client sit dangling her legs off the side of the bed for 5 minutes.
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?
Have the client void, and then massage the fundus until it is firm.
The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize?
Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean
The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply.
Incomplete emptying of the bladder; bladder distention; urinary retention
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?
Maintain correct posture and positioning.
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next?
Perform urinary catheterization.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
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?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.
The nurse is looking at the laboratory results for a postpartum client. Before giving birth, the client's hemoglobin level was 12.8 g/dl (128 g/l) and hematocrit level was 39% (0.39). The current laboratory results are hemoglobin 8.9 g/dl (89 g/l) and 30% (0.30). How does the nurse interpret these results?
The health care provider needs to be notified.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive?
The mother is reluctant to touch the newborn for fear of hurting her.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra.
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
applying ice
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?
increased heart rate
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?
bleeding
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?
difficult to separate clots
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
hydramnios uterine infection prolonged labor
The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?
lochia rubra
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors
A nurse is assessing a breastfeeding client in the third week postpartum. During the physical examination, the nurse observes that the rugae in the vagina have not reappeared. Which factor would the nurse identify as the possible cause of delayed return of rugae?
low circulating estrogen level
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5
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?
postpartum depression
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
showing increased confidence when caring for the newborn
A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading?
sitting on the side of the bed for 2 minutes
A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation?
suggest proper exercise
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?
taking-in
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?
taking-in phase
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go.
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?
touching
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?
white blood cell count 14,000/mm3 (14 ×109/L)