OB PrepU Chapter 16

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a. atony b. normal involution c. hemorrhage d. infection

a. atony

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? a. "Ask your 2-year-old to pick out a special toy for his sister." b. "Have your 2-year-old stay at home while you're here in the hospital." c. "Talk to your 2-year-old about the baby when you're driving him to day care." d. "Expect to see your 2-year-old become more independent when the baby gets home."

a. "Ask your 2-year-old to pick out a special toy for his sister."

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? a. encouraging the woman to empty her bladder completely every 2 to 4 hours b. increasing intravenous fluids c. increasing oral fluid intake d. screening for bacteriuria in the urine

a. encouraging the woman to empty her bladder completely every 2 to 4 hours

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? a. mastitis b. normal findings in breastfeeding mothers c. too much milk being retained d. an improperly positioned baby during feedings

a. mastitis

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a. Have the charge nurse review the assessment. b. Ask the client when she last changed her perineal pad. c. Vigorously massage the fundus. d. Immediately call the primary care provider.

b. Ask the client when she last changed her perineal pad.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment? a. proximity b. reciprocity c. commitment d. all of the above

b. reciprocity

A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action? a. holds and smiles at the infant b. talks to company and ignores the baby lying next to her c. kisses the infant on her cheek d. strokes the infant's head

b. talks to company and ignores the baby lying next to her

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? a. allowing the mother to pick the best time to hold her newborn b. showing a video of parents feeding their babies c. bringing the newborn into the room d. talking about how the nurse held her own newborn while on the birthing table

c. bringing the newborn into the room

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after birth? a. after 60 minutes b. every 30 minutes c. every 15 minutes d. after 45 minutes

c. every 15 minutes

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? a. 1,000 additional calories per day b. 250 additional calories per day c. 750 additional calories per day d. 500 additional calories per day

d. 500 additional calories per day

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? a. Recommend a moisturizing soap to clean the nipples. b. Encourage use of breast pads with plastic liners. c. Fasten nursing bra flaps immediately after feeding. d. Offer suggestions based on observation to correct positioning or latching.

d. Offer suggestions based on observation to correct positioning or latching.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding? a. The urinary output is inadequate suggestive of urinary retention. b. The urinary output is inadequate and the mother needs to drinks more fluids. c. The urinary output is above expected levels. d. The urinary output is normal.

d. The urinary output is normal.

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? a. infection b. DVT c. nothing—it is normal d. hematoma

d. hematoma

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next? a. Massage the client's fundus. b. Assess the client's blood pressure. c. Notify the healthcare provider. d. Change the client's peri-pad.

a. Massage the client's fundus.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? a. Ask the client when she last urinated. b. Determine if the client is emptying her bladder. c. Perform an in and out catheter on the client. d. Educate the client on how to perform Kegel exercises.

d. Educate the client on how to perform Kegel exercises.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a. when the white blood cell count is less than 10,000/mm³ b. after any period of decreased intake c. when the elevated temperature exceeds 100.4°F (38°C) d. during the first 24 hours after birth owing to dehydration from exertion

d. during the first 24 hours after birth owing to dehydration from exertion

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening? a. fluid volume overload b. infection c. pulmonary emboli d. hemorrhage

d. hemorrhage

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? a. Stop using a peri-pad. b. Massage the client's fundus. c. Reassess the client in 1 hour. d. Document the lochia as scant.

d. Document the lochia as scant.

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? a. 100.8°F (38.2°C) b. 97.5°F (36.9°C) c. 99.2°F (37.3°C) d. 100.1°F (37.8°C)

a. 100.8°F (38.2°C)

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? a. hemorrhage b. infection c. pulmonary emboli d. depression

b. infection

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: a. light. b. scant. c. heavy. d. moderate.

d. moderate.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? a. talking b. touching c. looking d. feeding

b. touching

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. a. head-to-toe assessment of newborn b. vital signs of mother c. head-to-toe assessment d. pain level e. newborn's vital signs

b. vital signs of mother c. head-to-toe assessment d. pain level

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action? a. Call the primary care provider. b. Nothing—excessive postpartum blood loss is normal. c. Massage the boggy fundus until it is firm. d. Document the findings.

c. Massage the boggy fundus until it is firm.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? a. Avoid performing pelvic floor exercises. b. Use oral contraceptives for contraception. c. Resume intercourse if bright red bleeding stops. d. Avoid use of water-based gel lubricants.

c. Resume intercourse if bright red bleeding stops.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? a. generally after 12 weeks b. generally within 3 to 6 weeks c. usually within a couple weeks d. whenever the couple wishes

b. generally within 3 to 6 weeks

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? a. lochia that is the color of menstrual blood b. lochia appearing pinkish-brown on the fourth day c. an absence of lochia d. red-colored lochia for the first 24 hours

c. an absence of lochia

A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? a. The color of the flow is red. b. Her uterus is soft to your touch. c. The flow is over 500 mL. d. The flow contains large clots.

a. The color of the flow is red.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? a. Continue to monitor the woman's temperature every 4 hours; this finding is normal. b. Inspect the perineum for hematoma formation. c. Obtain a urine culture; the woman most likely has a urinary tract infection. d. Notify the health care provider about this elevation; this finding reflects infection.

a. Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? a. Walk with the nurse the length of her room. b. Avoid elevating her feet when she rests in a chair. c. Avoid getting out of bed for another 2 days. d. Walk the length of the hallway to regain her strength.

a. Walk with the nurse the length of her room.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? a. dehydration b. fluid volume overload c. infection d. change in the temperature from the birth room

a. dehydration

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? a. "My mom always used dibucaine." b. "Sitz baths worked the last time." c. "I only eat a low-fiber diet." d. "I already have some pads with witch hazel at home."

c. "I only eat a low-fiber diet."

A nurse is assessing a postpartum client. Which measure is appropriate? a. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. b. Instruct the client to empty her bladder before the examination. c. Wear sterile gloves when assessing the pad and perineum. d. Perform the examination as quickly as possible.

b. Instruct the client to empty her bladder before the examination.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? a. bonding b. attachment c. being spoiled d. none of the above

b. attachment

When palpating for fundal height on a postpartum woman, which technique is preferable? a. placing one hand on the fundus, one on the perineum b. resting both hands on the fundus c. palpating the fundus with only fingertip pressure d. placing one hand at the base of the uterus, one on the fundus

d. placing one hand at the base of the uterus, one on the fundus

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of: a. postpartum psychosis. b. postpartum depression. c. postpartum blues. d. postpartum adjustment.

b. postpartum depression.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? a. first 3 to 5 days b. first 30 to 60 minutes c. first 6 months d. first month

b. first 30 to 60 minutes

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? a. infection b. thromboembolic disorder of the lower extremities c. normal response to the body converting back to prepregnancy state d. hormonal shifting of relaxin and estrogen

b. thromboembolic disorder of the lower extremities

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? a. Auscultating bowel sounds, and measuring urine output b. Inspecting posture, color, and respiratory effort c. Determining chest and head circumference d. Checking for identifying birthmarks or skin injuries

b. Inspecting posture, color, and respiratory effort

In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. a. women using street drugs b. women on antineoplastic medications c. women on antithyroid medications d. women who had difficulties with breastfeeding in the past e. women with more than one infant

a. women using street drugs b. women on antineoplastic medications c. women on antithyroid medications

The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care? a. Postpartum depression only impacts women with two or more children. b. Symptoms of postpartum depression can easily go undetected. c. Only mental health professionals can detect postpartum depression. d. Symptoms occur within a week after giving birth.

b. Symptoms of postpartum depression can easily go undetected.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. a. Help the mother initiate breastfeeding within 30 minutes of birth. b. Provide breastfeeding newborns with pacifiers. c. Encourage breastfeeding of the newborn infant on demand. d. Place baby in uninterrupted skin-to-skin contact with the mother. e. Give newborns water and other foods to balance nutritional needs.

a. Help the mother initiate breastfeeding within 30 minutes of birth. c. Encourage breastfeeding of the newborn infant on demand. d. Place baby in uninterrupted skin-to-skin contact with the mother.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a. venous duplex ultrasound of the right leg b. transthoracic echocardiogram c. venogram of the right leg d. noninvasive arterial studies of the right leg

a. venous duplex ultrasound of the right leg

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process? a. policies that allow visitors b. policies that allow flexibility for cultural differences c. policies that allow rooming the infant and mother together d. policies that discourage unwrapping and exploring the infant

d. policies that discourage unwrapping and exploring the infant

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply. a. age 30 years b. first pregnancy c. severe varicose veins d. previous oral contraceptive use e. preeclampsia

c. severe varicose veins d. previous oral contraceptive use e. preeclampsia

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? a. "It might take up to a week for your bowels return to their normal pattern." b. "Let me call your healthcare provider about this problem." c. "I'll get a laxative prescribed so that you can move your bowels." d. "That's unusual. Are you making sure to eat enough?"

a. "It might take up to a week for your bowels return to their normal pattern."

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type? a. first-degree laceration b. second-degree laceration c. third-degree laceration d. fourth-degree laceration

c. third-degree laceration

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? a. "If you don't attempt to void, I'll need to catheterize you." b. "I'll check on you in a few hours." c. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." d. "I'll contact your primary care provider."

c. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate? a. "Walking is the best way to prevent complications such as blood clots." b. "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." c. "If you do not get up to walk you will not recover." d. "Maybe you will feel better after you take pain medication."

a. "Walking is the best way to prevent complications such as blood clots."

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation (dilatation) and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is: a. At risk for interruption of tissue integrity. b. At risk for inadequate healing due to decreased nutrition. c. At risk for postpartum depression due to inadequate rest. d. At risk for safety due to low hemoglobin.

c. At risk for postpartum depression due to inadequate rest.

A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding? a. Explain that breastfeeding comes naturally to all mothers. b. Ensure that the mother breastfeeds the newborn using the cradle method. c. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. d. Tell her that breastfeeding is a mechanical procedure that involves burping once in a while and that she should try finishing it quickly.

c. Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a. at the level of the umbilicus b. below the symphysis pubis c. one fingerbreadth below the umbilicus d. one fingerbreadth above the umbilicus

c. one fingerbreadth below the umbilicus

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: a. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." b. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." c. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood." d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."

d. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."