Nursing Management During the Postpartum Period
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Expect to see your 2-year-old become more independent when the baby gets home." "Have your 2-year-old stay at home while you're here in the hospital." "Ask your 2-year-old to pick out a special toy for his sister." "Talk to your 2-year-old about the baby when you're driving him to day care."
"Ask your 2-year-old to pick out a special toy for his sister."
A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? 100.1°F (37.8°C) 99.2°F (37.3°C) 100.8°F (38.2°C) 97.5°F (36.9°C)
100.8°F (38.2°C)
A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time? Apply an ice pack to the perineal area. Instruct in the use of witch hazel compresses. Encourage use of a sitz bath. Apply a glycerin-based ointment to the area.
Apply an ice pack to the perineal area.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Educate the client on how to perform Kegel exercises. Perform an "in and out" catheter on the client. Determine if the client is emptying her bladder. Ask the client when she last urinated.
Educate the client on how to perform Kegel exercises.
A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Use ice packs for a week after birth. Apply ice packs for 40 minutes continuously. Ensure ice pack is changed frequently. Apply ice packs directly to the perineal area.
Ensure ice pack is changed frequently.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. Low self-esteem Low socioeconomic status Feeling overwhelmed and out of control Lack of social support Involving family in infant care
Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support
A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The flow is over 500 mL. Her uterus is soft to your touch. The color of the flow is red. The flow contains large clots.
The color of the flow is red.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is above expected levels. The urinary output is normal. The urinary output is inadequate suggestive of urinary retention. The urinary output is inadequate and the mother needs to drinks more fluids.
The urinary output is normal.
A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? Lochia is less than usual. Uterus is boggy. Bladder is nonpalpable. Percussion reveals tympany.
Uterus is boggy.
Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? lochia that is the color of menstrual blood lochia appearing pinkish-brown on the fourth day red-colored lochia for the first 24 hours an absence of lochia
an absence of lochia
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: assess and massage the fundus. increase the flow of an IV. call the primary care provider or the nurse-midwife. inspect the perineum for lacerations.
assess and massage the fundus.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? infection atony hemorrhage normal involution
atony
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? bladder distention extreme diaphoresis uterine atony delayed hemorrhage
delayed hemorrhage
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? third degree first degree fourth degree second degree
fourth degree
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? infection hematoma nothing—it is normal DVT
hematoma
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? below the symphysis pubis one fingerbreadth above the umbilicus at the level of the umbilicus one fingerbreadth below the umbilicus
one fingerbreadth below the umbilicus
A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? placenta removed via manual extraction multiparity hemoglobin of 11.5 mg/dl (115 g/L) labor less than 3 hours
placenta removed via manual extraction
During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus? places a gloved hand just above the symphysis pubis places index and middle fingers across the muscle palpates the abdomen while feeling the uterine fundus massages the fundus carefully to expel any blood clots
places a gloved hand just above the symphysis pubis
A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action? talks to company and ignores the baby lying next to her strokes the infant's head kisses the infant on her cheek holds and smiles at the infant
talks to company and ignores the baby lying next to her
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: 2 cm below the umbilicus. the level of the umbilicus. 1 cm below the umbilicus. between the umbilicus and symphysis pubis.
the level of the umbilicus.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? transthoracic echocardiogram noninvasive arterial studies of the right leg venogram of the right leg venous duplex ultrasound of the right leg
venous duplex ultrasound of the right leg
In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. women with more than one infant women who had difficulties with breastfeeding in the past women using street drugs women on antithyroid medications women on antineoplastic medications
women on antithyroid medications women on antineoplastic medications women using street drugs
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "If you don't attempt to void, I'll need to catheterize you." "I'll check on you in a few hours." "I'll contact your primary care provider."
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? Stop using a peri-pad. Massage the client's fundus. Document the lochia as scant. Reassess the client in 1 hour.
Document the lochia as scant.
During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply. To identify the client's need for antidepressant medications To identify clients at risk for suicide To identify the need for additional support in the home To identify client at risk for perinatal depressions To identify the client's attachment to the newborn
To identify client at risk for perinatal depressions To identify clients at risk for suicide
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? hemorrhage fluid volume overload infection pulmonary emboli
hemorrhage
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: maintaining previous household routines to prevent infection. listing signs of infection that she will report to her health care provider. discussing methods that the woman will use to prevent infection. the client will show no signs of infection.
maintaining previous household routines to prevent infection.
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: moderate. light. scant. heavy.
moderate.
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? policies that allow rooming the infant and mother together policies that allow flexibility for cultural differences policies that discourage unwrapping and exploring the infant policies that allow visitors
policies that discourage unwrapping and exploring the infant
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? infection normal response to the body converting back to prepregnancy state hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities
thromboembolic disorder of the lower extremities
The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. head-to-toe assessment head-to-toe assessment of newborn vital signs of mother newborn's vital signs pain level
vital signs of the mother pain level head-to-toe assessment
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? Auscultating bowel sounds, and measuring urine output Determining chest and head circumference Inspecting posture, color, and respiratory effort Checking for identifying birthmarks or skin injuries
Inspecting posture, color, and respiratory effort
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? Use oral contraceptive pills (OCPs) for contraception. Resume intercourse if bright red bleeding stops. Avoid performing pelvic floor exercises. Avoid use of water-based gel lubricants.
Resume intercourse if bright red bleeding stops.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? infection hemorrhage pulmonary emboli depression SUBMIT ANSWER
infection
At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of: postpartum blues. postpartum adjustment. postpartum psychosis. postpartum depression.
postpartum depression.
Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood."
"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? "Some women just can't breastfeed. Maybe I'm one of these women." "Breastfeeding takes time and practice." "Maybe a lactation specialist can help me work through this." "Some babies latch on and catch on quickly; others take a little more time."
"Some women just can't breastfeed. Maybe I'm one of these women."
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Encourage breastfeeding of the newborn infant on demand. Help the mother initiate breastfeeding within 30 minutes of birth. Provide breastfeeding newborns with pacifiers. Give newborns water and other foods to balance nutritional needs. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
