OB - Labor Delivery (ch 14) & Postpartum adaptations (ch 15)

The nurse is caring for a client in active labor who has had a fetal blood sampling to check for fetal hypoxia. The nurse determines that the fetus has acidosis when the pH is: 7.25 or more. 7.21. 7.15 or less. 7.20.

7.15 or less.

The nurse is monitoring a client who is recovering from a cesarean delivery with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine? Slow respiration, less than 12 breaths per minute Abdominal distention and pain Intense itching manifested by scratching Difficulty coughing and turning

Slow respiration, less than 12 breaths per minute

The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign? The urge to push occurs. Frequency of contractions are 5 to 6 minutes. Fetus is at -1 station. Emotions are calm and happy.

The urge to push occurs.

If the monitor pattern of uteroplacental insufficiency were present, which action would the nurse do first? Help the woman to sit up in a semi-Fowler's position. Administer oxygen at 3 to 4 L by nasal cannula. Ask her to pant with the next contraction. Turn her or ask her to turn to her side.

Turn her or ask her to turn to her side.

The nurse is assessing the laboring client to determine fetal oxygenation status. What indirect assessment method will the nurse likely use? external electronic fetal monitoring fetal oxygen saturation fetal blood pH fetal position

external electronic fetal monitoring

As a woman enters the second stage of labor, which would the nurse expect to assess? feelings of being frightened by the change in contractions reports of feeling hungry and unsatisfied expressions of satisfaction with her labor progress falling asleep from exhaustion

feelings of being frightened by the change in contractions

If a fetus were not receiving enough oxygen during labor because of uteroplacental insufficiency, which pattern would the nurse anticipate seeing on the monitor? variable decelerations, too unpredictable to count fetal heart rate declining late with contractions and remaining depressed a shallow deceleration occurring with the beginning of contractions fetal baseline rate increasing at least 5 mm Hg with contractions

fetal heart rate declining late with contractions and remaining depressed

A client who is 3 days postpartum calls the office and complains of excessive night sweats. Which explanation should the nurse provide for the client? Body secreting the excess fluids from pregnancy The body is trying to get rid of the extra blood made during pregnancy. Change in pregnancy hormone The patient may be drinking too much fluid.

Body secreting the excess fluids from pregnancy

A client is in active labor. Checking the EFM tracing, the nurse notes variables that are abnormal. What would be the nurse's first nursing intervention? Document the finding. Obtain assistance to check for a compressed umbilical cord. Prepare the woman for an emergency cesarean birth. Help the woman change positions.

Help the woman change positions.

At which time is it most important to monitor for umbilical cord prolapse? When the fetus is crowning At the onset of labor After rupture of membranes During transitional labor

After rupture of membranes

The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next? Risk factors Fetal status Maternal status Maternal obstetrical history

Fetal status

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? Place an ice pack. Put on a witch hazel pad. Apply a warm washcloth. Notify a primary care provider.

Place an ice pack.

A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage? Immersing the client in warm water in a pool or hot tub Administering an opioid such as meperidine or fentanyl Practicing effleurage on the abdomen Administering a sedative such as secobarbital or pentobarbital

Practicing effleurage on the abdomen

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage? "I didn't realize all that went into being a dad. I wasn't prepared for this." "I may not be a pro at helping out with the baby, but I enjoy being involved." "It'll be fun to have a baby in the house, but things shouldn't change too much." "I've learned how to diaper and bathe the baby so I can be a really involved dad."

"I didn't realize all that went into being a dad. I wasn't prepared for this."

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give? "It distracts your brain from the sensations of pain." "It blocks the transmission of nerve messages of pain at the receptors." "It causes the release of endorphins." "It disrupts the nerve signal of pain via mechanical irritation of the nerves."

"It distracts your brain from the sensations of pain."

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression."

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions? "You would probably be more successful if you wrapped him in on a warm blanket." "Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." "Maybe you your husband will have better luck calming him down. Why don't you let him hold him?" "Let me show you how to calm him down. I've been doing this for many years."

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure."

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? "You may have intercourse until next month with no fear of pregnancy." "Ovulation may return as soon as 3 weeks after birth." "You will not ovulate until your menstrual cycle returns." "Ovulation does not return for 6 months after birth."

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

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently." "Bruising and swelling of the perineum often causes excessive urination."

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

When planning a labor experience for a primigravid, understanding which characteristic of labor pain is most helpful? All pain is the same. Women innately know how to deal with labor pain. The characteristics of labor pain follow a pattern. If the woman is in too much pain, a cesarean section is an option.

The characteristics of labor pain follow a pattern.

Which possible outcome would be a major disadvantage of any pain relief method that also affects awareness of the mother? The father's coaching role may be disrupted at times. The mother may have continued memory loss postpartum. The infant may show increased drowsiness. The mother may have difficulty working effectively with contractions.

The mother may have difficulty working effectively with contractions.

The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods? These methods are a technique to prevent the painful stimuli from entering the brain. Pain perception is decreased if anxiety is present. The gating mechanism is located at the pain site. The gating mechanism opens so all the stimuli pass through to the brain.

These methods are a technique to prevent the painful stimuli from entering the brain.

There has been much research done on pain and the perception of pain. What is the result of research done on levels of satisfaction with the control of labor pain? Women report higher levels of satisfaction when the primary care provider makes the decision on what type of pain control to use. Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience. Women report higher levels of satisfaction when different types of relaxation techniques are used to control pain. Women report higher levels of satisfaction when regional anesthetics are used to control pain.

Women report higher levels of satisfaction when they felt they had a high degree of control over the pain experience.

A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: slightly increased. acutely increased. slightly decreased. acutely decreased.

acutely decreased.

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next? tactile stimulation fetal scalp stimulation application of vibroacoustic stimulation administration of oxygen by mask

administration of oxygen by mask

The nurse explains Leopold's maneuvers to a pregnant client. For which purposes are these maneuvers performed? Select all that apply. determining the size of the fetus determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus determining the weight of the fetus

determining the presentation of the fetus determining the position of the fetus determining the lie of the fetus

A woman is lightly stroking her abdomen in rhythm with her breathing during contractions. The nurse identifies this technique as: acupressure. therapeutic touch. effleurage. patterned breathing.

effleurage.

A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? every 10 minutes every 15 minutes every 20 minutes every 5 minutes

every 15 minutes

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? inability of infant to empty breasts cracking of the nipple inadequate secretion of prolactin improper positioning of infant

inability of infant to empty breasts

The student nurse is preparing to assess the fetal heart rate (FHR). She has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: left lower quadrant. right lower quadrant. right upper quadrant. left upper quadrant.

left lower quadrant.

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? progesterone prolactin estrogen oxytocin

oxytocin

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? trauma to pelvic muscles urinary overflow urinary tract infection postpartum diuresis

postpartum diuresis

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-hold phase attachment phase letting-go phase taking-in phase

taking-in phase

Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking-in, taking-on, letting-go. taking-in, taking-hold, letting-go. taking-in, holding-on, letting-go. taking, holding-on, letting-go.

taking-in, taking-hold, letting-go.

To assess the frequency of a woman's labor contractions, the nurse would time: the interval between the acme of two consecutive contractions. how many contractions occur in 5 minutes. the beginning of one contraction to the beginning of the next. the end of one contraction to the beginning of the next.

the beginning of one contraction to the beginning of the next.

A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider? touching recognizing the meaning of words pictures writing

touching

The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process? The client has the baby without any analgesic or anesthetic. The nurse suggests alternative methods of pain relief. Client priorities and preferences are incorporated into the plan. The health care provider decides the best pain relief for the mother and family

Client priorities and preferences are incorporated into the plan.

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? The size of her infant Her bladder for distension Her episiotomy Her hematocrit

Her bladder for distension

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. Note any hemorrhoids. Palpate the episiotomy for pain. Place the patient in Trendelenburg position for inspection. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Gently palpate for any hematomas.

Note any hemorrhoids. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Gently palpate for any hematomas.

A client asks her nurse what effleurage means. After instruction is given, the nurse determines learning has taken place when the client states: "Effleurage is massaging the perineum as the fetal enlarges the vaginal opening." "Effleurage is the pattern for cleaning the perineum before birth." "Effleurage is the effect of a full bladder on fetal descent." "Effleurage is light abdominal massage used to displace pain."

"Effleurage is light abdominal massage used to displace pain."

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification? "The client is experiencing lower back pain and I gave a backrub." "I changed the client position from her back to her side." "The client reports a pain level of 8. She has a low pain tolerance." "I instructed the client to ring if she felt the need to move her bowels."

"The client reports a pain level of 8. She has a low pain tolerance."

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? "You might try using a water-soluble lubricant to ease the discomfort." "It takes a while to get your body back to its normal function after having a baby." "This is entirely normal, and many women go through it. It just takes time." "Try doing Kegel exercises to get your pelvic muscles back in shape."

"You might try using a water-soluble lubricant to ease the discomfort."

The nurse is working with a client approaching her due date. Arrange the sequence of typical labor pain that the client may experience from onset to birth of the fetus. Use all options. 1 Cramping in the lower abdomen 2 Burning in the perineum 3 Pain noted in the lower back, buttocks and thighs 4 Intense contractions resulting in fetal movement

1 Cramping in the lower abdomen 3 Pain noted in the lower back, buttocks and thighs 4 Intense contractions resulting in fetal movement 2 Burning in the perineum

The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? 1 cm above the umbilicus At level of umbilicus At the symphysis pubis 1 cm below the umbilicus

1 cm below the umbilicus

A client is reporting considerable postpartum abdominal and perineal pain at a 7 on a scale of 1 to 10. The nurse will prioritize which action after noting the client is currently receiving ibuprofen 600 mg every 8 hours? Apply a cold pack to the perineum. Administer acetaminophen with codeine. Offer a hot pad for the abdomen. Assist the client to change position.

Administer acetaminophen with codeine.

Which statement is true regarding analgesia versus anesthesia? Decreased FHR variability is a common side effect when regional anesthesia is used. Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area. Hypotension is the most common side effect when systemic analgesia is used.

Analgesia only reduces pain, but anesthesia partially or totally blocks all pain in a particular area.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax? Decreased anxiety will increase trust in the nurse. Anxiety will increase blood pressure, increasing risk with an epidural. Anxiety can slow down labor and decrease oxygen to the fetus. Increased anxiety will increase the risk for needing anesthesia.

Anxiety can slow down labor and decrease oxygen to the fetus.

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema? Use a warm sitz bath or tub bath. Use ointments locally. Apply moist heat. Apply ice.

Apply ice.

The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize? Assess return of sensory and motor functions to the lower extremities. Make sure the client receives plenty of fluids. Help the client get up and walk around immediately. Let the client rest and recover while keeping her legs slightly elevated.

Assess return of sensory and motor functions to the lower extremities.

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? Full bowel Poor bladder tone Bladder distention Uteruine atony

Bladder distention

The nurse is assessing a client who has just given birth and notes her prelabor vital signs reveal a temperature 98.8oF (37.1oC), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize? Shaking chills with a fever of 100.3° F (37.9° C) Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. Bradycardia and excessive, soaking diaphoresis Blood loss of 250 mL and WBC 25,000 cells/mL

Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? Decreased level of consciousness Difficulty breathing Staggering gait Intense pain

Difficulty breathing

The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding? Engagement of fetus Bloody show Dilation of cervix Rupture of amniotic membranes

Dilation of cervix

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Provide the infant oral nystatin. Dry the nipples following feedings. Feed the baby at least every two or three hours. Apply cold compresses to the breasts.

Feed the baby at least every two or three hours.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? Have the client void, and then massage the fundus until it is firm. Notify the primary care provider, and document the findings. Check and inspect the lochia, and document all findings. Assess a full set of vital signs.

Have the client void, and then massage the fundus until it is firm.

The nurse is monitoring the EFM and notes the following: variable V-shaped decelerations in the FHR lasting about 30 seconds, accelerations of about 5 bpm before and after each deceleration, no overshoot, and baseline FHR within normal limits. Which response should the nurse prioritize? Start an oxytocic infusion and decrease the rate of IV fluids. Help the woman change positions. Position the woman on her side with a pillow under her left hip. Discontinue supplemental oxygen.

Help the woman change positions.

A multigravida client admitted in active labor has progressed well and the client ane fetus have remained in good condition. Which action should the nurse prioritize if the client suddenly shouts out, "The baby is coming!"? Contact the primary care provider. Time the contractions. Inspect the perineum. Auscultate the fetal heart tones.

Inspect the perineum.

A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone? sitz baths Kegel exercises abdominal crunches urinating immediately when the urge is felt

Kegel exercises

A nurse is auscultating the fetal heart rate of a woman in labor. To ensure that the nurse is assessing the FHR and not the mother's heart rate, which action would be most appropriate for the nurse to do? Instruct the woman to bend her knees and flex her hips. Have the woman lie completely flat on her back while auscultating. Ask the woman to hold her breath while assessing the FHR. Palpate the mother's radial pulse at the same time.

Palpate the mother's radial pulse at the same time.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? Showing increased confidence when caring for the newborn Talking about her labor experience to others around her Having feelings of grief or guilt Pointing out specific features in the newborn

Showing increased confidence when caring for the newborn

The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive? The parents explore the newborn's extremities, counting fingers and toes. The mother states that she has her father's eyes. The mother is reluctant to touch the newborn for fear of hurting her. The father holds the newborn en face and talks to her.

The mother is reluctant to touch the newborn for fear of hurting her.

The pain of labor is influenced by many factors. What is one of these factors? The woman is prepared for labor and birth. The woman has a high tolerance for pain. The woman has a high threshold for pain. The woman has lots of visitors during labor.

The woman is prepared for labor and birth.

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic? This would cause fetal depression in utero. This can lead to maternal hypertension. The effects would wear off before delivery. This may prolong labor and increase complications.

This may prolong labor and increase complications.

What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery? To determine if the mother's milk is coming in To answer questions the new parents may have To monitor the mother's blood pressure to note any elevations To check for postpartum hemorrhage

To check for postpartum hemorrhage

A nurse caring for a pregnant client in labor observes that the fetal heart rate (FHR) is below 110 beats per minute. Which interventions should the nurse perform? Select all that apply. Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes. Ignore questions from the client. Reduce intravenous (IV) fluid rate.

Turn the client on her left side. Administer oxygen by mask. Assess client for underlying causes.

Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply. Wash her hands before and after caring for the client. Have the mother maintain a low activity level to allow the perineum to heal. Recommend that the mother change her peripads every 12 hours. Encourage intake of fluids following delivery and after discharge. Teach proper positioning of the infant for breast-feeding.

Wash her hands before and after caring for the client. Teach proper positioning of the infant for breast-feeding. Encourage intake of fluids following delivery and after discharge.

The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Run warm water over the breast in the shower. Wear a tight, supportive bra. Massage the breasts when they are painful. Express small amounts of milk when they are too full.

Wear a tight, supportive bra.

At what time is the laboring client encouraged to push? When the cervix is fully dilated When the health care provider has arrived When the fetal head can be seen When she feels the urge to push

When the cervix is fully dilated

When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal? a scant amount of lochia alba a scant amount of lochia serosa a moderate amount of lochia rubra a moderate amount of lochia alba

a moderate amount of lochia rubra

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? applying warm compresses administering bromocriptine restricting fluids applying ice

applying ice

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior? engrossment engorgement attachment involution

attachment

A nurse is caring for woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? green malodorous clear cloudy

clear

A client who requested "no drugs" in labor asks the nurse what other options are available for pain relief. The nurse reviews several options for nonpharmacologic pain relief, and the client thinks effleurage may help her manage the pain. This indicates that the nurse will: press down firmly with her index finger and forefinger on key trigger points on the client's ankle or wrist. instruct the client to perform controlled chest breathing with a slow inhale and a quick exhale. instruct the client or her partner to perform light fingertip repetitive abdominal massage. lead the client through a series of visualizations to aid in relaxation.

instruct the client or her partner to perform light fingertip repetitive abdominal massage.

A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production? prolactin oxytocin progesterone estrogen

prolactin

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? prolonged decelerations accelerations early decelerations variable decelerations

prolonged decelerations

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next? uterine contractions temperature pulse respiratory rate

respiratory rate

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

taking-in

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem? uterus 1 cm below umbilicus diaphoresis lochia serosa edematous vagina

uterus 1 cm below umbilicus

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. Which type of lochia pattern should the nurse point out needs to be reported to her primary care provider immediately during the discharge teaching? moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5 lochia progresses from rubra to serosa to alba within 10 days moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 moderate lochia rubra on day 3, mixed serosa and rubra on day 4, light serosa on day 5

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5

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 letting-go phase the taking-hold phase the taking-in phase the binding-in phase

the taking-hold phase

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 breast-feeding 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."

"I am breast-feeding so I can anticipate that there will be reddened, painful areas in my breasts when I am engorged."

After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement? "This line on my belly will go away over time." "I might lose some hair, but it will grow back." "I can't wait for these stretch marks to disappear after I give birth." "My nipples won't be so dark after I give birth."

"I can't wait for these stretch marks to disappear after I give birth."

A woman states that she does not want any medication for pain relief during labor. Her primary care provider has approved this for her. What the nurse's best response to her concerning this choice? "That's wonderful. Medication during labor is not good for the baby." "Your health care provider is a man and has never been in labor; he may be underestimating the pain you will have." "Let me get you something for relaxation if you don't want anything for pain." "I respect your preference whether it is to have medication or not."

"I respect your preference whether it is to have medication or not."