Normal Postpartum- Davis Practice Q's

A nurse is performing a postpartum assessment on a newly delivered client. Which of the following actions will the nurse perform? Select all that apply. 1. Palpate the breasts. 2. Auscultate the carotid. 3. Check vaginal discharge. 4. Assess the extremities. 5. Inspect the perineum.

1, 3, 4, and 5 are correct. 1. The nurse should palpate the breasts to assess for fullness and/or engorgement. 3. The nurse should check the client's vaginal discharge. 4. The nurse should assess the client's extremities. 5. The nurse should inspect the client's perineum. The best way to remem- ber the items in the postpartum assessment is to remember the acronym BUBBLEHE. The letters stand for: B—breasts; U—uterus; B—bladder; B—bowels and rectum (for hemorrhoids); L—lochia; E—episiotomy; H—Homan's sign; and E—emotional status. But it is important to note that Homan's sign is no longer recommended. Rather, careful inspection of the calves for signs of DVT should be performed.

A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Encourage the woman exclusively to breastfeed her baby. 2. Have the woman massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the woman.

1. Clients should be strongly encouraged exclusively to breastfeed their babies to prevent engorgement. The lactating breast produces milk in response to being stimulated. When a feeding is skipped, milk is still produced for the baby. When the baby is not fed, breast congestion or engorgement results. Not only is engorgement uncomfortable, it also gives the body the message to stop producing milk, resulting in an insufficient milk supply.

The nurse must initiate discharge teaching with the couple regarding the need for an infant car seat for the day of discharge. Which of the following responses indicates that the nurse acted appropriately? The nurse discussed the need with the couple: 1. On admission to the labor room. 2. In the client room after the delivery. 3. When the client put the baby to the breast for the first time. 4. The day before the client and baby are to leave the hospital.

1. Discharge teaching should be initiated at the time of admission. This nurse is correct in initiating the process in the labor room. It is essential that nurses begin discharge teaching upon entry to the hospital. If nurses wait until the time of discharge, clients are expected to process a large amount of information during a very stressful time. Even when initiated early in the hospital stay, the nurse will likely need to repeat his or her instructions many times before the client is fully prepared to leave the hospital.

Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis? 1. Encourage early ambulation. 2. Promote oral fluid intake. 3. Massage the legs of the client twice daily. 4. Provide the client with high-fiber foods.

1. Early ambulation does help to prevent thrombophlebitis. Postpartum clients are at high risk for thrombophlebitis because of an increase in the quantity of circulating clotting factors. To prevent clot formation, clients should ambulate as soon as possible after delivery. If they must be bed bound because of complica- tions, the nurse should contact the physician for an order for antiembolic stockings and/or antiembolic pressure boots and have the client perform active range-of-motion exercises.

Which of the following complementary therapies can a nurse suggest to a multiparous woman who is complaining of severe afterbirth pains? 1. Lie prone with a small pillow cushioning her abdomen. 2. Contract her abdominal muscles for a count of ten. 3. Slowly ambulate in the hallways. 4. Drink ice tea with lemon or lime.

1. Lying prone on a pillow helps to relieve some women's afterbirth pains. Afterbirth pains can be quite uncomfortable, especially for multi- paras. The nurse should suggest that the clients take prn medications—ibuprofen is especially helpful—and try complementary therapies like lying on a small pillow and placing a hot water bottle on the abdomen.

During a postpartum assessment, it is noted that a G1 P1001 woman, who delivered vaginally over an intact perineum, has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the woman's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure.

1. Sitz baths do have a soothing affect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum. 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids. Hemorrhoids are vari- cose veins of the rectum. They develop as a result of the weight of the gravid uterus on the client's dependent blood vessels. In addition to the actions noted above, the client should be advised to eat high-fiber foods and drink to prevent constipation.

Immediately after delivery, a woman is shaking uncontrollably. Which of the following nursing actions is most appropriate? 1. Provide the woman with warm blankets. 2. Put the woman in the Trendelenburg position. 3. Notify the primary health care provider. 4. Increase the intravenous infusion.

1. The appropriate action is to provide the client with warm blankets. Postpartum shaking is thought to be caused by nervous responses and/or vasomotor changes. The shaking is very common and, unless accompanied by a fever, is of no physio- logical concern. The best action by the nurse is supportive—providing the client with a warm blanket and reassuring her that the response is within normal limits.

The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary health care provider to order a milk suppressant.

1. The client should apply ice packs to her axillae and breasts. Breast milk is produced in the glandular tissue of the breast. An adequate blood supply to the area is required for the milk production. When cold is applied to the breast, the blood vessels constrict, decreasing the blood supply to the area. This is a relatively easy, nonhazardous action that helps to suppress breast milk production.

A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. The nurse would report to the anesthesiologist if which of the following were assessed? 1. Respiratory rate 8 rpm. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles.

1. This action is appropriate. This client's respiratory rate is below normal. One of the serious complications of narcotic administration is respiratory depression. This client's respiratory rate is well below expected. The nurse should continue to monitor the client carefully and notify the anesthesiologist of the complication.

The obstetrician has ordered that a post-op cesarean section client's patient-controlled analgesia (PCA) be discontinued. Which of the following actions by the nurse is appropriate? 1. Discard the remaining medication in the presence of another nurse. 2. Recommend waiting until her pain level is zero to discontinue the medicine. 3. Discontinue the medication only after the analgesia is completely absorbed. 4. Return the unused portion of medication to the narcotics cabinet.

1. This answer is correct. Because the medication in a PCA pump is con- trolled by law, the medication must be wasted in the presence of another nurse. There are a number of considerations that the nurse must make when giving medications, especially when administering controlled substances. The nurse is legally bound to account for the administration of or the disposal of narcotic medications. If any narcotic is wasted, a second nurse must cosign the disposal.

A client has been transferred to the post-anesthesia care unit from a cesarean delivery. The client had spinal anesthesia for the surgery. Which of the following interventions should the nurse perform at this time? 1. Assess the level of the anesthesia. 2. Encourage the client to urinate in a bedpan. 3. Provide the client with the diet of her choice. 4. Check the incision for signs of infection.

1. This answer is correct. The nurse should assess the level of anesthesia every 15 minutes while in the postanesthesia care unit. The key to answering this question is the fact that the client has just moved from the operating room. The nurse in the postanesthesia care unit (PACU) is concerned with monitoring for immediate postoperative and postpartum complications and the client's recovery from the anesthesia.

A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery. 2. Obtain an order for a urine culture. 3. Assess the urine for cloudiness. 4. Ask the woman if she is prone to urinary tract infections.

1. This response is correct. Reassuring the client is appropriate. Frequent urination is normal after a delivery. The urine of a postpartum client will be blood tinged. This does not mean that the client has red blood cells in her urine, but rather that the lochia from the vagina has con- taminated the sample. Unless a catheter- ized sample is obtained, it is virtually impossible to obtain an uncontaminated urine sample in the postpartum period.

A client who is 3 days postpartum asks the nurse, "When may my husband and I begin having sexual relations again?" The nurse should encourage the couple to wait until after which of the following has occurred? 1. The client has had her six-week postpartum checkup. 2. The episiotomy has healed and the lochia has stopped. 3. The lochia has turned to pink and the vagina is no longer tender. 4. The client has had her first postpartum menstrual period.

1. This response is correct. The couple is encouraged to wait until after involu- tion is complete. There have been some cases, albeit rare, of women dying from air emboli when they had intercourse early in the puerperium. It is recom- mended that couples wait 6 weeks before resuming intercourse.

A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the hospital. Which of the following rationales should guide the nurse's response? 1. The client's obstetric status is optimal for receiving the vaccine. 2. The client's immune system is highly responsive during the postpartum period. 3. The client's baby will be high risk for acquiring rubella if the woman does not receive the vaccine. 4. The client's insurance company will pay for the shot if it is given during the immediate postpartum period.

1. This statement is correct. Because the vaccine is teratogenic, the best time to administer it is when the client is not pregnant. The correct answer did not explicitly state that the vaccine is administered during the immediate post- partum period because the woman is not pregnant and is unlikely to become preg- nant within the next 4 weeks. But the test taker must know that a woman's obstetric status immediately after delivery is opti- mal for receiving the medication precisely because she is not pregnant and very unlikely to become pregnant.

A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? 1. The woman should not become pregnant for at least 4 weeks. 2. The woman should pump and dump her breast milk for 1 week. 3. Surgical masks must be worn by the mother when she holds the baby. 4. Antibodies transported through the breast milk will protect the baby.

1. This statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can develop if the woman becomes pregnant within 4 weeks of receiving the injection. If rubella is contracted during pregnancy, the fetus is at very high risk for injury. Whenever gravid clients are found to be nonimmune to rubella— defined as a titer of 1:8 or lower—they are advised to receive the vaccine during the early postpartum period and are counseled regarding the teratogenic properties of the vaccine.

A breastfeeding client, G10 P6408, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time? 1. Pulse. 2. Fundus. 3. Bladder. 4. Breast.

2. An assessment of the woman's fundus is the most important assessment to perform on this client. This client's gravidity and parity indicate that she is a grand multi- para. She has been pregnant 10 times, carrying 6 babies to term and 4 babies preterm. Because her uterus has been stretched so many times, she is at high risk for uterine atony during the postpartum period. The nurse must, therefore, moni- tor the postpartum contraction of her uterus very carefully.

One nursing diagnosis that a nurse has identified for a postpartum client is: Risk for intrauterine infection r/t vaginal delivery. During the postpartum period, which of the following goals should the nurse include in the care plan in relation to this diagnosis? Select all that apply. 1. The client will drink sufficient quantities of fluid. 2. The client will have a stable white blood cell count. 3. The client will have a normal temperature. 4. The client will have normal-smelling vaginal discharge. 5. The client will take two or three sitz baths each day.

2. An important goal is that the woman's WBC will remain stable. 3. An important goal is that the woman's temperature will remain normal. 4. An important goal is that the woman's lochia will smell normal. The WBC is elevated during late pregnancy, delivery, and early postpartum, but if it rises very rapidly, the rise is often associated with a bacterial infection. The lochia usually smells "musty." When a client has endometritis, however, the lochia smells "foul." A temperature above 100.4°F after the first 24 hours postpartum is indicative of a puerperal infection.

The nurse is caring for a client who had an emergency cesarean section, with her husband in attendance, the day before. The baby's Apgar was 9/9. The woman and her partner had attended childbirth education classes and had anticipated having a water birth with family present. Which of the following comments by the nurse is appropriate? 1. "Sometimes babies just don't deliver the way we expect them to." 2. "With all of your preparations, it must have been disappointing for you to have had a cesarean." 3. "I know you had to have surgery, but you are very lucky that your baby was born healthy." 4. "At least your husband was able to be with you when the baby was born."

2. This comment conveys sensitivity and understanding to the client. Clients who must have cesarean sections when they had devel- oped birth plans for vaginal deliveries are often very disappointed. They may express regret and/or anger over the experience. The nurse must realize that such clients are not angry with the nurse, but rather at the situation. It is essential for the nurse to accept the clients' feelings with under- standing and caring.

A woman is receiving patient-controlled analgesia (PCA) post-cesarean section. Which of the following must be included in the patient teaching? 1. The client should monitor how often she presses the button. 2. The client should report any feelings of nausea or itching to the nurse. 3. The family should press the button whenever they feel the woman is in pain. 4. The family should inform the nurse if the client becomes sleepy.

2. This information is correct. Clients often experience nausea and/or itching when PCA narcotics are administered. It is important for the nurse to teach a client's family members not to touch the PCA pump. Even though the pump is programmed with a minimum time between medication attempts, there is a possibility that the client could receive an overdose of medication if someone else controls the administrations. If a client is able to push the button herself she is, by definition, awake and alert.

A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.

2. This information is correct. The blues usually resolve within 2 weeks of delivery. The test taker must not confuse the three psychological changes that mothers may experience postpartum: postpartum blues, postpartum depression, and postpartum psychosis. Postpartum blues is a normal phenomenon related to fatigue, hormonal shifts, and the enormous responsibility of becoming a mother. Postpartum depression and postpartum psychosis are pathological conditions that only some women experience.

The surgeon has removed the surgical cesarean section dressing from a post-op day 1 client. Which of the following actions by the nurse is appropriate? 1. Irrigate the incision twice daily. 2. Monitor the incision for drainage. 3. Apply steristrips to the incision line. 4. Palpate the incision and assess for pain.

2. This is appropriate. The nurse should assess for all signs on the REEDA scale. Once the dressing has been removed, the nurse on each shift should monitor the incision line for all signs on the REEDA scale—redness, edema, ecchymosis, discharge, and approximation.

A client who delivered a 3,900-gram baby vaginally over a right mediolateral episiotomy states, "How am I supposed to have a bowel movement? The stitches are right there!" Which of the following is the best response by the nurse? 1. "I will call the doctor to order a stool softener for you." 2. "Your stitches are actually far away from your rectal area." 3. "If you eat high-fiber foods and drink fluids you should have no problems." 4. "If you use your topical anesthetic on your stitches you will feel much less pain."

2. This is the best response. A right mediolateral episiotomy is angled away from the perineum and rectum. Women often are fearful of having a bowel movement when they have had an episiotomy or a laceration. Unless they have a third- or fourth-degree laceration, they should be assured that the stitches are a distance away from the rectal area.

A breastfeeding woman, 1 1/2 months postdelivery, calls the nurse in the obstetrician's office and states, "I am very embarrassed but I need help. Last night I had an orgasm when my husband and I were making love. You should have seen the milk. We were both soaking wet. What is wrong with me?" The nurse should base the response to the client on which of the following? 1. The woman is exhibiting signs of pathological galactorrhea. 2. The same hormone stimulates orgasms and the milk ejection reflex. 3. The woman should have a serum galactosemia assessment done. 4. The baby is stimulating the woman to produce too much milk.

2. This is true. Oxytocin stimulates sexual orgasms and is also the hormone that stimulates the milk ejection reflex. It is important for the nurse in the obstetrician's office to warn breastfeeding clients of this situation. Because clients are strongly encouraged to refrain from having intercourse until they are 6 weeks postpartum, the postpartum nurse may not include this information in the client's discharge instructions. When the client is seen for her postpartum check, however, the information should be included.

The nurse takes a newborn to a primipara for a feeding. The mother holds the baby en face, strokes his cheek, and states that this is the first newborn she has ever held. Which of the following nursing assessments is most appropriate? 1. Positive bonding and client needs little teaching. 2. Positive bonding but teaching related to newborn care is needed. 3. Poor bonding and referral to a child abuse agency is essential. 4. Poor bonding but there is potential for positive mothering.

2. This response is correct. The client is showing signs of positive bonding— en face positioning and stroking of the baby's cheeks—and is in need of infor- mation on child care. This client has never held a newborn before. The nurse, there- fore, should be prepared to provide the client with information on newborn care. Two signs of positive bonding are holding a baby in the en face position—so that the mother is looking directly into the baby's eyes—and stroking the baby's cheeks.

A maternity nurse knows that obstetric clients are most at high risk for cardiovascular compromise during the one hour immediately following a delivery because of which of the following? 1. Weight of the uterine body is significantly reduced. 2. Excess blood volume from pregnancy is circulating in the woman's periphery. 3. Cervix is fully dilated and the lochia flows freely. 4. Maternal blood pressure drops precipitously once the baby's head emerges.

2. This response is true. Once the placenta is birthed, the reservoir for the mother's large blood volume is gone. It is essential that the nurse closely monitor the vital signs of a newly delivered gravida. Because of the surge in blood volume resulting from the delivery of the placenta, the woman is high risk for cardiovascular compromise. Women frequently develop bradycardia, a normal finding, as a result of the increased peripheral blood volume.

The nurse informs a postpartum woman that which of the following is the reason ibuprofen (Advil) is especially effective for afterbirth pains? 1. Ibuprofen is taken every two hours. 2. Ibuprofen has an antiprostaglandin effect. 3. Ibuprofen is given via the parenteral route. 4. Ibuprofen can be administered in high doses.

2. This statement is correct. Ibuprofen has an antiprostaglandin effect. Prostaglandins are produced as part of the inflammatory response. When ibuprofen is administered, the client receives the pain-reducing action of the medication as well as its anti-inflammatory properties.

A post-cesarean section, breastfeeding client, whose subjective pain level is 2/5, requests her as needed (prn) narcotic analgesics every 3 hours. She states, "I have decided to make sure that I feel as little pain from this experience as possible." Which of the following should the nurse conclude in relation to this woman's behavior? 1. The woman needs a stronger narcotic order. 2. The woman is high risk for severe constipation. 3. The woman's breast milk volume may drop while taking the medicine. 4. The woman's newborn may become addicted to the medication.

2. This statement is correct. One of the common side effects of narcotics is constipation. Because clients who take narcotics are high risk for constipation, the nurse should inform clients of the potential and advise them to take necessary precautions. For example, the clients should be advised to drink fluids, eat high-fiber foods, and ambulate regularly.

A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.

2. This statement is true. The best way to prevent engorgement is to feed the baby every 2 to 3 hours.

The nurse should warn a client who is about to receive Methergine (ergonovine) of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue.

3. Cramping is an expected outcome of the administration of Methergine. Methergine is adminis- tered to postpartum clients to stimulate their uterus to contract. As a conse- quence, clients frequently complain of cramping after taking the medication. The nurse can administer the prn pain medication to the client at the same time the Methergine is administered to help to mitigate the client's discomfort.

A woman, 24 hours postpartum, is complaining of profuse diaphoresis. She has no other complaints. Which of the following actions by the nurse is appropriate? 1. Take the woman's temperature. 2. Advise the woman to decrease her fluid intake. 3. Reassure the woman that this is normal. 4. Notify the neonate's pediatrician.

3. Diaphoresis is normal during the post- partum period. Because the client's blood volume is returning to its nonpreg- nant level, the client loses fluids via both the kidneys and through insensible loss. As a result, postpartum women often awake from sleep with their nightwear saturated with perspiration.

A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with "latch on" and recommends that the mother do which of the following? 1. Use a nipple shield at each breastfeeding. 2. Cleanse the nipples with soap 3 times a day. 3. Rotate the baby's positions at each feed. 4. Bottle feed for 2 days then resume breastfeeding.

3. Rotating positions at feedings is one action that can help to minimize the severity of sore nipples. If a mother rotates positions at each breastfeeding, the baby is likely to put pressure on varying points on the nipple. A good, deep latch, however, is the most important way to prevent nipple soreness and cracking. The mother could also apply lanolin to her breasts after each feeding.

The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period? 1. Decreased urinary output. 2. Increased blood pressure. 3. Decreased blood volume. 4. Increased estrogen level.

3. The blood volume does drop precipi- tously during the early postpartum period. During pregnancy, the blood volume increased by almost 50%. Once the placenta is delivered, the client no longer needs the added blood volume. Immediately after delivery, therefore, the woman experiences marked diuresis and diaphoresis as the blood volume drops.

A 2-day postpartum mother, G2 P2002, states that her 2-year-old daughter at home is very excited about taking "my baby sister" home. Which of the following is an appropriate response by the nurse? 1. "It's always nice when siblings are excited to have the babies go home." 2. "Your daughter is very advanced for her age. She must speak very well." 3. "Your daughter is likely to become very jealous of the new baby." 4. "Older sisters can be very helpful. They love to play mother."

3. The nurse should forewarn the mother about the likelihood of the 2-year-old's jealousy. The test taker must be familiar with the growth and development of children at all ages and be prepared to convey this information to new parents. Older siblings, especially toddlers, often express jealousy when a new baby enters the home. This is normal, but the parents must be aware of the potential for tod- dlers to inadvertently injure the baby.

On admission to the labor and delivery unit, a client's hemoglobin (Hgb) was assessed at 11.0 g/dL, and her hematocrit (Hct) at 33%. Which of the following values would the nurse expect to see 2 days after a normal spontaneous vaginal delivery? 1. Hgb 12.5 g/dL; Hct 37%. 2. Hgb 11.0 g/dL; Hct 33%. 3. Hgb 10.5 g/dL; Hct 31%. 4. Hgb 9.0 g/dL; Hct 27%.

3. The nurse would expect these values— a slight decrease in both hemoglobin and hematocrit values. Because clients do lose blood during their deliveries, the nurse would expect to see approximately a 2% drop in the hematocrit and about a 0.5 gm/dL drop in the hemoglobin. If the hematocrit drops below 30%, the nurse should notify the health care practitioner.

A physician has ordered an iron supplement for a postpartum woman. The nurse strongly suggests that the woman take the medicine with which of the following drinks? 1. Skim milk. 2. Ginger ale. 3. Orange juice. 4. Chamomile tea.

3. The nurse would recommend that the iron be taken with orange juice because ascorbic acid, which is in orange juice, promotes the absorption of iron into the body. Since ascorbic acid promotes the absorption of iron into the body, it is appropriate for the nurse to recommend that the client take her iron supplement with a food source high in ascorbic acid, like orange juice.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following tasks should the registered nurse delegate to the nursing care assistant? 1. Assess client's fundal height. 2. Teach client how to massage her fundus. 3. Take the client's vital signs. 4. Document quantity of lochia in the chart.

3. This action can be delegated to a nursing assistant. Once the vital signs are checked, the nursing assistant can report the results to the nurse for his or her interpretation. Delegation is an impor- tant skill. Nurses are unable to meet all the needs of all of their patients. They must ask other health care workers, e.g., licensed practical nurses and nursing assistants, to meet some of the clients' needs. It is essential, however, that the nurse delegate appropriately. Assessment, teaching, and documentation are tasks that should not be delegated to nursing assistants.

A client, G2 P1102, is 30 minutes postpartum from a low forceps vaginal delivery over a right mediolateral episiotomy. Her physician has just finished repairing the incision. The client's legs are in the stirrups and she is breastfeeding her baby. Which of the following actions should the nurse perform? 1. Assess her feet and ankles for pitting edema. 2. Advise the client to stop feeding her baby while her blood pressure is assessed. 3. Lower both of her legs at the same time. 4. Measure the length of the episiotomy and document the findings in the chart.

3. This action is very important. If the legs are removed from the stirrups one at a time then the woman is at high risk for back and abdominal injuries. Stirrups may not be used during normal spontaneous deliveries; however, when forceps or vacuum- extractors are used, physicians often request that the client's legs be placed in stirrups. The nurse should raise the woman's legs simultaneously when plac- ing her legs in stirrups and lower her legs simultaneously when the delivery is complete to prevent injury. The nurse should also position the legs with care. Pressure on the popliteal space can lead to thrombus formation.

The home health nurse visits a client who is 6 days postdelivery. The client appears sad, weeps frequently, and states, "I don't know what is wrong with me. I feel terrible. I should be happy, but I'm not.". Which of the following nursing diagnoses is appropriate for this client? 1. Suicidal thoughts related to psychotic ideations. 2. Post-trauma response related to traumatic delivery. 3. Ineffective individual coping related to hormonal shifts. 4. Spiritual distress related to immature belief systems.

3. This diagnosis is appropriate. This client is showing signs of postpartum blues; one of the main reasons for this problem is related to the hormonal changes that occur after delivery. It is essential that nurses discuss postpartum blues with clients. When clients are unfamiliar with the phenomenon, they often feel like they are going crazy or that there is something very wrong with them. Other members of the family, especially the woman's partner, should also be forewarned.

A client has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority? 1. The client will breastfeed her baby every 2 hours. 2. The client will consume a normal diet. 3. The client will have a moderate lochial flow. 4. The client will ambulate to the bathroom every 2 hours.

3. This is the most important goal during the immediate postdelivery period. When establishing priorities, the test taker should consider the client's most important physiological functions—that is, the C-A-B —circulation, airway, and breathing. If the client were to bleed heavily, her circulation would be compromised. None of the other goals is directly related to the C-A-Bs.

The day after delivery, a woman, whose fundus is firm at 1 cm below the umbilicus and who has moderate lochia, tells the nurse that something must be wrong: "All I do is go to the bathroom." Which of the following is an appropriate nursing response? 1. Catheterize the client per doctor's orders. 2. Measure the client's next voiding. 3. Inform the client that polyuria is normal. 4. Check the specific gravity of the next voiding.

3. This response is correct. Polyuria is normal. This client's physical assessment is normal. If the client's bladder were distended, the client's fundus would be elevated in the abdomen and the client would have excess blood loss. It is unneces- sary, therefore, either to catheterize the woman or to measure her output. Polyuria is normal because the client no longer needs the large blood volume she produced during her pregnancy.

The nurse is examining a 2-day-postpartum client whose fundus is 2 cm below the umbilicus and whose bright red lochia saturates about 4 inches of a pad in 1 hour. What should the nurse document in the nursing record? 1. Abnormal involution, lochia rubra heavy. 2. Abnormal involution, lochia serosa scant. 3. Normal involution, lochia rubra moderate. 4. Normal involution, lochia serosa heavy.

3. This response is correct. The involu- tion is normal and the lochia is rubra. Lochia rubra is bright red, lochia serosa is pinkish to brownish, and lochia alba is whitish. The nurse would expect the fundus to descend below the umbilicus approximately 1 cm per postpartum day. In other words, 1 day postpartum, the fundus is usually felt 1 cm below the umbilicus; 2 days postpartum, it is usually felt 2 cm below the umbilicus, and so on.

A breastfeeding client, 7 weeks postpartum, complains to an obstetrician's triage nurse that when she and her husband had intercourse for the first time after the delivery, "I couldn't stand it. It was so painful. The doctor must have done something terrible to my vagina." Which of the following responses by the nurse is appropriate? 1. "After a delivery the vagina is always very tender. It should feel better the next time you have intercourse." 2. "Does your baby have thrush? If so, you should be assessed for a yeast infection in your vagina." 3. "Women who breastfeed often have vaginal dryness. A vaginal lubricant may remedy your discomfort." 4. "Sometimes the stitches of episiotomies heal too tight. Why don't you come in to be checked?"

3. This response is correct. The woman should be encouraged to use a lubricat- ing jelly or oil. When women breast- feed, their estrogen levels remain low. As a result, they often complain of vaginal dryness and dyspareunia. The woman should be advised to try an over-the- counter lubricant. If that is not helpful, the woman may be prescribed an estro- gen-based vaginal cream by her health care practitioner.

The nurse is developing a standard care plan for postpartum clients who have had midline episiotomies. Which of the following interventions should be included in the plan? 1. Assist with stitch removal on third postpartum day. 2. Administer analgesics every four hours per doctor's orders. 3. Teach client to contract her buttocks before sitting. 4. Irrigate incision twice daily with antibiotic solution.

3. This statement is correct. When clients contract their buttocks before sitting, they usually feel less pain than when they sit directly on the suture line. Clients who have had episiotomies often avoid sitting normally. Nurses should encourage them to take medications as needed, to contract their buttocks before sitting, and to sit nor- mally rather than trying to favor one buttock over the other. Mediolateral incisions do tend to be more painful than midline incisions.

A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal sutures are intact. Which of the following actions should the nurse take at this time? 1. Do nothing. This is a normal finding. 2. Massage the woman's fundus. 3. Take the woman to the bathroom to void. 4. Notify the woman's primary health care provider.

4. Because of the heavy lochia, the nurse should notify the woman's health care provider. The nurse must do some detective work when observing unexpected signs/symptoms. This client is bleeding more heavily than the nurse would expect. When the nurse assesses the two most likely sources of the bleeding—the fundus and the perineal sutures—normal findings are noted. The next most likely source of the bleeding —a laceration in the birth canal—is unobservable to the nurse because performing a postpartum internal examination is not a nursing function. The nurse, therefore, must notify the health care practitioner of the problem.

The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6 ̊F, 82, 18; fundus firm at umbilicus; moderate lochia rubra; ambulated to bathroom to void 4 times; breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.

4. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding newborn care as well as self-care. This is a difficult analy- sis level question. The test taker must determine, based on the facts given, which nursing diagnosis is appropriate. This question, however, should be approached the same way that all other questions are approached: (1) determine what is being asked; (2) develop possible answers to the question BEFORE reading the given responses; (3) read the responses and compare them with the list of possible answers; and (4) choose the one response that best compares with the list of possible answers.

The nurse is preparing to place a peripad on the perineum of a client who delivered her baby 10 minutes earlier. The client states, "I don't use those. I always use tampons." Which of the following actions by the nurse is appropriate at this time? 1. Remove the peripad and insert a tampon into the woman's vagina. 2. Advise the client that for the first two days she will be bleeding too heavily for a tampon. 3. Remind the client that a tampon would hurt until the soreness from the delivery resolves. 4. State that it is unsafe to place anything into the vagina until involution is complete.

4. This response is correct. It is unsafe to place anything in the vagina before involution is complete. This question examines whether or not the test taker is aware of changes in care that are determined by the situation. Because the cervix is still dilated and the uterine body is high risk for infec- tion, it is unsafe to insert anything into the vagina until involution is complete.

A client, G1 P1, who had an epidural, has just delivered a daughter, Apgar 9/9, over a mediolateral episiotomy. The physician used low forceps. While recovering, the client states, "I'm a failure. I couldn't stand the pain and couldn't even push my baby out by myself!" Which of the following is the best response for the nurse to make? 1. "You'll feel better later after you have had a chance to rest and to eat." 2. "Don't say that. There are many women who would be ecstatic to have that baby." 3. "I am sure that you will have another baby. I bet that it will be a natural delivery." 4. "To have things work out differently than you had planned is disappointing."

4. This response shows that the nurse has an understanding of the client's feelings. When clients express their feelings, nurses must provide accep - tance and implicit approval to encourage the clients to continue to express those feelings. Comments like "Don't say that. There are many women who would be ecstatic to have that baby" close down conversation and communicate disapproval.

A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your six-week postpartum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had during your prepregnancy." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."

4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on. It is important for the postpartum client to begin muscle toning early in the postpartum period. However, she should not do any weight lifting or high-impact or stressful aerobic exercising until after her 6-week postpartum check.

Which of the following is the priority nursing action during the immediate postpartum period? 1. Palpate fundus. 2. Check pain level. 3. Perform pericare. 4. Assess breasts.

1. Fundal assessment is the priority nurs- ing action. Hemorrhage is one of the primary causes of morbidity and mor- tality in postpartum women. It is essential, therefore, that nurses repeatedly assess a client's postpartum uterine contraction. When the uterus is well contracted, a woman is unlikely to bleed heavily after delivery.

The nurse is discussing the importance of doing Kegel exercises during the postpartum period. Which of the following should be included in the teaching plan? 1. She should repeatedly contract and relax her rectal and thigh muscles. 2. She should practice by stopping the urine flow midstream every time she voids. 3. She should get on her hands and knees whenever performing the exercises. 4. She should be taught that toned pubococcygeal muscles decrease blood loss.

2. Doing Kegel exercises during the postpartum period helps clients to regain the muscle tone in the pubococcygeal muscles that may have been affected during pregnancy and labor and delivery. Clients should be advised to perform them periodically throughout the day. They can be performed in any posi- tion and in any location.

The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin.

2. Prolactin will elevate sharply in the client's bloodstream. To answer this ques- tion correctly, it is important for the test taker to know what happens at the end of the third stage of labor—that is, the delivery of the placenta. Because the hormones of pregnancy produced by the placenta—progesterone and estro- gen—drop precipitously at this time, prolactin is no longer inhibited and, therefore, rises. The way the woman intends to feed her baby is irrelevant.

A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with his or her dependent hand. 3. The nurse palpates the fundus with the tips of his or her fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.

2. The nurse should stabilize the base of the uterus with his or her dependent hand. If the base of the uterus is not stabilized during the assessment, there is a possibility that the uterus may invert or prolapse. While stabilizing the base, the nurse should gently assess for the fundus by palpating the abdomen with the flat part of the fingers until the fun- dus is felt.

During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see? 1. Diaphoresis. 2. Lochia alba. 3. Cracked nipples. 4. Hypertension.

2. The nurse would expect that the client would have lochia alba. The normal progression of lochial change is as follows: lochia rubra, days 1 to 3; lochia serosa, days 3 to 10; and lochia alba, days 10 until discharge stops. There is some variation in the exact timing of the lochial change, but it is important for the client to know that the lochia should not revert backward. In other words, if a client whose lochia is alba again begins to have bright red discharge, she should notify her health care practitioner.

The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.

2. The nurse would expect to see well-approximated edges. The best tool to use when assessing any incision is the REEDA scale. The nurse assesses for: R—redness, E—edema, E—ecchymosis, D—drainage, and A—poor approximation. If there is evidence of any of the findings, they should be documented and monitored and reported.

Which of the following laboratory values would the nurse expect to see in a normal postpartum woman? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm3. 3. Red blood cell count, 5 million cells/mm3. 4. Hemoglobin, 15 grams/dL.

2. The nurse would expect to see an elevated white cell count. The white blood cell count elevates late in the third trimester and stays elevated during labor and the early postpartum period to protect the mother from infection during the delivery and puerperium.

Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually involute completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.

2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 diabetes later in life. Breastfeeding has many beneficial properties for both mothers and babies. It is a nursing responsibility to provide couples with the knowledge so that they can make fact-based decisions about how they will feed their babies.

A client, G1 P0101, postpartum 1 day, is assessed. The nurse notes that the client's lochia rubra is moderate and her fundus is boggy 2 cm above the umbilicus and deviated to the right. Which of the following actions should the nurse take first? 1. Notify the woman's primary health care provider. 2. Massage the woman's fundus. 3. Escort the woman to the bathroom to urinate. 4. Check the quantity of lochia on the peripad.

2. This action is the first that the nurse should take. When a postpartum client's bladder is distended, the uterus becomes displaced and boggy. The client should be escorted to the bathroom to void; the lochia flow should also be assessed. However, before escorting the client to urinate, the nurse should gently massage the uterus.

A primipara, 2 hours postpartum, requests that the nurse diaper her baby after a feeding because "I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following? 1. Social deprivation. 2. Child neglect. 3. Normal postpartum behavior. 4. Postpartum depression.

3. The client is exhibiting normal post- partum behavior. This client is exhibiting signs of the postpartum taking in phase. She is a primigravida who delivered only 2 hours earlier. Her comments are well within those expected of a client at this point during her postpartum period.

A client, G1 P1001, 1 hour postpartum from a spontaneous vaginal delivery with local anesthesia, states that she needs to urinate. Which of the following actions by the nurse is appropriate at this time? 1. Provide the woman with a bedpan. 2. Advise the woman that the feeling is likely related to the trauma of delivery. 3. Remind the woman that she still has a catheter in place from the delivery. 4. Assist the woman to the bathroom.

4. Because they have elevated clotting factors, postpartum clients are at high risk for thrombus formation. When they need to urinate, they should be encouraged to ambulate to the bathroom to prevent pooling of blood. Clients should be accompanied to the bathroom, however, because they may be light-headed from the stress and work of labor and delivery.

A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F. Which of the following is the appropriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the woman with cool compresses. 4. Encourage intake of water and other fluids.

4. It is likely that this client is dehydrated. She should be advised to drink fluids. In the early postpartum period, up to 24 hours after delivery, the most common reason for clients to have slight temperature elevations is dehydra- tion. During labor, clients work very hard, often utilizing breathing techniques as a form of pain control. As a result, the clients lose fluids through insensible loss via the respiratory system.

A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."

4. Many mothers who consume approxi- mately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding. Mothers should be advised to eat a well-balanced diet and drink sufficient quantities of fluids while breastfeeding. There is no absolute number of calories that the mother should consume, but if she does go on a restrictive diet, it is likely that her milk supply may dwindle. Babies do take in about 600 calories a day at the breast; therefore, mothers can be advised that breastfeeding alone is a form of dieting.

The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 2 cm below the umbilicus, lochia rubra. 4. Fundus 3 cm below the umbilicus, lochia serosa.

4. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia usually has turned to serosa by day 3. Although each client's postpartum course is slightly different, on day 3 postpartum, the nurse would expect the fundus of most clients to be 3 cm below the umbilicus and the lochia to have become serosa.

A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate? 1. Suggest that the woman bottle feed for a few days. 2. Instruct the patient on how to massage her fundus. 3. Instruct the patient to feed using an alternate position. 4. Discuss the action of breastfeeding hormones.

4. The nurse should discuss the action of oxytocin. Oxytocin, the hormone of labor, also stimulates the uterus to contract in the postpartum period to reduce blood loss at the placental site. Oxytocin is the same hormone that regu- lates the milk ejection reflex. Whenever a mother breastfeeds, therefore, oxytocin stimulates her uterus to contract. In essence, therefore, breastfeeding naturally benefits the mother by contracting the uterus and preventing excessive bleeding.

A nurse reports that a client has moderate lochia flow. Which of the following pads would be consistent with her evaluation? (Please mark the appropriate pad with an "X.")

Determining the amount of lochia flow does include some subjectivity. The best guidelines to follow for a 1-hour time frame are up to 1 inch of lochia on the peripad—a scanty amount; less than 4 inches on the pad—light amount; 4 to 6 inches on the pad—moderate amount; and saturated pad—heavy amount.

A postoperative cesarean section woman is to receive morphine 4 mg q 3-4 h subcutaneously for pain. The morphine is available on the unit in premeasured syringes 10 mg/1 mL. Each time the nurse administers the medication, how many milliliters (mL) of morphine will be wasted? Calculate to the nearest tenth. ___________ mL

Known dosage = Desired dosage Known volume Desired volume 10 mg = 6 mg 1 mL x mL 10 x = 6 x = 0.6 mL Since the medication on hand is 10 mg and the nurse is to give 4 mg, the nurse must waste 6 mg. The nurse, therefore, must determine the volume that is equivalent to 6 mg.

To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.

2. Clients should be advised to change their pads at each voiding. Postpartum women should be advised to perform three actions to prevent infections: (1) change their peripads at each toileting because blood is an excellent medium for bacterial growth; (2) spray the perineum from front to back with clear water to cleanse the area; and (3) wipe the perineum after toileting from front to back to prevent the rectal flora from contaminating sterile sites.

The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills like diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills like pumping.

2. During the taking in phase, clients need to internalize their labor experi- ences. Discussing the labor process is appropriate for this postpartum phase. The taking in postpar- tum phase is the first phase that clients pass through after they deliver their baby. During this time they are especially "me oriented." They wish and need to be cared for. This is a time when they should be given a bed bath and allowed to rest. They take in nourishment and take in the expe- rience that they have just been through. Primigravid and cesarean section clients often proceed more slowly through this phase than do other clients.

The nurse palpates a distended bladder on a woman who delivered vaginally 2 hours earlier. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses by the nurse is appropriate? 1. "Okay. I must be palpating your uterus." 2. "I understand but I still would like you to try to urinate." 3. "You still must be numb from the local anesthesia." 4. "That is a problem. I will have to catheterize you."

2. This statement is accurate. Mothers often do not feel bladder pressure after delivery. During pregnancy, the bladder loses its muscle tone because of the pressure exerted on it by the gravid uterus. As a result, after delivery mothers often fail to feel when their bladders become distended.

The nurse is assessing the laboratory report on a 2-day postpartum G1 P1001. The woman had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary health care provider? 1. White blood cells, 12,500 cells/mm3. 2. Red blood cells, 4,500,000 cells/mm3. 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL

3. The client's hematocrit is well below normal. This value should be reported to the client's health care provider. The hematocrit of a postpartum woman is likely to be below the "normal" of 35% to 45%, but a hematocrit of 30% or lower is considered abnormal and should be reported to the client's health care provider. It is likely that the client will be prescribed iron supplements.

The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend? 1. 1/2 cup raw celery dipped in 1 ounce cream cheese. 2. 8 ounce yogurt mixed with 1 medium banana. 3. 12 ounce strawberry milk shake. 4. 1 1/2 cup raw broccoli.

4. Broccoli is very high in vitamin A and also contains iron. Breastfeeding clients should be advised to consume a well- balanced diet high in vitamins and miner- als. As a result, nurses must be prepared to suggest foods that meet those needs.

The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is an excellent mother.

4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby. During the taking hold phase, clients regain their independence. They care for their own bodies and are very receptive to learning about child care as well as self-care. Primigravidas are especially open to learning about caring for their baby during this phase and are especially vulnerable if they feel incompe- tent when performing baby-care tasks.

A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.

4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. 5. The mother should be advised to stand with her back toward the warm shower water. The postpartum body naturally prepares to breastfeed a baby. To suppress the milk production, the mother should refrain from stimulating her breasts. Both massage and heat stimu- late the breasts to produce milk. Mothers, therefore, should be encouraged to refrain from touching their breasts and when showering to direct the warm water toward their backs rather than toward their breasts. A supportive bra will help to minimize any engorgement that the client may experience.

A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon? 1. Fundus at the umbilicus. 2. Nodular breasts. 3. Pulse rate 60 bpm. 4. Pad saturation every 30 minutes.

4. This blood loss is excessive, especially for a postoperative cesarean section client. The surgeon should be notified. Because the placenta is manually removed and the uterine cavity is manually scraped during cesarean deliveries, it is common for postoperative clients to have a scanty lochial flow. This client is having a heavy loss. After the fundal assessment is complete, the observations should be reported to the surgeon.

A woman had a cesarean section yesterday. She states that she needs to cough but that she is afraid to. Which of the following is the nurse's best response? 1. "I know that it hurts but it is very important for you to cough." 2. "Let me check your lung fields to see if coughing is really necessary." 3. "If you take a few deep breaths in, that should be as good as coughing." 4. "If you support your incision with a pillow, coughing should hurt less."

4. This is the appropriate response. The nurse is providing the client with a means of reducing the discomfort of post-surgical coughing. Clients with abdominal incisions experience significant postoper- ative pain. And because their abdominal muscles have been incised, the pain is increased when the clients breathe in and cough. Bracing the abdominal muscles with a pillow or a blanket helps to reduce the discomfort.

After a client's placenta is birthed, the obstetrician states, "Please add 20 units of oxytocin to the intravenous and increase the drip rate to 250 mL/hr." The client has 750 mL in her IV and the IV tubing delivers fluid at the rate of 10 gtt/mL. To what drip rate should the nurse set the intravenous? _____ gtt/min

42 gtt/min The formula to calculate an intravenous drip rate is: Volume × Drop factor Time in minutes 250 mL ×10 gtt/mL = 2,500 = 42 gtt/min

A woman had a 3,000-gram baby via normal spontaneous vaginal delivery 12 hours ago. Place an "X" on the location where the nurse would expect to palpate her fundus.

An "X" should be placed on the line drawing at the level of the umbilicus. TEST-TAKING TIP: By 12 hours after delivery, the fundus is usually felt at the level of the umbilicus. Every postpartum day thereafter, the fundus will descend about 1 cm.

During a postpartum assessment, the nurse assesses the calves of a client's legs. The nurse is checking for which of the following signs/symptoms? Select all that apply. 1. Pain. 2. Warmth. 3. Discharge. 4. Ecchymosis. 5. Redness.

1, 2, and 5 are correct. 1. The nurse would assess for pain. 2. The nurse would assess for warmth. 5. The nurse would assess for redness. Postpartum clients are high risk for deep vein thrombosis (DVT). At each postpartum assessment the nurse assesses the calves for signs of the compli- cation, i.e., those seen in any inflammatory response: pain, warmth, redness, and edema. If the signs/symptoms are noted, the nurse should request an order from the primary healthcare practitioner for diagnostic tests to be performed, like a Doppler series. Homan's sign is no longer recommended to assess for DVT.

The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time? 1. Elevate the head of the bed 60 degrees. 2. Report absence of bowel sounds to the physician. 3. Have her turn and deep breathe every 2 hours. 4. Assess for patellar hyperreflexia bilaterally.

3. The woman should turn, cough, and deep breathe every 2 hours. Spinal anesthesia is ad- ministered directly into the spinal column. As a result, spinal fluid is able to escape through the puncture wound. When there is a drop in the amount of spinal fluid, clients often develop severe headaches. It is recommended that clients who have had spinals be elevated only slightly during the early postoperative period. To maintain pulmonary health, however, it is essential that clients perform respiratory exercises frequently during the postoperative period.

A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time? 1. "That is very concerning. I will request that your physician order an enema for you." 2. "Two days is not that bad. Some patients go four days or longer without a movement." 3. "You have been taking antibiotics through your intravenous. That is probably why you are constipated." 4. "Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid."

4. Consuming fluids and fiber and exer- cising all help clients to reestablish normal bowel function. This client is 2 days postoperative. She may not be consuming a normal diet as yet, but she will be able to ambulate and to drink fluids. Once she is able to consume foods, she should be encouraged to eat nutritious, high-fiber foods like fresh fruits and vegetables.

A bottle-feeding woman, 1 1/2 weeks postpartum from a vaginal delivery, calls the obstetric office to state that she has saturated 2 pads in the past 1 hour. Which of the following responses by the nurse is appropriate? 1. "You must be doing too much. Lie down for a few hours and call back if the bleeding has not subsided." 2. "You are probably getting your period back. You will bleed like that for a day or two and then it will lighten up." 3. "It is not unusual to bleed heavily every once in a while after a baby is born. It should subside shortly." 4. "It is important for you to be examined by the doctor today. Let me check to see when you can come in."

4. This response is appropriate. The client should be examined to assess her involution. One important piece of information in this question is the fact that the client is bottle feeding her baby. If she were breastfeeding, she could be encouraged to put the baby to breast and see if the bleeding subsided. Since oxy- tocin is released when babies suckle at the breast, this is a noninvasive method of promoting uterine contraction.

The nurse has provided teaching to a post-op cesarean client who is being discharged on Colace (docusate sodium) 100 mg po tid. Which of the following would indicate that the teaching was successful? 1. The woman swallows the tablets whole. 2. The woman takes the pills between meals. 3. The woman calls the doctor if she develops a headache. 4. The woman understands that her urine may turn orange.

1. Colace capsules should not be crushed, broken, or chewed. The medication, a stool softener, is contained in a capsule that must be swallowed whole. Many physi- cians order Colace for postoperative cesarean section clients until their bowel patterns return to normal.

The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time? 1. Apply an ice pack to the perineum. 2. Advise the woman to use a sitz bath after every voiding. 3. Advise the woman to sit on a pillow. 4. Teach the woman to insert nothing into her rectum.

1. It is appropriate to apply an ice pack to the area. A second-degree lacera- tion affects the skin, vaginal mucosa, and underlying muscles. (It does not affect the rectum or rectal sphincter.) Because of the injury, the area often swells, causing pain. Ice packs help to reduce the inflam- matory response and numb the area.

The nurse has taught a new admission to the postpartum unit about pericare. Which of the following indicates that the client understands the procedure? Select all that apply. 1. The woman performs the procedure twice a day. 2. The woman washes her hands before and after the procedure. 3. The woman sits in warm tap water for ten minutes three times a day. 4. The woman sprays her perineum from front to back. 5. The woman mixes warm tap water with hydrogen peroxide.

2. This statement is correct. The woman should wash her hands before and after performing pericare care. 4. This statement is accurate. A postpartum client is taught to spray warm tap water with nothing added on the perineum, from front to back, after each toileting and whenever she changes her peripads. She should also be taught to wash her hands before and after the procedure.

A medication order reads: Methergine (ergonovine) 0.2 mg po q 6 h × 4 doses. Which of the following assessments should be made before administering each dose of this medication? 1. Apical pulse. 2. Lochia flow. 3. Blood pressure. 4. Episiotomy.

3. The blood pressure should be assessed before administering Methergine. Methergine is an oxytoxic agent that works directly on the myofibrils of the uterus. The smooth muscle of the vascular tree is also affected. The blood pressure may elevate, therefore, to danger- ous levels. The medication should be held if the blood pressure is 130/90 or higher and the woman's health care practitioner should be notified if appropriate.