OB Ch 17, Postpartum adaptions prepu, Chapter 15: Postpartum Adaptations, Chapter 15 - Postpartum Adaptations, Chapter 16 Nursing Management During the Postpartum Period, Prep U: Chapter 15: Postpartum Adaptations, OB: Chapter 22: Nursing Management…

Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone.

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? Insert a 20 gauge IV. Administer oxytocin IV. Notify the health care provider. Perform urinary catheterization.

Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads.

A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. Maintain correct posture. Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads. Use good body mechanics.

D

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A) "Your uterus is still shrinking in size; that's why you're feeling this pain." B) "Let me check your vaginal discharge just to make sure everything is fine." C) "Your body is responding to the events of labor, just like after a tough workout." D) "The baby's sucking releases a hormone that causes the uterus to contract."

B

A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A) expectations B) transition to mastery C) reality D) taking-in

"Take a warm shower just before feeding your infant." The breastfeeding woman should apply cold compresses, but not ice, to her breasts between feedings to reduce swelling.

A new mother comes in for her first visit and reports pain and tenderness in her breast just before feeding. Based on her description, the nurse determines she is experiencing breast engorgement. Which instruction should the nurse provide to her? "Take a warm shower just before feeding your infant." "Wear a supportive tight bra all day long." "Try not to touch your breasts or nipples until the swelling subsides." "Use ice for about 15 minutes every other hour to promote comfort."

Demonstrating how to do cord care on the newborn When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage? Changing the infant's diapers for the mother Demonstrating how to do cord care on the newborn Correcting the mother when she holds the newborn incorrectly. Telling the mother to feed the baby when it cries.

C

A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event would the nurse expect to occur first? A) reestablishing relationships with others B) demonstrating increasing confidence in care of the newborn C) assuming a passive role in meeting her own needs D) becoming preoccupied with the present

D

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem? A) elevated white blood cell count B) slightly increased hematocrit C) increased levels of clotting factors D) pulse rate of 110 beats/minute

postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.

A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? urinary overflow postpartum diuresis urinary tract infection trauma to pelvic muscles

oxytocin

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

Administer pain medications.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first? Administer pain medications. Assess client vital signs. Assist the client in emptying her bladder. Encourage the client to stop breastfeeding until the pains stop.

Tell the client to take an NSAID orally. The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.

A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next? Tell the client to take an NSAID orally. Have the client stop breastfeeding. Instruct the client to take a warm shower. Ask how often the client is breastfeeding.

B

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: A) involution. B) engorgement. C) mastitis. D) engrossment

C. suggest proper exercise This client developed diastasis recti abdominis which is a condition in which the abdominal muscles separate during the pregnancy, leaving part of the abdominal wall without muscular support.

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? A. apply warm compresses B. massage the muscles C. suggest proper exercise D. apply moist heat

B

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? A) demonstrates pleasure when touching or holding the newborn B) identifies imperfections in the newborn's appearance C) is able to distinguish his newborn from others in the nursery D) shows feelings of pride with the birth of the newborn

B C D

A nurse is preparing a presentation about changes in the various body systems during the postpartum period and their effects for a group of new mothers. The nurse explains which event as influencing a postpartum woman's ability to void? Select all that apply. A) use of an opioid anesthetic during labor B) generalized swelling of the perineum C) decreased bladder tone from regional anesthesia D) use of oxytocin to augment labor E) need for an episiotomy

taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.

A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase? taking-in phase letting-go phase attachment phase taking-hold phase

A

A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding? A) Client states, "He has my eyes and nose." B) Client shows interest in caring for the newborn. C) Client performs self-care independently. D) Client confidently cares for the newborn

C

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: A) puerperium. B) lactation. C) attachment. D) engrossment

D

A nurse is teaching a new mother about breast-feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? A) prolactin B) estrogen C) progesterone D) oxytocin

"I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." Breast engorgement may be uncomfortable but there should never be reddened, painful areas on either breast and, if this occurs, the health care provider needs to be called. This is not normal and the mother needs further teaching. Development of a fever or the lochia becoming foul-smelling both indicate a possible infection and the physician needs to be notified. The mother is correct in stating that the episiotomy should heal over the next few weeks.

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 need to let the doctor know if my lochia begins to have a foul smell." "I am breastfeeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged." "My episiotomy should begin to heal and feel better over the next few weeks" "If I develop chills or my fever goes above 100.4℉ (38℃), I need to let someone know."

D

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? A) increase in clotting factors B) vessel damage C) immobility D) increase in red blood cell production

Body secreting the excess fluids from pregnancy

A patient who delivered her infant 3 days ago and was discharged home calls her provider's office with a complaint of sweating all night. What is the cause of the increased perspiration?

D

A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A) shapeless. B) circular. C) triangular. D) slit-like

D

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which contributor would the nurse identify as being a significant to this condition? A) early ambulation B) short duration of labor C) breast-feeding D) use of anesthetics

B

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A) "It's difficult to say, but it will probably return in about 2 to 3 weeks." B) "It varies, but you can estimate it returning in about 7 to 9 weeks." C) "You won't have to worry about it returning for at least 3 months." D) "You don't have to worry about that now. It'll be quite a while."

"Applying ice to the area can help." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath." The presence of swollen hemorrhoids may heighten discomfort in the perineum. Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain.

A postpartum woman tells the home care nurse, "My hemorrhoids are really uncomfortable. Is there anything I can do?" Which suggestion(s) by the nurse would be appropriate? Select all that apply. "Applying ice to the area can help." "You should pour cold water over the area with your peribottle." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath." "You might think anesthetic sprays help but they do not."

B

A postpartum woman who has experienced diastasis recti asks the nurse about what to expect related to this condition. Which response by the nurse would be most appropriate? A) "You'll notice that this will fade to silvery lines." B) "Exercise will help to improve the muscles." C) "Expect the color to lighten somewhat." D) "You'll notice that your shoe size will increase."

B

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? A) two fingerbreadths above the umbilicus B) at the level of the umbilicus C) two fingerbreadths below the umbilicus D) four fingerbreadths below the umbilicus

"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." Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.

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: "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." "I need to get your vital signs and check your fundus to be sure you are not going into shock." "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."

B

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A) "You must have an infection, so let me get a urine specimen." B) "Your body is undergoing many changes that cause your bladder to fill quickly." C) "Your uterus is not contracting as quickly as it should." D) "The anesthesia that you received is wearing off and your bladder is working again."

inability of infant to empty breasts

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?

The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient? A) Absence of lochia B) Red-colored lochia for the first 24 hours C) Lochia that is the color of menstrual blood D) Lochia appearing pinkish-brown on the fourth day

A) Absence of lochia Lochia should never be absent during the first 1 to 3 weeks because absence of lochia may indicate postpartal infection. Red-colored lochia for the first 24 hours is normal. Lochia that is the color of menstrual blood is normal. Lochia appearing pinkish-brown on the fourth postpartum day is normal.

The nurse is concerned that a new mother is ambivalent about the newborn and does not participate in newborn care. What action should the nurse take to help both the mother and newborn at this time? A) Contact the Social Services department. B) Schedule home care for the mother and infant. C) Assess who is going to take care of the baby at home. D) Ask the patient if it would be better that the baby is put up for adoption.

A) Contact the Social Services department. Some patients do not openly voice a wish to give up a child, but their actions demonstrate they feel little attachment to their newborn. A woman who has doubts about wanting the baby is slow to make contact, barely touching the baby even by the time of discharge, and asking few questions about newborn care. When this happens, the hospital social service department can be of assistance in helping the patient plan the child's future. The nurse needs to do more than schedule home care for the mother and infant. The nurse should consult with Social Services that will assess who is going to care for the infant at home and find out if the patient wants to give the baby up for adoption. This is not the nurse's role.

The nurse manager of a postpartum care area is planning educational sessions for the nursing staff to support the 2020 National Health Goals for postpartum care. Which information should be included in this staff training? (Select all that apply.) A) Encourage postpartum patients to participate in breastfeeding. B) Provide information on reproductive life planning if requested. C) Suggest postpartum patients remain on bed rest for at least 2 postpartum days. D) Recommend new mothers to attend prenatal classes to learn infant care after delivery. E) Explain the importance of close observation to detect postpartum maternal hemorrhage.

A) Encourage postpartum patients to participate in breastfeeding. B) Provide information on reproductive life planning if requested. E) Explain the importance of close observation to detect postpartum maternal hemorrhage. Nurses can help the nation achieve the 2020 National Health Goals for postpartum care by maintaining close observation in the immediate postpartal period to detect maternal hemorrhage, encouraging and supporting women as they begin breastfeeding, and ensuring women receive reproductive life planning information if desired. Bed rest and attending prenatal classes to learn newborn care are not strategies to support the 2020 National Health Goals for postpartum care.

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time? A) Health-seeking behaviors related to care of newborn B) Ineffective coping related to expectation to provide newborn care C) Risk for altered family coping related to an additional family member D) Risk for impaired parenting related to disappointment in the sex of the child

A) Health-seeking behaviors related to care of newborn The new mother is asking the nurse to validate actions being performed while providing newborn care. The nursing diagnosis most appropriate for the new mother at this time would be health-seeking behaviors related to care of the newborn. The new mother is not demonstrating signs of ineffective coping. There is no information to support a risk for altered family coping or risk for impaired parenting.

The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum patient. Which outcome indicates that teaching has been effective? A) Patient performs perineal care independently with every morning shower. B) Patient explains the purpose of performing perineal care at least once a day. C) Patient flushes the commode before standing when performing perineal care. D) Patient washes the perineum from back to front when performing perineal care.

A) Patient performs perineal care independently with every morning shower. The nurse should instruct the postpartum patient to include perineal care as part of a daily bath or shower and after every voiding or bowel movement. The patient should stand before flushing the commode when performing perineal care because water from the commode can splash the perineum and cause an infection. The patient should be instructed to wash the perineum from front to back to reduce the potential for contamination from the rectal area.

8. A nurse is providing care to a postpartum woman. The nurse determines that the client is in the taking-in phase based on which finding? A. The client states, "He has my eyes and nose." B. The client shows interest in caring for the newborn. C. The client performs self-care independently. D. The client confidently cares for the newborn.

Answer: A Rationale: During the taking-in phase, new mothers when interacting with their newborns spend time claiming the newborn and touching him or her, commonly identifying specific features in the newborn such as "he has my nose" or "his fingers are long like his father's." Independence in self-care and interest in caring for the newborn are typical of the taking-hold phase. Confidence in caring for the newborn is demonstrated during the letting-go phase.

16. When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding? A. elevated white blood cell count B. acute decrease in hematocrit C. increased levels of clotting factors D. pulse rate of 60 beats/minute

Answer: B Rationale: Despite a decrease in blood volume after birth, hematocrit levels remain relatively stable and may even increase. An acute decrease is not an expected finding. Red blood cell production ceases early in the puerperium, causing mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours. During the next 2 weeks, both levels rise slowly. The white blood count, which increases in labor, remains elevated for first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3. The WBC count remains elevated for the first 4 to 6 days and clotting factors remain elevated for 2 to 3 weeks. Bradycardia (50 to 70 beats per minute) for the first two weeks reflects the decrease in cardiac output. The increase in cardiac output and stroke volume during pregnancy begins to diminish after birth once the placenta has been delivered. This decrease in cardiac output is reflected in bradycardia (40 to 60 bpm) for up to the first 2 weeks postpartum.

1. A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected? A. two fingerbreadths above the umbilicus B. at the level of the umbilicus C. two fingerbreadths below the umbilicus D. four fingerbreadths below the umbilicus

Answer: B Rationale: During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

18. A nurse is making a home visit to a postpartum woman who gave birth to a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as: A. involution. B. engorgement. C. mastitis. D. engrossment.

Answer: B Rationale: Engorgement is the process of swelling of the breast tissue as a result of an increase in blood and lymph supply as a precursor to lactation (Figure 15.4). Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the next 24 to 36 hours (Chapman, 2011). Engorgement can occur from infrequent feeding or ineffective emptying of the breasts and typically lasts about 24 hours. Breasts increase in vascularity and swell in response to prolactin 2 to 4 days after birth. If engorged, the breasts will be hard and tender to touch. Involution refers to the process of the uterus returning to its prepregnant state. Mastitis refers to an infection of the breasts. Engrossment refers to the bond that develops between the father and the newborn.

7. A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate? A. "It's difficult to say, but it will probably return in about 2 to 3 weeks." B. "It varies, but you can estimate it returning in about 7 to 9 weeks." C. "You won't have to worry about it returning for at least 3 months." D. "You don't have to worry about that now. It'll be quite a while."

Answer: B Rationale: For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after birth.

9. A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? A. demonstrates pleasure when touching or holding the newborn B. identifies imperfections in the newborn's appearance C. is able to distinguish his newborn from others in the nursery D. shows feelings of pride with the birth of the newborn

Answer: B Rationale: Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

23. A nurse is visiting a postpartum woman who gave birth to a healthy newborn 5 days ago. Which finding would the nurse expect? A. bright red discharge B. pinkish brown discharge C. deep red mucus-like discharge D. creamy white discharge

Answer: B Rationale: Lochia serosa is pinkish brown and is expelled 3 to 10 days postpartum. Lochia rubra is a deep-red mixture of mucus, tissue debris, and blood that occurs for the first 3 to 4 days after birth. Lochia alba is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content and occurs from days 10 to 14 but can last 3 to 6 weeks postpartum.

14. A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate? A. "You must have an infection, so let me get a urine specimen." B. "Your body is undergoing many changes that cause your bladder to fill quickly." C. "Your uterus is not contracting as quickly as it should." D. "The anesthesia that you received is wearing off and your bladder is working again."

Answer: B Rationale: Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines, the buildup and retention of extra fluids during pregnancy, and a decreasing production of aldosterone—the hormone that decreases sodium retention and increases urine production. All these factors contribute to rapid filling of the bladder within 12 hours of birth. Diuresis begins within 12 hours after childbirth and continues throughout the first week postpartum.

12. A father of a newborn tells the nurse, "I may not know everything about being a dad, but I'm going to do the best I can for my son." The nurse interprets this as indicating the father is in which stage of adaptation? A. expectations B. transition to mastery C. reality D. taking-in

Answer: B Rationale: The father's statement reflects transition to mastery because he is making a conscious decision to take control and be at the center of the newborn's life regardless of his preparedness. The expectations stage involves preconceptions about how life will be with a newborn. Reality occurs when fathers realize their expectations are not realistic. Taking-in is a phase of maternal adaptation.

20. The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which stage? A. expectations B. reality C. transition to mastery D. taking-hold

Answer: B Rationale: The partner's statement reflects stage 2 (reality), which occurs when fathers or partners realize that their expectations in stage 1 are not realistic. Their feelings change from elation to sadness, ambivalence, jealousy, and frustration. Many wish to be more involved in the newborn's care and yet do not feel prepared to do so. New fathers or partners pass through stage 1 (expectations) with preconceptions about what home life will be like with a newborn. Many men may be unaware of the dramatic changes that can occur when this newborn comes home to live with them. In stage 3 (transition to mastery), the father or partner makes a conscious decision to take control and be at the center of his newborn's life regardless of his preparedness. Taking-hold is a stage of maternal adaptation.

21. A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as: A. puerperium. B. lactation. C. attachment. D. engrossment.

Answer: C Rationale: Attachment is a formation of a relationship between a parent and her/his newborn through a process of physical and emotional interactions. Puerperium refers to the postpartum period. Lactation refers to the process of milk secretion by the breasts. Engrossment refers to the bond that develops between the father and the newborn.

6. When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation?A. deep red, fleshy-smelling lochia B. voiding of 350 cc C. blood pressure 90/50 mm Hg D. profuse sweating

Answer: C Rationale: In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

11. A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?A. reduces lochia B. promotes uterine involution C. improves pelvic floor tone D. alleviates perineal pain

Answer: C Rationale: Muscle clenching perineal exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

15. The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? A. reduce lochia B. promote uterine involution C. improve pelvic floor tone D. alleviate perineal pain

Answer: C Rationale: Pelvic floor muscle training or Kegel exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

19. A nurse is assessing a postpartum woman's adjustment to her maternal role. Which event would the nurse expect to occur first? A. reestablishing relationships with others B. demonstrating increasing confidence in care of the newborn C. assuming a passive role in meeting her own needs D. becoming preoccupied with the present

Answer: C Rationale: The first task of adjusting to the maternal role is the taking-in phase in which the mother demonstrates dependent behaviors and assumes a passive role in meeting own basic needs. During the taking-hold phase, the mother becomes preoccupied with the present. During the letting-go phase, the mother reestablishes relationships with others and demonstrates increased responsibility and confidence in caring for the newborn.

2. When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A. greater than after a vaginal birth. B. about the same as after a vaginal birth. C. less than after a vaginal birth. D. saturated with clots and mucus.

Answer: C Rationale: Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

10. A postpartum client comes to the clinic for her 6-week postpartum checkup. When assessing the client's cervix, the nurse would expect the external cervical os to appear: A. shapeless. B. circular. C. triangular. D. slit-like.

Answer: D Rationale: After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

24. A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? A. increase in clotting factors B. vessel damage C. immobility D. increase in red blood cell production

Answer: D Rationale: Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the puerperium, which leads to mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks.

13. A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which factor would the nurse identify as being a significant contributor to this condition? A. early ambulation B. short duration of labor C. breastfeeding D. use of anesthetics

Answer: D Rationale: Factors that inhibit involution include prolonged labor and difficult birth, incomplete expulsion of amniotic membranes and placenta, uterine infection, overdistention of uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus), full bladder (which displaces the uterus and interferes with contractions), anesthesia (which relaxes uterine muscles), and close childbirth spacing. Factors that facilitate uterine involution include complete expulsion of amniotic membranes and placenta at birth, complication-free labor and birth process, breastfeeding, and early ambulation.

3. The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation? A. encouraging the woman to manually express milk B. suggesting that she take frequent warm showers to soothe her breasts C. telling her to limit the amount of fluids that she drinks D. instructing her to apply ice packs to both breasts every other hour

Answer: D Rationale: If the woman is not breastfeeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.

17. A nurse is teaching a new mother about breastfeeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down? A. prolactin B. estrogen C. progesterone D. oxytocin

Answer: D Rationale: Oxytocin is released from the posterior pituitary to promote milk let-down. Prolactin levels increase at term with a decrease in estrogen and progesterone; estrogen and progesterone levels decrease after the placenta is delivered. Prolactin is released from the anterior pituitary gland and initiates milk production.

5. A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate? A. "Your uterus is still shrinking in size; that's why you're feeling this pain." B. "Let me check your vaginal discharge just to make sure everything is fine." C. "Your body is responding to the events of labor, just like after a tough workout." D. "The baby's sucking releases a hormone that causes the uterus to contract."

Answer: D Rationale: The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

A postpartum patient is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the patient about this medication? (Select all that apply.) A) This medication has no adverse effects. B) Be sure to engage in activity to aid in intestinal motility. C) One pill should be taken after every meal for the first week. D) This medication works the best when a high-fiber diet is consumed. E) Take each dose of the medication with a full glass of water or juice.

B) Be sure to engage in activity to aid in intestinal motility. D) This medication works the best when a high-fiber diet is consumed. E) Take each dose of the medication with a full glass of water or juice. Docusate sodium (Colace) is used in the postpartal period to prevent constipation. It works by lowering the surface tension of feces, allowing water and lipids to penetrate the stool and soften it. The nurse should instruct the patient to engage in activity to promote intestinal motility, consume a diet high in fiber, and take each dose of the medication with a full glass of water or juice. This medication has abdominal pain and diarrhea as potential adverse effects. This medication is not taken after every meal but rather one dose per day.

A postpartum patient is concerned about loose tissue around the abdominal area. Which exercise should the nurse recommend that the patient begin on postpartum day 2 to strengthen and tighten these muscles? A) Sit-ups B) Chin-to-chest C) Pelvic rocking D) Kegel exercises

B) Chin-to-chest The chin-to-chest exercise is excellent for the second day to tighten abdominal muscles. The exercise can be done 3 or 4 times a day, and the patient should feel the abdominal muscles pull and tighten if it is being done correctly. Sit-ups, pelvic rocking, and Kegel exercises are not identified to assist with tightening the muscles of the abdominal region.

The nurse assesses a postpartum patient's discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? A) Lochia alba B) Lochia rubra C) Lochia serosa D) Lochia normalia

B) Lochia rubra Lochia that is red in color, or bloody, is termed lochia rubra. Lochia alba is colorless flow that occurs around postpartum day 10. Lochia serosa is pink or brown in color and appears around postpartum day 4. Lochia normalia is not a term used to describe lochia.

A new mother asks if it is possible to have rooming-in with the newborn. What should the nurse respond to this patient's request? A) It depends on whether the patient plans to breastfeed. B) Rooming-in allows increased maternal-newborn contact. C) This puts too much responsibility on a first-time mother. D) Resting for the first 3 days postpartum will be better for the patient.

B) Rooming-in allows increased maternal-newborn contact. The more time a woman has to spend with her baby, the sooner she can become better acquainted with her child, feel more confident in her ability to care for her baby, and more likely form a sound mother-child relationship. Rooming-in is when the mother and child are together 24 hours a day. Rooming-in does not depend on whether the patient is planning to breastfeed the infant. Rooming-in helps the new mother become confident in abilities to care for the baby. Resting for 3 postpartum days is not recommended.

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting? A) Supine B) Sims position C) Knee-chest position D) Trendelenburg position

B) Sims position Assuming a Sims position several times a day aids in good venous return to the rectal area and reduces the discomfort of hemorrhoids. Supine, knee-chest, and Trendelenburg are not recommended positions to aid in the pain of hemorrhoids.

A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse emphasize when teaching the patient about this treatment approach? A) Sitz baths may lead to increased postpartal infection. B) Sitz baths increase the blood supply to the perineal area. C) Sitz baths cause perineal vasoconstriction and decreased bleeding. D) The longer a sitz bath is continued, the more therapeutic it becomes.

B) Sitz baths increase the blood supply to the perineal area. Moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. Sitz baths do not cause postpartal infections. Sitz baths do not cause perineal vasoconstriction and decreased bleeding. Every use of a sitz bath is therapeutic.

The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective? A) "I should limit stair climbing to four times a day." B) "I can have coitus at any time after returning home." C) "I should plan to return to my full-time job after 6 weeks." D) "I should notify the physician if my discharge decreases in amount."

C) "I should plan to return to my full-time job after 6 weeks." It is usually advised that a woman not return to an outside job for at least 3 to 6 weeks not only for her own health but also for enjoyment of the early weeks with the newborn. Stair climbing should be limited to one flight/day for the first week at home. Coitus is safe as soon as the patient's lochia has turned to alba and, if present, an episiotomy is healed. The patient should notify the primary care provider if there is an increase, not a decrease, in lochial discharge.

A postpartum patient has a history of thrombophlebitis. What should the nurse do to determine if the patient is developing this after delivery? A) Assess for warmth in the legs. B) Assess temperature every 4 hours. C) Assess for calf redness and edema. D) Palpate the feet for tingling or numbness.

C) Assess for calf redness and edema. Assess for thrombophlebitis by dorsiflexing the ankle and asking if pain occurs in the calf region. Assess also for redness in the calf area and edema of the ankle. Warmth is not an indication of a thrombophlebitis. Body temperature is not used to assess for thrombophlebitis. Feet numbness and tingling are not indications of thrombophlebitis.

The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus? A) Fundus 4 cm above symphysis pubis and firm B) Fundus height 4 cm below umbilicus and midline C) Fundus two fingerbreadths below umbilicus and firm D) Fundus two fingerbreadths above symphysis pubis and hard

C) Fundus two fingerbreadths below umbilicus and firm Because uterine contraction begins immediately after placental delivery, the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases one fingerbreadth or centimeter per day and will be palpable 1 cm below the umbilicus. For the second postpartal day, the uterus will be two fingerbreadths or centimeters below the umbilicus. The fundus should not be palpated 4 cm above the symphysis pubis, 4 cm below the umbilicus, or two fingerbreadths above the symphysis pubis on the second postpartum day. The fundus should not be hard.

The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior? A) Disappointment with the child's sex B) Difficulty accepting the role changes C) Reacting normally to accepting a new child D) Cultural customs do not include kissing children

C) Reacting normally to accepting a new child More often, a woman enters into a relationship with her newborn tentatively and with qualms and conflicts that must be addressed before the relationship can be meaningful. This is because parental love is only partly instinctive. The tentative behavior does not indicate disappointment with the child's sex, difficulty accepting role changes, or cultural customs that do not include kissing children.

Taking Hold The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.

During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing? the taking-in phase the taking-hold phase the binding-in phase the letting-go phase

Bladder distention Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

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? Uterine atony Full bowel Bladder distention Poor bladder tone

D

The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved? A) catabolism B) muscle fiber contraction C) epithelial regeneration D) vasodilation

In approximately 10 days

The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out? For 6 weeks On and off for 2 to 3 weeks Stops in 1 to 2 weeks In approximately 10 days

B

The partner of a woman who has given birth to a healthy newborn says to the nurse, "I want to be involved, but I'm not sure that I'm able to care for such a little baby." The nurse interprets this as indicating which stage? A) expectations B) reality C) transition to mastery D) taking-hold

Ovulation may return as soon as 3 weeks after birth."

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 teaching to address this issue?

applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?

C

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response? A) reduces lochia B) promotes uterine involution C) improves pelvic floor tone D) alleviates perineal pain

B

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which finding would the nurse expect? A) bright red discharge B) pinkish brown discharge C) deep red mucus-like discharge D) creamy white discharge

C

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? A) two fingerbreadths above the umbilicus B) at the level of the umbilicus C) two fingerbreadths below the umbilicus D) four fingerbreadths below the umbilicus

A

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence? A) estrogen B) hCG C) hPL D) progesterone

4. The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? A. cannot be palpated B. 2 cm below the umbilicus C. 6 cm below the umbilicus D. 10 cm below the umbilicus

Answer: A Rationale: By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

22. The nurse is providing an in-service education program to a group of home health care nurses who provide care to postpartum women. After teaching the group about the process of involution, the nurse determines that additional teaching is needed when the group identifies which process as being involved? A. catabolism B. muscle fiber contraction C. epithelial regeneration D. vasodilation

Answer: D Rationale: Involution involves three retrogressive processes: contraction of muscle fibers to reduce those previously stretched during pregnancy; catabolism, which reduces enlarged myometrial cells; and regeneration of uterine epithelium from the lower layer of the deciduas after the upper layers have been sloughed off and shed during lochial discharge. Vasodilation is not involved.

B

As part of an education program for a group of pregnant women, the nurse teaches them about the changes that occur in the respiratory system during the postpartum period. The women demonstrate understanding of the information when they identify which occurrence as a postpartum adaptation? A) continued shortness of breath B) relief of rib aching C) diaphragmatic elevation D) decrease in respiratory rate

While documenting patient care, the nurse notes that a postpartum patient is accepting the birth of the child well. What did the nurse most likely observe to come to this conclusion? A) Names the child after a well-loved friend B) Asks the nurse to take a photo of the child C) Turns the face to meet the infant's eyes when holding the baby D) Comments that the baby has the most hair of any in the nursery

C) Turns the face to meet the infant's eyes when holding the baby Looking directly at the newborn's face, with direct eye contact or the en face position, is a sign a woman is beginning effective attachment. Naming the child after a well-loved friend, taking a photo of the child, or commenting on the child's hair are not indications that the postpartum patient is accepting the birth of the child well.

resumption of intercourse activity signs and symptoms of infection

Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? resumption of intercourse activity resumption of prepregnancy diet signs and symptoms of infection infant formula selection

6 to 8 weeks after pregnancy

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status? 6 to 8 weeks after pregnancy 4 to 6 weeks after pregnancy 8 to 10 weeks after pregnancy 2 to 4 weeks after pregnancy

peribottle and warm water

During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?

b. place an ice pack

The nurse is conducting a postparum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy appropriately approximated without signs of a hematoma. Which action should the nurse prioritize? a. put on witch hazel pad b. place an ice pack c. notify a primary care provider d. apply a warm washcloth

C

The nurse develops a teaching plan for a postpartum client and includes teaching about how to perform pelvic floor muscle training or Kegel exercises. The nurse includes this information for which reason? A) reduce lochia B) promote uterine involution C) improve pelvic floor tone D) alleviate perineal pain

discomfort due to hemorrhoids

The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor? discomfort due to hemorrhoids distention of abdominal muscles separation of rectus muscles relaxation of abdominal muscles

rise in hematocrit

The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit? rise in hematocrit transient tachycardia increase in circulatory blood volume increase in cardiac output

increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period

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 blood pressure increased cardiac output increased hematocrit level increased heart rate

hemoglobin and hematocrit The health care provider will order hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia

The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time? blood type folic acid level hemoglobin and hematocrit iron level

D

The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation? A) encouraging the woman to manually express milk B) suggesting that she take frequent warm showers to soothe her breasts C) telling her to limit the amount of fluids that she drinks D) instructing her to apply ice packs to both breasts every other hour

A

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus? A) cannot be palpated B) 2 cm below the umbilicus C) 6 cm below the umbilicus D) 10 cm below the umbilicus

B

When assessing a postpartum woman, the nurse suspects the woman is experiencing a problem based on which finding? A) elevated white blood cell count B) acute decrease in hematocrit C) increased levels of clotting factors D) pulse rate of 60 beats/minute

Edema Slight bruising

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. Edema Redness Slight bruising Discharge Bleeding

C

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be: A) greater than after a vaginal delivery. B) about the same as after a vaginal delivery. C) less than after a vaginal delivery. D) saturated with clots and mucus

C

When the nurse is assessing a postpartum client approximately 6 hours after delivery, which finding would warrant further investigation? A) deep red, fleshy-smelling lochia B) voiding of 350 cc C) blood pressure 90/50 mm Hg D) profuse sweating

taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience.

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? letting-go taking-hold taking-in acquaintance/attachment