OB Test 2 (Chps. 14, 18, 19, 21)

C, D (The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 mL (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 mL (15% to 30% of blood volume). During the first few days after birth the plasma volume decreases further as a result diuresis. Pregnancy-induced hypervolemia (an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth.)

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply): A. 100 mL B. 250 mL or less C. 300 to 500 mL D. 500 to 1000 mL E. 1500 mL or greater

A (500 mL in the first 24 hours after vaginal delivery.)

Early postpartum hemorrhage is defined as a blood loss greater than: a. 500 mL in the first 24 hours after vaginal delivery. b. 750 mL in the first 24 hours after vaginal delivery. c. 1000 mL in the first 48 hours after cesarean delivery. d. 1500 mL in the first 48 hours after cesarean delivery.

D (In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.)

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. The father of the infant. b. Her mother (the infant's grandmother). c. Her eldest daughter (the infant's sister). d. The nurse.

A, B, D

Medications used to manage postpartum hemorrhage include (choose all that apply): A. Pitocin B. Methergine C. Terbutaline D. Hemabate E. Magnesium sulfate

D (Homans' sign is an assessment test used to determine whether the patient has VTE. Presence of Homans' sign indicates that the patient may have VTE. Uterine atony can be assessed by palpating the uterine fundus. Hypotensive shock can be assessed by checking the patient's vitals. Mastitis can be assessed by the examining the patient's breasts.)

On reviewing the medical reports of a postpartum patient, the nurse finds that the patient has Homans' sign. What does the nurse interpret from this finding? A. Risk of uterine atony B. Hypotensive shock C. Risk of developing mastitis D. Venous thromboembolism (VTE)

A (The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women spider nevi persist indefinitely.)

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed? A. Nail brittleness B. Darker pigmentation of the areolae and linea nigra C. Striae gravidarum on the breasts, abdomen, and thighs D. Spider nevi

A (Methergine provides long-sustained contraction of the uterus.)

The nurse should expect medical intervention for subinvolution to include: a. oral methylergonovine maleate (Methergine) for 48 hours. b. oxytocin intravenous infusion for 8 hours. c. oral fluids to 3000 mL/day. d. intravenous fluid and blood replacement.

C (This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.)

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: a. Retained placental fragments. b. Unrepaired vaginal lacerations. c. Uterine atony. d. Puerperal infection

D ("I'll warm the soup in the microwave for you" shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. "What is that anyway?" does not show cultural sensitivity.)

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

B (Rationale: When caring for a client who has suffered perinatal loss, the nurse should provide opportunity for her to bond with the dead infant and for the infant to become part of the family unit. Parents not given that opportunity may have fantasies about the infant that are worse than reality. If the child has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her child, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Allowing the father to determine which information the client is given is inappropriate.)

A client gives birth to a stillborn infant at 36 weeks. When caring for this client, which strategy by the nurse would be most helpful? A. Be selective in providing the information that the client seeks B. Encourage the client to see, touch and hold the dead infant C. Provide information about the possible causes of the stillbirth only if the client requests it D. Let the child's father decide what information the mother receives.

B (Rationale: Cardiac output increases immediately after delivery as blood that had been diverted to the uterus reenters the central circulation. A client who cannot tolerate these changes may experience cardiac decompensation and cardiac failure. After delivery, renal function increases. There is usually not an increase in pain after delivery except for small increments attributable to uterine cramps, perineal discomfort and breast tenderness. Although hepatic blood flow decreases to normal levels after delivery, this does not affect cardiac function.)

A client with cardiac disease delivers a baby. Afterwards, the nurse assesses the client for signs of cardiac decompensation. During the postpartum period, which condition can cause cardiac decompensation? A. Increased pain B. Increased cardiac output C. Decreased renal function D. Decreased hepatic blood flow

B (Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two drugs to work together more effectively, but it does not ensure maternal or fetal complications will not occur. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a woman is unlikely to be able to sleep through transitional labor and birth. "This is what the doctor has ordered for you" may be true, but it is not an acceptable comment for the nurse to make.)

A first-time mother is concerned about the type of medications she will receive during labor. She is in a fair amount of pain and is nauseous. In addition, she appears to be very anxious. You explain that opioid analgesics often are used with sedatives because: a. "The two together work the best for you and your baby." b. "Sedatives help the opioid work better, and they also will assist you to relax and relieve your nausea." c. "They work better together so you can sleep until you have the baby." d. "This is what the doctor has ordered for you."

A (Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is' possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.)

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b. Determine which pad is best. c. Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off.

B (Rationale: Just telling her to breathe more slowly does not ensure a change in respirations. The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her air would increase the carbon dioxide level. Turning her on her side will not solve this problem. Administration of a sedative could lead to neonatal depression since this woman, being in the transition phase, is near the birth process. The side-lying position would be appropriate for supine hypotension.)

A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to: A) encourage the woman to breathe more slowly. B) help the woman breathe into a paper bag. C) turn the woman on her side. D) administer a sedative.

C (An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Fentanyl, promethazine, and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Demerol on the neonate. Although meperidine (Demerol) is a low-cost medication and readily available, the use of Demerol in labor has been controversial because of its effects on the neonate.)

A laboring woman received an opioid agonist (meperidine) intravenously 90 minutes before she gave birth. Which medication should be available to reduce the postnatal effects of Demerol on the neonate? a. Fentanyl (Sublimaze) b. Promethazine (Phenergan) c. Naloxone (Narcan) d. Nalbuphine (Nubain)

C (The recommended caloric intake for a lactating mother who breastfeeds more than one infant is more than 2700 kcal/day. If a lactating mother of twins takes less than 2200 kcal/day, she may not produce enough milk. An intake of 1800 to 2200 kcal/day is recommended for nonlactating mothers.)

A lactating patient who gave birth to twins 1 month earlier approaches the primary health care provider (PHP) for a general checkup. What suggestion does the nurse give to the patient about the recommended calorie intake? A. Less than 1800 kcal/day B. Less than 2200 kcal/day C. More than 2700 kcal/day D. Should be 1800 to 2200 kcal/day

C (Increased frequency of urination in a postpartum patient is termed postpartal diuresis. Postpartum patients have decreased estrogen and progesterone levels. In addition, removal of increased venous pressure in the lower extremities and loss of the remaining pregnancy-induced increase in blood volume may also cause diuresis. Diuresis helps get rid of excess fluids from the body. The levels of oxytocin are not related to postpartum diuresis. The aldosterone levels drop after childbirth and are not related to postpartum diuresis. hCG tends to disappear after the childbirth and has no role in diuresis.)

A lactating postpartum patient reports frequent urination. What could be the reason for increased frequency of urination in the patient? A decrease in the levels of: A. Estrogen and aldosterone B. Oxytocin and progesterone C. Progesterone and estrogen D. Human chorionic gonadotropin (hCG)

C (The organisms are localized in the breast tissue and are not excreted in the breast milk.)

A mother with mastitis is concerned about breastfeeding while she has an active infection. The nurse should explain that: a. the infant is protected from infection by immunoglobulins in the breast milk. b. the infant is not susceptible to the organisms that cause mastitis. c. the organisms that cause mastitis are not passed to the milk. d. the organisms will be inactivated by gastric acid.

B (Treatment of excessive bleeding requires the collaboration of the physician and the nurses. Do not leave the client alone.)

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000 g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find, and the rubra lochia remains heavy. The nurse should: a. continue to massage the fundus. b. notify the physician. c. recheck vital signs. d. insert a Foley catheter.

C (When TENS is applied for pain relief, the electrodes provide continuous low-intensity electrical impulses or stimuli from a battery-operated device. TENS is most useful for lower back pain during the early first stage of labor. TENS involves the placing of two pairs of flat electrodes on either side of the woman's thoracic and sacral spine. During a contraction, the patient increases the stimulation from low to high intensity by turning the control knobs on the device.)

A patient asks the nurse about the use of transcutaneous electrical nerve stimulation (TENS). What does the nurse teach about TENS? A. It involves the use of one pair of electrodes. B. It is kept at low intensity during contractions. C. It releases continuous low-intensity impulses. D. It is useful for pain in the second stage of labor.

A, C, E (Hypnosis is a form of deep relaxation, similar to daydreaming or meditation. It enhances relaxation and diminishes fear, anxiety, and perception of pain. It allows the patient to have a greater sense of control over painful contractions. Failure to dehypnotize properly may result in mild dizziness, nausea, and headache. Self-hypnosis must be learnt during childbirth preparation classes. It is not performed by a support person. Although hypnosis is beneficial, studies have not found it to be more effective than the use of a placebo or other interventions for pain management during labor.)

A patient inquires about the use of hypnosis for pain management during a prenatal assessment. What does the nurse teach the patient about this modality? Select all that apply. A. It gives a better sense of control. B. It must be performed by a support person. C. It is a form of deep relaxation or meditation. D. It is more effective than the use of a placebo. E. It can cause dizziness, nausea, and headache

B (Lochial bleeding is normal and decreases with time. Nonlochial bleeding occurs as a result of the tears in either the cervical or vaginal regions. In normal condition (lochial), the bleeding decreases with time. However, in this patient there is continuous bleeding even 4 weeks after childbirth. Normally, the color of the blood is bright red in the beginning (known as lochia rubra); after that, the color of the blood becomes slightly less pigmented. Therefore the patient has nonlochial discharge evident by the continuous bright red color bleeding. The odor of the lochia is the same as of the menstrual bleeding. The offensive odor of the lochia indicates presence of infection.)

A patient reports continuous bleeding 4 weeks after childbirth. Upon assessment, the nurse finds that the bleeding is bright red in color with an offensive odor. What does the nurse suspect as the cause of the bleeding? A. Lochial; the odor is caused by infection. B. Nonlochial; the odor is caused by infection. C. Lochial; the odor is normal in all postpartum patients. D. Nonlochial; the odor is normal in all postpartum patients

D (Thromboembolism refers to the condition in which a blood vessel is blocked by a blood clot. As the postpartum period is characterized by a hypercoagulation state, the patient is at risk of thromboembolism. Thrombophlebitis is the inflammation of the vein and is not associated with hypercoagulation. Thrombocytopenia refers to the condition in which low levels of platelet are found in the blood. Thrombocytosis is a condition characterized by a significant increase in the number of platelets in the blood.)

A patient who had a cesarean birth is immobile in the immediate postoperative period. Which risk is increased in the patient as a result of the hypercoagulable state of the puerperal period? A. Thrombocytosis B. Thrombophlebitis C. Thrombocytopenia D. Thromboembolism

A (The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean.)

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient? A. Take stool softeners regularly. B. Continue prenatal vitamins. C. Include iron supplements. D. Take analgesics as prescribed.

B, E (A patient who has had a cesarean birth and has remained in the bed for more than 8 hours is at risk of venous thromboembolism. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the leg, the nurse should notify the PHP immediately. Meanwhile, the patient should remain in bed with the affected limb elevated on pillows. Applying heat increases discomfort because the affected limb is already warm. Applying antiinflammatory ointment to the leg at the reddened site would not be useful because the redness is caused by embolism, not inflammation.)

A patient who has had a cesarean birth has been on bed rest for 8 hours after surgery and has warmth and redness in the left lower limb. Which interventions taken by the nurse would be most beneficial to the patient? Select all that apply. A. Advise the patient to apply a hot compress at the reddened site. B. Inform the primary health care provider (PHP) about the patient's condition immediately. C. Advise the patient to apply an antinflammatory ointment at the reddened site. D. Have the patient sit upright and lower the reddened leg. E. Have the patient remain in bed with reddened limb elevated on pillows.

A (Patients with a history of dysmenorrhea may experience increased pain during childbirth. These patients are known to have high levels of prostaglandin. Low levels of prostaglandin do not increase the intensity of pain during labor. The level of beta (β) endorphins increases during pregnancy and birth. β endorphins are endogenous opioids that reduce pain. Back pain associated with menstruation also increases the likelihood of contraction-related low back pain.)

A patient who is pregnant for the first time is anxious about the pain related to labor. Which physiologic factor does the nurse relate that may increase the intensity of pain during childbirth? A. History of dysmenorrhea B. Low level of prostaglandin C. Cramps during menstruation D. High level of β-endorphin

A (If the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient.)

A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation? A. Apply ice packs in the perineum. B. Administer fluids to the patient. C. Administer blood to the patient. D. Refer the patient for hematologic tests.

B (A rapid labor and delivery may cause exhaustion of the uterine muscle and prevent contraction.)

A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a: a. 5-lb, 2-oz infant with outlet forceps. b. 6.5-lb infant after a 2-hour labor. c. 7-lb infant after an 8-hour labor. d. 8-lb infant after a 12-hour labor.

D (Stretch marks never disappear altogether; however, they gradually fade to silvery lines.)

A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is: A. "They will continue to fade and should be gone by your 6-week checkup." B. "No, never." C. "Yes, eventually." D. "They will fade to silvery lines but won`t disappear completely."

C, D, E (Patients who choose not to breastfeed may experience breast engorgement and related discomfort. The nurse should instruct the patient to wear a well-fitted support bra or use a breast binder to support the breasts, which can relieve discomfort. Applying ice packs with a 15-minutes-on, 45-minutes-off schedule also helps relieve breast engorgement and reduce discomfort. Expressing milk from the breast or performing nipple stimulation may increase milk production and may worsen breast engorgement.)

A postpartum patient has chosen not to breastfeed. What instructions should the nurse provide to the patient to prevent discomfort caused by breast engorgement? Select all that apply. A. Express the milk from both breasts. B. Perform regular breast stimulation. C. Wear a well-fitted support bra. D. Use a breast binder. E. Apply ice packs on the breasts

C (The pelvic floor is a broad sling of muscles, ligaments, and sheet-like tissues. It stretches from the pubic bone at the front of the body to the base of the spine at the back. It is responsible for movement, balance, stability, and flexibility. The supportive tissues of the pelvic floor are torn or stretched during childbirth. This results in urinary incontinence while coughing, sneezing, or performing exercises. Kegel exercises consist of repeated contractions and relaxations of the muscles that form the pelvic floor. These exercises help strengthen the perineal muscles and can prevent urinary incontinence. The intake of more fluids is recommended after childbirth if the woman has constipation. However, the administration of fluids for urinary incontinence causes irritation of the bladder. An epidural block is a medicine given in the epidural spaces for causing numbness in the lower half of the body. Therefore it causes urinary incontinence after childbirth. Personal hygiene is not related to urinary incontinence, but it helps prevent infections.)

A postpartum patient has urinary incontinence. What is the best nursing intervention to help this patient? A. Provide an epidural block. B. Encourage the patient to intake more fluids. C. Tell the patient to perform more Kegel exercises. D. Have the patient practice better personal hygiene.

A (A WBC count in the upper ranges of normal (20,000 to 30,000) may indicate an infection.)

A white blood cell (WBC) count of 28,000 cells/mm3 on the morning of the first postpartum day indicates: a. possible infection. b. normal WBC limit. c. serious infection. d. suspicion of sexually transmitted disease.

C (Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A "fleshy" odor, not a foul odor, is within normal limits.)

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is: a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

D (Fluid retention and swelling are common during pregnancy and increase the pressure in the narrow and inflexible space in the hand, compressing the median nerve that runs through the hand. This results in numbness, tingling of fingers, and the inability to lift and carry objects and is a condition known as carpal tunnel syndrome, which this patient has. Itching and discomfort around the anus and bright red bleeding upon defecation are the symptoms of hemorrhoids. These symptoms are not observed in the patient; therefore the patient does not have hemorrhoids. Fever, pain, and abdominal tenderness during menstrual discharge are the symptoms of endometritis. The nurse does not find these symptoms in the patient, so the patient does not have endometritis. Vitamin A deficiency does not affect the muscles, nor does it cause periodic numbness or tingling of the fingers. Therefore the patient does not have a vitamin A deficiency.)

A pregnant patient complains to the nurse about periodic numbness, tingling of fingers, and the inability to lift and carry any object. What patient clinical condition does the nurse interpret from this assessment? A. Hemorrhoids B. Endometritis C. Vitamin A deficiency D. Carpal tunnel syndrome

D (Fingernails may regain strength to the prepregnancy state in a few weeks after delivery. Brittle and soft nails are caused by iron deficiency, not potassium deficiency. Carpal tunnel syndrome causes physiologic edema due to compression of the median nerve, but it does not cause brittle and soft nails. Moisture can cause soft and brittle fingers, so moisture should be reduced, not enhanced.)

A pregnant patient reports to the nurse, "My nails are soft and brittle, and I am worried about it." What is the nurse's best response to the patient? A. "You should make sure your nails are well moisturized." B. "You have low potassium, so take potassium supplements." C. "Your nails are soft and brittle due to carpal tunnel syndrome." D. "After delivery your nails should return to normal consistency and strength."

B (The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.)

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to: A. Establish venous access B. Perform fundal massage C. Prepare the woman for surgical intervention D. Catheterize the bladder

A (Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant's elimination patterns.)

A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? a. The woman leaves the infant on her bed while she takes a shower. b. The woman continues to hold and cuddle her infant after she has fed her. c. The woman reads a magazine while her infant sleeps. d. The woman changes her infant's diaper and then shows the nurse the contents of the diaper.

C (If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby's sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.)

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a. Discusses her labor and birth experience excessively. b. Believes that her baby is more attractive and clever than any others. c. Has not given the baby a name. d. Has a partner or family members who react very positively about the baby.

B (Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction.)

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests: a. uterine atony. b. lacerations of the genital tract. c. perineal hematoma. d. infection of the uterus.

B (Rationale: Based on the signs and symptoms presented by the client (especially the elevated temperature), the physician should be notified because the client probably has mastitis, an infection in the breast. An antibiotic that is tolerated by the infant as well as the mother may be prescribed. The mother should continue to nurse on both breasts but should start the infant on the unaffected breast while the affected breast lets down.)

A ten-day postpartum breastfeeding client telephones the postpartum unit complaining of a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, the nurse tells the client to: A. "Stop breastfeeding because you probably have an infection." B. "Notify your physician because you may need medication." C. "Continue breastfeeding because this is a normal response in breastfeeding mothers." D. "Breastfeed only with the unaffected breast."

A (Amniotic fluid embolism (AFE))

A thrombosis results from the formation of a blood clot or clots inside a blood vessel and is caused by inflammation or partial obstruction of the vessel. Three thromboembolic conditions are of concern during the postpartum period and include all except: a) Amniotic fluid embolism (AFE) b) Superficial venous thrombosis c) Deep vein thrombosis d) Pulmonary embolism

D (Increased activity can cause excessive bleeding. Therefore postpartum women should not lift heavy weights and should go up and down stairs slowly. If the bleeding starts to get heavier, the patient should take a rest from being on her feet. Hemorrhage can occur after delivery when the uterus does not shrink completely. It can be caused by infection in the uterus or a residual placenta. However, infection or residual placenta is not associated with excess loss of blood; instead there will be a steady loss of blood. Hemorrhage conditions typically present with continuous loss of blood, leading to shock-type symptoms. There is no evidence that the patient is experiencing a hemorrhage situation. Breastfeeding immediately after delivery and in the early postpartum days increases the release of oxytocin. Oxytocin helps to decrease blood loss and reduces the risk for postpartum hemorrhage. Oxytocin strengthens and coordinates the uterine contractions (UCs), which help compress the blood vessels and promote hemostasis.)

A woman complains of excess vaginal bleeding after childbirth. The patient reports that the presence of excess blood is not continuous and denies any headaches or dizziness. What does the nurse suspect to be the cause of this excess bleeding? A. Oxytocin B. Hemorrhage C. Breastfeeding D. Increased activity

B (Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated.)

A woman delivered a 9-lb, 10-oz baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she "feels all wet underneath." You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action? a. Call for help. b. Assess the fundus for firmness. c. Take her blood pressure. d. Check the perineum for lacerations.

B (Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.)

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

B (Excessive uterine bleeding)

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: a) Urinary tract infection b) Excessive uterine bleeding c) A ruptured bladder d) Bladder wall atony

B (Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.)

A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony.

A (An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications.)

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman's vital signs, the nurse would be concerned to see: A. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50. B. Temperature 37.4° C, heart rate 88, respirations 36, BP 126/68. C. Temperature 38° C, heart rate 80, respirations 16, BP 110/80. D. Temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.

D (Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.)

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman? A. Lochia rubra B. Lochia sangra C. Lochia alba D. Lochia serosa

A (Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. The fundus descends about 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus normally is halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.)

A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman's fundus? A. One centimeter above the umbilicus B. Two centimeters below the umbilicus C. Midway between the umbilicus and the symphysis pubis D. Nonpalpable abdominally

D (These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.)

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

C (The platelet count indicates a coagulopathy, specifically, thrombocytopenia (low platelets), which is a contraindication to epidural analgesia/anesthesia. Typically epidural analgesia/anesthesia is used in the laboring woman when a regular labor pattern has been achieved, as evidenced by progressive cervical change. The laboratory values show that the woman's hemoglobin and hematocrit are in the normal range and show a slight increase in the WBC count that is not uncommon in laboring women.)

A woman has requested an epidural for her pain. She is 5 cm dilated and 100% effaced. The baby is in a vertex position and is engaged. The nurse increases the woman's intravenous fluid for a preprocedural bolus. She reviews her laboratory values and notes that the woman's hemoglobin is 12 g/dL, hematocrit is 38%, platelets are 67,000, and white blood cells (WBCs) are 12,000/mm3. Which factor would contraindicate an epidural for the woman? a. She is too far dilated. b. She is anemic. c. She has thrombocytopenia. d. She is septic.

A (Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs. Stadol and Nubain are opioid agonist-antagonist analgesics.)

A woman in active labor receives an analgesic opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease? a. Meperidine (Demerol) b. Promethazine (Phenergan) c. Butorphanol tartrate (Stadol) d. Nalbuphine (Nubain)

A (Meperidine (Demerol))

A woman in active labor receives an opioid agonist analgesic. Which medication relieves severe, persistent, or recurrent pain, creates a sense of well-being, overcomes inhibitory factors, and may even relax the cervix but should be used cautiously in women with cardiac disease? a) Meperidine (Demerol) b) Promethazine (phenergan) c) Butorphanol tartrate (Stadol) d) Nalbuphine (Nubain)

C (The most important nursing intervention for a woman who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a woman receiving an epidural, to prevent hypotension. The nurse observes for signs of fetal bradycardia. The nurse monitors for signs of maternal tachycardia secondary to hypotension.)

A woman in labor has just received an epidural block. The most important nursing intervention is to: a. Limit parenteral fluids. b. Monitor the fetus for possible tachycardia. c. Monitor the maternal blood pressure for possible hypotension. d. Monitor the maternal pulse for possible bradycardia.

C (This is an application of nitrous oxide, which could be used in either the first or second stage of labor (or both) as part of the preparation for a vaginal birth. Nitrous oxide is self-administered and found to be very helpful.)

A woman in labor is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. This procedure is: a. Not used much anymore. b. Likely to be used in the second stage of labor but not in the first stage. c. An application of nitrous oxide. d. A prelude to cesarean birth.

A (Rationale: Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. *Stadol and Nubain are opioid agonist-antagonist analgesics. Their use may precipitate withdrawals in a patient with a history of opiate use.*)

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's MOST appropriate analgesic for pain control is: A) fentanyl (Sublimaze). B) promethazine (Phenergan). C) butorphanol tartrate (Stadol). D) nalbuphine (Nubain).

A (Fentanyl is a commonly used opioid agonist analgesic for women in labor. It is fast and short acting. This patient may require higher than normal doses to achieve pain relief due to her opiate use. Phenergan is not an analgesic. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Stadol is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use. Nubain is an opioid agonist-antagonist analgesic. Its use may precipitate withdrawals in a patient with a history of opiate use.)

A woman in latent labor who is positive for opiates on the urine drug screen is complaining of severe pain. Maternal vital signs are stable, and the fetal heart monitor displays a reassuring pattern. The nurse's most appropriate analgesic for pain control is: A. fentanyl (Sublimaze). B. promethazine (Phenergan). C. butorphanol tartrate (Stadol). D. nalbuphine (Nubain)

D (Help her breathe into a paper bag.)

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a) Notify the woman's physician b) Tell the woman to slow the pace of her breathing c) Administer oxygen via mask or nasal canula d) Help her breathe into a paper bag

D (This woman is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the woman breathe into a paper bag held tightly around her mouth and nose may eliminate respiratory alkalosis. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion.)

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. The nurse should: a. Notify the woman's physician. b. Tell the woman to slow the pace of her breathing. c. Administer oxygen via a mask or nasal cannula. d. Help her breathe into a paper bag

C (Rationale: Since the client is already hemorrhaging, it is inappropriate to initiate a pad count. Fundal massage and administration of oxytocics would be indicated if the hemorrhage is due to uterine atony. If a full bladder is displacing the uterus and preventing it from contracting, insertion of an indwelling catheter would be an appropriate response.)

A woman is experiencing an early postpartum hemorrhage. Which of the following actions would be inappropriate? A. Insertion of an indwelling urinary catheter B. Fundal massage C. Pad count D. Administration of oxytocics

A (Rationale: Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.)

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A) counterpressure against the sacrum. B) pant-blow (breaths and puffs) breathing techniques. C) effleurage. D) biofeedback.

A (Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain; however, it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.)

A woman is experiencing back labor and complains of constant, intense pain in her lower back. An effective relief measure is to use: A. counterpressure against the sacrum. B. pant-blow (breaths and puffs) breathing techniques. C. effleurage. D. biofeedback

A (Counterpressure against the sacrum)

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a) Counterpressure against the sacrum b) Pant-blow (breaths and puffs) breathing techniques c) Effleurage d) Biofeedback

A (Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.)

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use: a. Counterpressure against the sacrum. b. Pant-blow (breaths and puffs) breathing techniques. c. Effleurage. d. Conscious relaxation or guided imagery.

C (Rationale: Encouraging the woman to empty her bladder will not help the hypotensive state and may cause her to faint if she ambulates to the bathroom. The IV rate should be kept at the current rate or increased to maintain the appropriate perfusion. Turning the woman to her left side is the best action to take in this situation since this will increase placental perfusion to the infant while waiting for the doctor's or nurse midwife's instruction. Hypotension indicated by a 20% drop from preblock level is an emergency situation and action must be taken.)

A woman is in the second stage of labor and has a spinal block in place for pain management. The nurse obtains the woman's blood pressure and notes that it is 20% lower than the baseline level. Which action should the nurse take? A) Encourage her to empty her bladder. B) Decrease her intravenous (IV) rate to a keep vein-open rate. C) Turn the woman to the left lateral position or place a pillow under her hip. D) No action is necessary since a decrease in the woman's blood pressure is expected.

C (Pain and tenderness in the extremities, which show warmth, redness, and hardness, is likely thrombophlebitis. A Doppler ultrasound is a common noninvasive way to confirm diagnosis.)

A woman who has recently given birth complains of pain and tenderness in her leg. Upon physical examination, the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect _____ and should confirm the diagnosis by _____. A. Disseminated intravascular coagulation; asking for laboratory tests B. von Willebrand disease; noting whether bleeding times have been extended C. Thrombophlebitis; using real time and color Doppler ultrasound D. Coagulopathies; drawing blood for laboratory analysis

A (Rationale: Sudden dyspnea, diaphoresis and confusion are the classic signs of the dislodgment of a thrombus (stationary blood clot) from a varicose vein and its travel to and its becoming enlodged in the pulmonary circulation. Chills and fever would indicate infection. A person with a pulmonary embolism would be hypotensive and not hypertensive.)

A woman with a past history of varicose veins has just delivered and the nurse suspects she has developed a pulmonary embolism. Which of the data below would lead to this nursing judgment? A. Sudden dyspnea and confusion B. Hypertension C. Chills and fever D. Leg pain

A (Wear a snug, supportive bra)

The breasts of a bottle-feeding woman are engorged. The nurse should instruct her to A) Wear a snug, supportive bra B) Allow warm water to soothe the breasts during a shower C) Express milk from breasts occasionally to relieve discomfort D) Place absorbent pads with plastic liners into her bra to absorb leakage

B (Referred)

After change of shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a) Visceral b) Referred c) Somatic d) Afterpain

B (Rationale: *Visceral pain* is that which predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. As labor progresses the woman often experiences *referred pain*. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. *Somatic pain* is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.)

After change of shift report, the nurse assumes care of a multiparous patient in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: A) visceral. B) referred. C) somatic. D) afterpain.

B (As labor progresses the woman often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates in the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.)

After change-of-shift report the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Visceral. b. Referred. c. Somatic. d. Afterpain.

B, D, E (Rationale: The nurse should suspect the patient is suffering from a postdural puncture headache (PDPH). Characteristically, assuming an upright position triggers or intensifies the headache, whereas assuming a supine position achieves relief (Hawkins and Bucklin, 2012). Conservative management for a PDPH includes administration of oral analgesics and methylxanthines (e.g., caffeine or theophylline). Methylxanthines cause constriction of cerebral blood vessels and may provide symptomatic relief. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for PDPH. Close monitoring of vital signs is essential.)

After delivering a healthy baby boy with epidural anesthesia, a woman on the postpartum unit complains of a severe headache. The nurse should anticipate which actions in the patient's plan of care? (Select all that apply.) A) Keeping the head of bed elevated at all times B) Administration of oral analgesics C) Avoid caffeine D) Assisting with a blood patch procedure E) Frequent monitoring of vital signs

D (Breastfeeding immediately after childbirth increases the release of the oxytocin hormone, which decreases blood loss and reduces the risk of postpartum hemorrhage. Therefore the nurse instructs the patient to immediately start breastfeeding. Oxytocin does not have any effect on hemorrhoids; therefore it does not help reduce the risk of hemorrhoids. Breastfeeding may not affect endometritis. Breastfeeding prevents infection in the child, but it does not prevent infection in the mother.)

After the delivery of a baby, the nurse instructs the patient to immediately start breastfeeding. Which complication is the nurse trying to prevent by giving this instruction? A. Hemorrhoids B. Endometritis C. Maternal infection D. Postpartum hemorrhage

D (Each woman's pain during childbirth is unique and is influenced by a variety of physiologic, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the woman during labor and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the laboring woman. This client clearly needs support.)

An 18-year-old pregnant woman, gravida 1, is admitted to the labor and birth unit with moderate contractions every 5 minutes that last 40 seconds. The woman states, "My contractions are so strong that I don't know what to do with myself." The nurse should: a. Assess for fetal well-being. b. Encourage the woman to lie on her side. c. Disturb the woman as little as possible. d. Recognize that pain is personalized for each individual.

A (Little if any change)

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding is: a) Little if any change b) Leakage of milk at let-down c) Swollen, warm and tender on palpation d) A few blisters and a bruise on each areola

B (Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination.)

As relates to rubella and Rh issues, nurses should be aware that: a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b. Women should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

C (Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.)

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: A. Kidney function returns to normal a few days after birth. B. Diastasis recti abdominis is a common condition that alters the voiding reflex. C. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. D. With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

A (1 hour)

Baby-friendly hospitals mandate their infants be put to breast within the first _______ after birth. a) 1 hour b) 30 minutes c) 2 hours d) 4 hours

D (Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.)

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. Pouring water from a squeeze bottle over the woman's perineum. b. Placing oil of peppermint in a bedpan under the woman. c. Asking the physician to prescribe analgesics. d. Inserting a sterile catheter.

A (Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments.)

The perinatal nurse caring for the postpartum woman understands that late postpartum hemorrhage is most likely caused by: A. Subinvolution of the placental site B. Defective vascularity of the decidua C. Cervical lacerations D. Coagulation disorders

D (The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees.)

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports: A. "I contract my thighs, buttocks, and abdomen." B. "I do 10 of these exercises every day." C. "I stand while practicing this new exercise routine." D. "I pretend that I am trying to stop the flow of urine midstream."

C (Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage.)

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. Von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postdelivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is: A. Cryoprecipitate B. Factor VIII and vWf C. Desmopressin D. Hemabate

A (Discharge planning, the teaching of maternal and newborn care, begins on the woman's admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.)

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a. At the time of admission to the nurse's unit. b. When the infant is presented to the mother at birth. c. During the first visit with the physician in the unit. d. When the take-home information packet is given to the couple.

C (When a spinal anesthetic is given, the need for episiotomy, forceps-assisted birth, or vacuum-assisted birth tends to increase because voluntary expulsive efforts are reduced or eliminated. Maternal consciousness is maintained. Fetal hypoxia is absent as maternal blood pressure is maintained within a normal range. There is no muscular tension; excellent muscular relaxation is achieved.)

During a prenatal assessment a patient asks the nurse about the disadvantages of spinal anesthesia. What does the nurse teach the patient about the potential effect of spinal anesthesia? A. It reduces maternal consciousness. B. It increases maternal muscular tension. C. It increases probability of operative birth. D. It increases the possibility of fetal hypoxia.

C (A parent that is grieving over a recent loss (in the process of detachment) will have the most difficulty bonding with the new baby. Knowledge of parent-infant attachment or being an only child are not related to successful bonding. A job loss does not have the impact that death of a family member does.)

During the early postpartum period, the nurse is evaluating a client's attachment to her neonate. Which type of parent has the most difficulty attaching to her newborn? A. One who has little knowledge of parent-infant attachment B. One who recently lost a job C. One whose father recently died D. One who is an only child

C (The patient makes choices about the nonpharmacologic pain management methods that are best suited. This provides the patient with a sense of control over childbirth. These measures are relatively simple and inexpensive. They do not require intensive training. However, the patient may obtain best results from the practice. It can be used throughout labor.)

During the prenatal assessment of a patient, the nurse teaches the patient about nonpharmacologic pain management. What does the nurse tell the patient about this method? A. It is technical and expensive. B. It requires intensive training. C. It provides the patient with a sense of control. D. It is used only in stage I of labor.

C (The nurse must watch for symptoms of hyperventilation and resulting respiratory alkalosis. Symptoms of respiratory alkalosis during pattern-paced breathing include dizziness, light-headedness, tingling of fingers, or circumoral numbness. Pallor, nausea, and diaphoresis are generally observed in the active and transition phases of the first stage of labor. They are physiologic effects of pain.)

During the second phase of labor the patient initiates pattern-paced breathing. What adverse symptoms must the nurse watch for when the patient initiates this method? A. Pallor B. Nausea C. Dizziness D. Diaphoresis

C (Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.)

Excessive blood loss after childbirth can have several causes; however, the most common is: A. Vaginal or vulvar hematomas. B. Unrepaired lacerations of the vagina or cervix. C. Failure of the uterine muscle to contract firmly. D. Retained placental fragments.

C (Failure of the uterine muscle to contract firmly)

Excessive blood loss after childbirth can have several causes; however, the most common is: a) Vaginal or vulvar hematomas b) Unrepaired lacerations of the vagina or cervix c) Failure of the uterine muscle to contract firmly d) Retained placental fragments

C (Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.)

Excessive blood loss after childbirth can have several causes; the most common is: a. Vaginal or vulvar hematomas. b. Unrepaired lacerations of the vagina or cervix. c. Failure of the uterine muscle to contract firmly. d. Retained placental fragments.

C (Blue cohosh)

Herbal remedies have been used with some success to control PPH after initial management. Some herbs have homeostatic actions, whereas others work as oxytocic agents to contract the uterus. ________________ is a commonly used oxytocic herbal remedy. a) Witch hazel b) Lady's mantel c) Blue cohosh d) Yarrow

C (Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans' sign (calf muscle pain or warmth, redness, or tenderness) requires the physician's immediate attention.)

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid? a. Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b. Having the patient flex, extend, and rotate her feet, ankles, and legs. c. Having the patient sit in a chair. d. Notifying the physician immediately if a positive Homans' sign occurs.

B (The woman should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect.)

If an opioid antagonist is administered to a laboring woman, she should be told that: a. Her pain will decrease. b. Her pain will return. c. She will feel less anxious. d. She will no longer feel the urge to push.

D (D&C allows examination of the uterine contents and removal of any retained placenta or membranes.)

If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition? a. Hysterectomy b. Laparoscopy c. Laparotomy d. D&C

B (An abnormal odor of the lochia indicates infection in the uterus.)

If the nurse suspects a uterine infection in the postpartum client, she should assess the: a. pulse and blood pressure. b. odor of the lochia. c. episiotomy site. d. abdomen for distention.

C (During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.)

If the patient's white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should: A. Tell the physician immediately. B. Have the laboratory draw blood for reanalysis. C. Recognize that this is an acceptable range at this point postpartum. D. Begin antibiotic therapy immediately.

A (The VAS is a means of adding the woman's assessment of her pain to the nurse's observations. Drowsiness is a side effect of medications, not usually (sedatives aside) a sign of effectiveness. The fist clenching likely is a sign of apprehension that may need attention. Skin turgor, along with the moistness of the membranes and the concentration of the urine, is a sign that helps the nurse evaluate hydration.)

In assessing a woman for pain and discomfort management during labor, a nurse most likely would: a. Have the woman use a visual analog scale (VAS) to determine her level of pain. b. Note drowsiness as a sign that the medications were working. c. Interpret a woman's fist clenching as an indication that she is angry at her male partner and the physician. d. Evaluate the woman's skin turgor to see whether she needs a gentle oil massage.

A (The diagnosis of DIC is made according to clinical findings and laboratory markers. Physical examination reveals unusual bleeding. Petechiae may appear around a blood pressure cuff on the woman's arm. Excessive bleeding may occur from the site of a slight trauma, such as venipuncture sites.)

In caring for an immediate postpartum client, you note petechiae and oozing from her IV site. You would monitor her closely for the clotting disorder: A. Disseminated intravascular coagulation B. Amniotic fluid embolism C. Hemorrhage D. HELLP syndrome

A (Primary medical management in all cases of DIC involves correction of the underlying cause, volume replacement, blood component therapy, optimization of oxygenation and perfusion status, and continued reassessment of laboratory parameters.)

In caring for the woman with disseminated intravascular coagulation (DIC), what order should the nurse anticipate? A. Administration of blood B. Preparation of the client for invasive hemodynamic monitoring C. Restriction of intravascular fluids D. Administration of steroids

A (Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers.)

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. Is inconsistent with the Baby Friendly Hospital Initiative. b. Promotes longer periods of breastfeeding. c. Is perceived as supportive to both bottle-feeding and breastfeeding mothers. d. Is associated with earlier cessation of breastfeeding.

D (Encouraging expectant parents to attend childbirth preparation class is most important because preparation increases a woman's confidence and thus her ability to cope with labor and birth. Although still popular, the "method" format of classes is being replaced with other offerings such as Hypnobirthing and Birthing from Within.)

In the current practice of childbirth preparation, emphasis is placed on: a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Having expectant parents attend childbirth preparation in any or no specific method.

A (A full bladder displaces the uterus and prevents contraction of the uterus and uterine atony is the primary cause of postpartum hemorrhage. Shock, infection and DIC are not related to bladder distention)

In the fourth stage of labor, a full bladder increases the risk for A. Hemorrhage B. Dissesminated intravascular coagulation C. Infection D. Shock

A (If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.)

In the recovery room, if a woman is asked either to raise her legs off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she: a. Has recovered from epidural or spinal anesthesia. b. Has hidden bleeding underneath her. c. Has regained some flexibility. d. Is a candidate to go home after 6 hours.

B (Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman's alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace.)

It is important for the nurse to develop a realistic birth plan with the pregnant woman in her care. The nurse can explain that a major advantage of nonpharmacologic pain management is: a. Greater and more complete pain relief is possible. b. No side effects or risks to the fetus are involved. c. The woman remains fully alert at all times. d. A more rapid labor is likely.

D (Placenta abruptio is premature separation of the placenta as opposed to partial or complete adherence. This occurs between the 20th week of gestation and delivery in the area of the decidua basilis. Symptoms include localized pain and bleeding.)

It is important for the perinatal nurse to be knowledgeable regarding conditions of abnormal adherence of the placenta. This occurs when the zygote implants in an area of defective endometrium and results in little to no zone separation between the placenta and decidua. Which classification of separation is not recognized as an abnormal adherence pattern? A. Placenta accreta B. Placenta increta C. Placenta percreta D. Placenta abruptio

A (Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples.)

Knowing that the condition of the new mother's breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except: A. Breast tenderness is likely to persist for about a week after the start of lactation. B. As lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day. C. In nonlactating mothers colostrum is present for the first few days after childbirth. D. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

B, C, D (Nursing interventions for maternal hypotension arising from analgesia or anesthesia include turning the woman to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the woman's legs, notifying the physician, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until these are stable. Placing the client in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure.)

Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure (Select all that apply)? a. Place the woman in a supine position. b. Place the woman in a lateral position. c. Increase intravenous (IV) fluids. d. Administer oxygen. e. Perform a vaginal examination.

D (Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Women can stay in a bath as long as they want, although repeated baths with breaks may be more effective than a long soak. Counterpressure can help the woman cope with lower back pain.)

Maternity nurses often have to answer questions about the many, sometimes unusual ways people have tried to make the birthing experience more comfortable. For instance, nurses should be aware that: a. Music supplied by the support person has to be discouraged because it could disturb others or upset the hospital routine. b. Women in labor can benefit from sitting in a bathtub, but they must limit immersion to no longer than 15 minutes at a time. c. Effleurage is permissible, but counterpressure is almost always counterproductive. d. Electrodes attached to either side of the spine to provide high-intensity electrical impulses facilitate the release of endorphins.

D (Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH.)

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage. For instance: A. PPH is easy to recognize early; after all, the woman is bleeding. B. Traditionally, it takes more than 1000 ml of blood after vaginal birth and 2500 ml after cesarean birth to define the condition as PPH. C. If anything, nurses and doctors tend to overestimate the amount of blood loss. D. Traditionally, PPH has been classified as early or late with respect to birth.

A, D, E (Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in arms between the mother's room and the nursery, but rather is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photos of their new baby on the Internet and other public forums.)

Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? Select All That Apply a. The mother should check the photo ID of any person who comes to her room. b. The baby should be carried in the parent's arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the patient's room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person.

A (Rationale: Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.)

Nurses should be aware of the difference experience can make in labor pain, such as: A) sensory pain for nulliparous women often is greater than for multiparous women during early labor. B) affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C) women with a history of substance abuse experience more pain during labor. D) multiparous women have more fatigue from labor and therefore experience more pain.

D (The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician would be notified after the nurse completes the assessment of the woman.)

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a. Begin an intravenous (IV) infusion of Ringer's lactate solution. b. Assess the woman's vital signs. c. Call the woman's primary health care provider. d. Massage the woman's fundus.

A (Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue. Test-Taking Tip: Be alert for grammatical inconsistencies. If the response is intended to complete the stem (an incomplete sentence) but makes no grammatical sense to you, it might be a distractor rather than the correct response. Question writers typically try to eliminate these inconsistencies.)

Nurses should be aware of the difference experience can make in labor pain, such as: A. sensory pain for nulliparous women often is greater than for multiparous women during early labor. B. affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. C. women with a history of substance abuse experience more pain during labor. D. multiparous women have more fatigue from labor and therefore experience more pain.

A (Sensory pain for nulliparous women often is greater than for multiparous women during early labor.)

Nurses should be aware of the difference experience can make in labor pain, such as: a) Sensory pain for nulliparous women often is greater than for multiparous women during early labor b) Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor c) Women with a history of substance abuse experience more pain during labor d) Multiparous women have more fatigue from labor and therefore experience more pain

A (Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.)

Nurses should be aware of the differences experience can make in labor pain such as: a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

B (The leading cause of PPH is uterine atony, which complicates one in 20 births. The uterus is overstretched and contracts poorly after the birth.)

Nurses should first look for the most common cause of PPH, _____, by _____. A. Lacerations of the genital tract; checking for the source of blood B. Uterine atony; evaluating the contractility of the uterus C. Inversion of the uterus; feeling for a smooth mass through the dilated cervix D. Retained placenta; noting the type of bleeding

C (Hispanic women may be stoic early and more vocal and ready for medications later. Chinese women may not show reactions to pain. Medical interventions must be offered more than once. Arab or Middle Eastern women may be vocal in response to labor pain from the start. They may prefer pain medications. African-American women may express pain openly; use of medications for pain is more likely to vary with the individual.)

Nurses with an understanding of cultural differences regarding likely reactions to pain may be better able to help clients. Nurses should know that _____ women may be stoic until late in labor, when they may become vocal and request pain relief. a. Chinese b. Arab or Middle Eastern c. Hispanic d. African-American

D (Many professionals believe that the nurse's nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. "Mothering the mother" is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.)

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. Formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby.") b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there.") c. Including other family members in the teaching of self-care and child care. ("We're all in this together.") d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

A (According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord and thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the woman's position, giving prescribed medication, and encouraging rest do not reduce or block the capacity of nerve pathways to transmit pain using the gate-control theory.)

Nursing care measures are commonly offered to women in labor. Which nursing measure reflects application of the gate-control theory? a. Massaging the woman's back b. Changing the woman's position c. Giving the prescribed medication d. Encouraging the woman to rest between contractions

C (Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products.)

Nursing measures that help prevent postpartum urinary tract infection include: a. promoting bed rest for 12 hours after delivery. b. discouraging voiding until the sensation of a full bladder is present. c. forcing fluids to at least 3000 mL/day. d. encouraging the intake of orange, grapefruit, or apple juice.

D (Massage the woman's fundus)

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a) Begin an IV infusion of Ringer's lactate solution b) Assess the woman's vital signs c) Call the woman's primary health care provider d) Massage the woman's fundus

D (Postpartum or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on 2 successive days of the first 10 postpartum days, starting 24 hours after birth.)

One of the first symptoms of puerperal infection to assess for in the postpartum woman is: A. Fatigue continuing for longer than 1 week B. Pain with voiding C. Profuse vaginal bleeding with ambulation D. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth

D (The peribottle should be used in a backward direction over the perineum . The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash is appropriate. Washing from the symphysis pubis back to the episiotomy is appropriate. Changing the perineal pad every 2 to 3 hours is appropriate.)

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse recognizes the need for additional instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from the symphysis pubis back to the episiotomy. C. Changes her perineal pad every 2 to 3 hours. D. Uses the peribottle to rinse upward into her vagina.

D (Uses the peribottle to rinse upward into her vagina)

Perineal care is an important infection control measure. When evaluation a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a) Uses soap and warm water to wash the vulva and perineum b) Washes from symphysis pubis back to the episiotomy c) Changes her perineal pad every 2 to 3 hours d) Uses the peribottle to rinse upward into her vagina

D (An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births and usually increases with ambulation and breastfeeding.)

Postbirth uterine/vaginal discharge, called lochia: A. Is similar to a light menstrual period for the first 6 to 12 hours. B. Is usually greater after cesarean births. C. Will usually decrease with ambulation and breastfeeding. D. Should smell like normal menstrual flow unless an infection is present.

d (Should smell like normal menstrual flow unless an infection is present)

Postbirth uterine/vaginal discharge, called lochia: a) Is similar to a light menstrual period for the first 6 to 12 hours b) Is usually greater after cesarean births c) Will usually decrease with ambulation and breastfeeding d) Should smell like normal menstrual flow unless an infection is present

C (Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.)

Postpartal overdistention of the bladder and urinary retention can lead to which complications? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture

A (An Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.)

Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh?2-, baby Rh+ c. Mother Rh+, baby Rh+ b. Mother Rh?2-, baby Rh?2- d. Mother Rh+, baby Rh?2-

A, C, E (The woman experiencing maternal opioid withdrawal syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly.)

The class of drugs known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to women with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include (Select all that apply): a. Yawning, runny nose. b. Increase in appetite. c. Chills and hot flashes. d. Constipation. e. Irritability, restlessness.

B (Rho(D) immune globulin (RhoGam) is given to the Rho(D)-negative mother, within 72 hours after delivery of an Rho(D)-positive baby (if the Coombs is negative). RhoGam is never given to the baby.)

The client has just given birth to a healthy, full-term infant. The client is Rho(D) negative and her baby is Rho(D) positive. Which intervention will take place to reduce the possibility of isoimmunization? A. Administering Rho(D) immune globulin to the baby, IM, within 72 hours B. Administering Rho(D) immune globulin to the mother, IM, within 72 hours C. Administering Rho(D) immune globulin to the mother, IM, at her 6-week visit D. Administering Rho(D) immune globulin to the mother, IM, within 3 months

B (Lochia and infectious material are eliminated by gravity drainage.)

The client who is being treated for endometritis is placed in Fowler's position because it: a. promotes comfort and rest. b. facilitates drainage of lochia. c. prevents spread of infection to the urinary tract. d. decreases tension on the reproductive organs.

D (Rationale: A woman that develops postpartum psychosis usually does so within four weeks of delivery. Only 1% of women develop this disorder. Suicide and infanticide are common and the disorder is considered a medical emergency. Delusions and hallucinations accompany the disorder and the woman usually has a past history of a psychiatric disorder and treatment.)

The clinic nurse is caring for a woman who is suspected of developing postpartum psychosis. Which of the following statements characterizes this disorder: A. Symptoms start within several days of delivery B. The disorder is common in postpartum women C. Suicide and infanticide are uncommon in this disorder D. Delusions and hallucinations accompany this disorder

C (The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.)

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to: A. Call the woman's primary health care provider B. Administer the standing order for an oxytocic C. Palpate the uterus and massage it if it is boggy D. Assess maternal blood pressure and pulse for signs of hypovolemic shock

D (The puerperium, also called the fourth trimester or the postpartum period of pregnancy, lasts about 3 to 6 weeks. Involution marks the end of the puerperium, or the fourth trimester of pregnancy. Lochia refers to the various vaginal discharges during the puerperium, or fourth trimester of pregnancy.)

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the: A. Involutionary period because of what happens to the uterus. B. Lochia period because of the nature of the vaginal discharge. C. Mini-tri period because it lasts only 3 to 6 weeks. D. Puerperium, or fourth trimester of pregnancy.

A (This client's rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.)

The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d. A Kleihauer-Betke test should be performed.

C (Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman engage in another activity.)

The laboring woman who imagines her body opening to let the baby out is using a mental technique called: a. Dissociation. b. Effleurage. c. Imagery. d. Distraction.

C (Strict adherence by all health care personnel to aseptic techniques during childbirth and the postpartum period is very important and the least expensive measure to prevent infection.)

The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? A. Large doses of vitamin C during pregnancy B. Prophylactic antibiotics C. Strict aseptic technique, including handwashing, by all health care personnel D. Limited protein and fat intake

C (Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation.)

The mother-baby nurse must be able to recognize what sign of thrombophlebitis? a. Visible varicose veins b. Positive Homans' sign c. Local tenderness, heat, and swelling d. Pedal edema in the affected leg

B (A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.)

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called: a. An epidural. b. A pudendal. c. A local. d. A spinal block.

A, D, E (The nurse must ensure that the consent form has the correct date. The nurse must ensure that the patient has not been compelled to consent for the procedure. The form must carry the signature of the anesthetic care provider, certifying that the patient has received and expresses understanding of the explanation. The consent form must be written or explained in the patient's primary language. The nurse need not obtain a family member's signature on the document. The patient's signature is important.)

The nurse acts as an advocate for the patient during an informed consent. What care must the nurse take while obtaining an informed consent? Select all that apply. A. Check for the patient's signature. B. Ensure that the consent is in English. C. Obtain a family member's signature. D. Check for the date on the consent form. E. Check the anesthetic care provider's signature.

D (A firm, muscular wall with less adipose tissue would ensure that the patient is able to regain the prepregnancy abdominal tone after delivery. Thus the nurse should advise the patient to do static abdominal exercises during pregnancy. The abdominal tone is not a factor based on which the nurse can determine whether the patient would have a normal vaginal delivery. Patients with weak abdominal muscles, especially those who have multifetal gestation or a large fetus, are at the risk of having diastasis recti abdominis. These abdominal striations usually do not fade away completely. Although the abdominal skin retains its tone, some striae always remain.)

The nurse advises a pregnant patient to do static abdominal exercises. How would these exercises benefit the patient? A. They will lead to a normal vaginal childbirth. B. The patient will have diastasis recti abdominis. C. The patient will not have any abdominal striations. D. They will help the patient to gain proper abdominal tone after delivery.

A (During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia may indicate that large clots are blocking the flow. Thirst, fatigue and a temperature up to 100.4oF (38oC) are normal within the first 24 hours. Immediately after delivery, vasomotor changes may cause a shaking chill.)

The nurse assesses a client who delivered 24 hours ago. Which of the following suggests the need for further assessment? A. Scant lochia rubra B. Chills C. Thirst and fatigue D. A temperature of 100.2oF (37.9oC)

C (Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.)

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation? A. Administer prostaglandins. B. Administer oxytocin. C. Document the findings and continuing to monitor. D. Massage the fundus every 15 minutes.

D (Retained placental fragments or infection cause subinvolution of the uterus. Therefore the nurse should assess the patient for any placental fragments in the uterus. Estrogen and progesterone stimulate massive growth of the uterus during pregnancy. In the postpartum stage, the hormone levels are reduced and, therefore, do not affect involution of the uterus. Platelet aggregation causes uterine muscle contraction, but it does not result in involution of the uterus.)

The nurse assesses a postpartum patient several hours after delivery and suspects that the uterus is subinvoluted. What could be a potential etiology for this finding? A. Estrogen levels B. Progesterone levels C. Impaired platelet aggregation D. Retained placental fragments

A (A nulliparous woman has prominent rugae in introitus along with erythema and edema. Nulliparous women may have mild uterine cramping resulting in fewer or less severe afterpains compared to multiparous woman. Single gestation may cause mild afterpains, but it does not cause prominence of rugae or erythema or edema in the introitus. A multiparous woman usually has more afterpains compared with a nulliparous woman. Rugae are also seen in a multiparous woman, but the rugae are less prominent and flattened. Multiple gestation usually causes severe afterpains.)

The nurse assessing a patient finds prominent rugae erythema and edema in the vaginal introitus. The patient reports having mild afterpains. What does the nurse interpret about the patient's clinical A. Nulliparous B. Multiparous C. Single gestation D. Multiple gestation

D (Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue.)

The nurse caring for the postpartum woman understands that breast engorgement is caused by: A. Overproduction of colostrum. B. Accumulation of milk in the lactiferous ducts. C. Hyperplasia of mammary tissue. D. Congestion of veins and lymphatics.

D (Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.)

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a. Overproduction of colostrum. b. Accumulation of milk in the lactiferous ducts and glands. c. Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

B (A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.)

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: A. Place her on a bedpan to empty her bladder. B. Massage her fundus. C. Call the physician. D. Administer Methergine, 0.2 mg IM, which has been ordered prn.

B (Massage her fundus)

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: a) Place her on a bedpan to empty her bladder b) Massage her fundus c) Call the physician d) Administer methylergonovine (Methergine), 0.2mg IM, which has been ordered prn

B (A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient.)

The nurse finds that a postpartum patient's perineal pad is soaked after 15 minutes. What should the nurse infer from the finding? A. Normal finding after childbirth B. Sign of excessive hemorrhage C. Presence of lochial discharge D. Sign of postpartum hypotension

D (Fibrinogen is normally increased during pregnancy and remains elevated in the immediate puerperium. Fibrinogen may lead to thromboembolism due to immobility. Therefore the nurse instructs the patient to exercise the lower limbs frequently to prevent the risk of thromboembolism. Hemorrhoids occur as a result of the pressure from the fetus on the abdomen, hormonal changes, and increased intraabdominal pressures during pregnancy. Exercise of the lower limbs is not helpful in reducing the risk of hemorrhoids. Lower-limb exercise does not reduce the risk of endometritis either, because it is associated with uterine discharge. Lower-limb exercises do not produce any effect on uterine discharge. Estrogen deficiency is responsible for a decreased amount of vaginal lubrication, and it leads to dyspareunia. Exercise of the lower limbs is not increase estrogen.)

The nurse instructs the pregnant patient to exercise her lower limbs frequently. What clinical condition is the nurse trying to prevent? A. Hemorrhoids B. Endometritis C. Dyspareunia D. Thromboembolism

B (If the area of saturated pad is less than 2.5 cm, it indicates that the patient had scanty bleeding. If it is less than 10 cm, then the patient had light bleeding. If the pad is saturated within 2 hours, the patient had heavy bleeding. If it is 10 cm or more, the patient had moderate bleeding.)

The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5 cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding? A. Light bleeding B. Scanty bleeding C. Heavy bleeding D. Moderate bleeding

B (During the first phase of labor, as contractions increase in frequency and intensity, the patient must change breathing patterns to a modified-paced breathing technique. This breathing pattern is shallower and faster than the patient's normal rate of breathing, but should not exceed twice the resting respiratory rate. Slow-paced breathing is performed at approximately half the normal breathing rate and is initiated when the patient can no longer walk or talk through contractions. Patterned-paced breathing is suggested in the second phase of labor. It consists of panting breaths combined with soft blowing breaths at regular intervals. The patterns may vary, the 3:1 pattern is pant, pant, pant, blow and the 4:1 pattern is pant, pant, pant, pant, and blow.)

The nurse is assisting a patient in labor. What breathing pattern must the nurse remind the patient to use when the contractions increase in frequency and intensity in the first phase of labor? A. Slow-paced breathing B. Modified-paced breathing C. 3:1 pattern-paced breathing D. 4:1 pattern-paced breathing

B (The patient must remember that all breathing patterns begin with a deep, relaxing "cleansing breath" to "greet the contraction." The patient must then exhale a deep breath to "blow the contraction away." These deep breaths ensure adequate oxygen for the mother and the baby and signal that a contraction is beginning or has ended. The patient must take three to four breaths per minute when performing slow-paced breathing. As contractions increase in frequency and intensity, the patient takes shallow, fast breaths, about 32 to 40 per minute.)

The nurse is assisting a patient who is prepared to use the paced breathing method. What does the nurse remind the patient to do at the beginning of the breathing pattern? A. Exhale a deep breath. B. Take a deep relaxing breath. C. Take 32 breaths per minute. D. Take three breaths per minute.

C (To reduce breast irritation, the nurse advises the patient to wear breast shells. This will increase comfort during breastfeeding. Application of ice packs between feedings reduces breast engorgement. Hydrogel pads can be applied if the patient has sore nipples between feedings. Cold cabbage leaves applied to the breasts for 15 to 20 minutes between feedings can reduce breast engorgement by reducing tissue swelling and facilitating the flow of milk.)

The nurse is caring for a 2-day postpartum patient who is breastfeeding. The patient reports breast irritation. Which intervention would be beneficial to the patient? A. Apply ice packs to the breasts between feedings. B. Place hydrogel pads to the breasts between feedings. C. Tell the patient to wear breast shells. D. Apply cold cabbage leaves to the breasts between the feedings.

C (A patient who complains of abdominal discomfort and gas pains should be encouraged to use a rocking chair because it stimulates the passage of flatus and relieves discomfort. The patient should not be encouraged to drink coffee because the caffeine present in it intensifies the pain by increasing bowel movements. Analgesic medication does not relieve gas, but the administration of antigas or antiflatulent medications may help relieve gas. Offering soups and beverages may cause more discomfort and gas in the patient.)

The nurse is caring for a 24-hour-postpartum patient who had a cesarean birth with general anesthesia. The patient complains of abdominal discomfort and gas pains. What would be the most suitable nursing intervention in this situation? A. Encourage the patient to drink coffee. B. Administer analgesic medications to patient. C. Encourage the patient to use a rocking chair. D. Offer soups and beverages to the patient

D (To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn)

The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding? A. Hand the father the newborn and instruct him to change the diaper. B. Ask the father why he is so anxious and nervous. C. Tell the father that he will get used to the newborn in time. D. Provide education about newborn care when the father is present.

A, B, D (Engorgement in a breastfeeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Taking warm showers can increase milk flow. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. Cold cabbage leaves work well to reduce pain and swelling and should be applied every 4 hours. Binding the breasts is not appropriate because it decreases the milk supply. To ease the discomfort associated with sore nipples, the mother may apply topical preparations such as purified lanolin or hydrogel pads.)

The nurse is caring for a lactating patient with a body temperature of 102° F (38.9° C). The nurse finds that the patient's breasts are engorged, swollen, hard, and red. Which interventions related to patient care would be helpful in managing breast engorgement? Select all that apply. A. Taking warm showers before breastfeeding B. Nursing the baby frequently C. Using a tight supportive bra or a breast binder D. Applying cold cabbage leaves to the breasts E. Avoiding use of lanolin or hydrogel pads

C (Parity influences the perception of labor pain. The nulliparous patient often has longer labor and therefore, greater fatigue. Sensory pain for nulliparous women is often greater than that for multiparous women during early labor, because their reproductive tract structures are less supple. Affective pain in the nulliparous patient is greater in the first stage as compared to a multiparous patient. It decreases for both patients during the second stage of labor. During the second stage of labor, the multiparous patient may experience greater sensory pain than the nulliparous patient. This is because tissues of the multiparous patient are more supple and increase the speed of fetal descent, thereby intensifying the pain. Test-Taking Tip: Answer every question because, on the NCLEX exam, you must answer a question before you can move on to the next question.)

The nurse is caring for a nulliparous patient in labor. How is the experience for a nulliparous patient different from that of a multiparous patient? The patient experiences: A. Less sensory pain during early labor. B. Greater sensory pain in the second stage of labor. C. Greater fatigue due to longer duration of labor. D. Greater affective pain in the second stage of labor.

D (Fear and excessive anxiety leads to increased muscle tension. It causes more catecholamine secretion. This increases the stimuli to the brain from the pelvis due to increased muscle tension and decreased blood flow. Thus fear and anxiety magnifies the perception of pain. Anxiety does not increase uterine contractions, but reduces the effectiveness of the contractions leading to increased discomfort. This slows the progress of labor. Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.)

The nurse is caring for a patient in the last trimester of pregnancy. What assessments will the patient display related to the effects of fear and anxiety during labor? An increase in: A. Blood flow. B. The progression of labor. C. Contractions. D. Muscle tension

A (Local perineal infiltration anesthesia may be used when an episiotomy is to be performed. It may also be used when lacerations must be sutured after birth in a patient who does not have regional anesthesia. Pudendal nerve block is administered late in the second stage of labor if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Low spinal anesthesia (block) may be used for cesarean birth.)

The nurse is caring for a patient who is administered local perineal infiltration anesthesia. In what situation does the nurse expect the use of local perineal infiltration anesthesia? When a(n): A. Episiotomy is required. B. Forceps birth is expected. C. Cesarean birth is expected. D. Vacuum extractor is to be used.

C (Fentanyl citrate (Sublimaze) is a potent short-acting opioid agonist analgesic. Therefore it provides quick pain relief. It rapidly crosses the placenta, so it is present in the fetal blood within 1 minute after intravenous maternal administration. It is a short-acting drug, so the patient will require more frequent dosing. It is often administered as a patient controlled analgesic. It has fewer neonatal effects as compared to meperidine, and causes less maternal sedation and nausea.)

The nurse is caring for a patient who is using fentanyl citrate (Sublimaze) through patient-controlled analgesia (PCA) while in labor. What effects of fentanyl citrate does the nurse expect? A. Provides long duration of action B. Requires only a single dose C. Provides quick relief to pain D. Causes sedation and nausea

A (Uterine atony is marked hypotonia of the uterus. It is the leading cause of postpartum hemorrhage.)

The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: A. Uterine atony B. Uterine inversion C. Vaginal hematoma D. Vaginal laceration

C (If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination.)

The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding? A. Risk of infection B. Evidence of severe pain C. Potential risk of hypovolemic shock D. Potential risk of impaired urinary elimination

B (Lochia serosa is a pink or brown fluid containing old blood, serum, leukocytes, and tissue debris. The lochia serosa starts 3 to 4 days after childbirth. Lochia alba is a yellow to white fluid containing leukocytes, serum, epithelial cells, bacteria, and decidua. It starts 10 days after childbirth in most women. In the case of a vaginal tear, the patient would have bright red bleeding for more than 2 hours after delivery. Lochia rubra, a bright red fluid containing small clots, starts from the end of the childbirth and disappears within 2 hours.)

The nurse is caring for a postpartum patient and finds that the patient has brown vaginal discharge. What is the cause of the discharge? A. Lochia alba B. Lochia serosa C. Lochia rubra D. Vaginal or cervical tear

D, E (Internal hemorrhoids can evert while the woman is pushing the baby during childbirth. The patient has internal hemorrhoids due to pregnancy. During pregnancy, pressure from the fetus on the abdomen, as well as hormonal changes, cause hemorrhoids to enlarge. Delivery also leads to increased intraabdominal pressures, which result in internal hemorrhoids. An itching sensation and bleeding upon defecation are the symptoms of internal hemorrhoids. Hemorrhoids usually decrease in size within 6 weeks of childbirth. Abdominal tenderness is a sign of endometritis. White or yellow uterine discharge is a normal finding after delivery.)

The nurse is caring for a postpartum patient and finds that the patient has internal hemorrhoids. Which clinical manifestations would be consistent with the nurse's findings? Select all that apply. A. Abdominal tenderness B. White uterine discharge C. Yellow uterine discharge D. Bleeding upon defecation E. Itching sensation in the anus

D (The psychosocial assessment includes evaluating adaptation to parenthood, as evidenced by the parents' reactions to the baby and interactions with the new baby. Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning baby comfortably, and maintaining eye-to-eye contact are appropriate behaviors that increase parent-infant attachment.)

The nurse is caring for a postpartum patient who gave birth recently. The nurse is evaluating the parent's behavior toward the new baby. Which parent-infant behaviors should the nurse investigate further? A. Change the baby's diapers when needed. B. Position the baby comfortably. C. Demonstrate eye-to-eye contact with the baby. D. Complete the child care activities silently, without looking at the baby.

C (Vaginal deliveries cause the pelvic muscles and ligaments to stretch and weaken. Kegel exercises help strengthen the pelvic floor muscles and thereby can prevent uterine complications, such as prolapse. The physical activity of climbing stairs may delay the process of healing from an episiotomy, so it is usually avoided. However, avoiding stairs does not prevent uterine prolapse. A diet high in protein is necessary to build muscle strength, but it cannot prevent uterine prolapse. Because the patient has already undergone delivery, sleeping in prone position does not cause any harm.)

The nurse is caring for a postpartum patient who had a normal vaginal delivery. The nurse tells the patient, "This will help you prevent uterine prolapse in later stages of life." Which instruction from the primary health care provider (PHP) is the nurse most likely explaining to the patient? A. "Avoid climbing of the stairs." B. "Maintain a high-protein diet." C. "Do Kegel exercises every day." D. "Avoid sleeping in the prone position."

C (Patients with episiotomy may have soreness and back pain. To relieve soreness and back pain, the nurse should advise the patient to place an ice pack on the affected area. This provides comfort and reduces the inflammation and pain. A sitz bath helps relieve lower back pain and discomfort, so the patient should be encouraged to use sitz baths at a temperature of 38° to 40° C (100° to 104° F) at least twice a day to prevent edema. Not cleaning the perineal area may cause infection, so the nurse should advise the patient to clean her perineum frequently. Drinking plenty of water and eating foods such as fresh fruit and vegetables that contain fibers can relieve constipation or hemorrhoids but does not help reduce soreness.)

The nurse is caring for a postpartum patient who has an episiotomy wound. The nurse finds that the patient has soreness at the incision site and lower back pain. What does the nurse tell the patient? A. Avoid using sitz baths. B. Avoid cleaning the perineal area frequently. C. Place a covered ice pack on the affected area. D. Drink plenty of water and eat foods containing fiber

D (Orthostatic hypotension develops as a result of splanchnic engorgement after birth, which causes dizziness immediately upon standing upright. Decreased blood pressure results from hypovolemia due to hemorrhage. Manifestations of endometritis include pain, fever, and abdominal tenderness, along with continued flow of lochia serosa or alba up to 3 to 4 weeks. Manifestations of hemorrhoids include itching, discomfort, and bright red bleeding upon defecation. Puerperal sepsis manifests by an increase in the maternal temperature up to 38° C (100.4° F) 24 hours after childbirth. This increased temperature persists or recurs for about 2 days.)

The nurse is caring for a postpartum patient who reports dizziness upon standing. What does the nurse believe to be the most likely cause for this occurrence? A. Endometritis B. Hemorrhoids C. Puerperal sepsis D. Orthostatic hypotension

C (Postpartum hemostasis is facilitated by uterine muscle contractions, which results in the compression of intramyometrial blood vessels. Hemostasis is influenced by the hormone oxytocin. The uterine contractions (UCs) decrease during the first 1 to 2 hours after delivery due to low levels of oxytocin. Therefore the nurse needs to administer exogenous oxytocin to the pregnant woman. Postpartum hemostasis does not take place by platelet aggregation or clot formation. Moreover, administering platelet aggregators may increase the risk of clot formation within the blood vessels. Estrogen and progesterone play a vital role in the development and maintenance of pregnancy, but they do not induce any uterine muscle contractions.)

The nurse is caring for a pregnant patient who just delivered a baby. The woman has continuous, heavy vaginal bleeding after the delivery. What should be the immediate medication intervention? A. Platelet aggregators B. Exogenous estrogen C. Exogenous oxytocin D. Exogenous progesterone

C (Estrogen and progesterone play a vital role in the development of the uterus during pregnancy. They are responsible for the growth of the uterus and may cause hypertrophy and hyperplasia of the uterine muscle cells. A decrease in estrogen and progesterone results in decreased growth of the uterus, which might even lead to miscarriage. Low estrogen and progesterone may not cause increased UCs. Moreover, the pituitary hormone oxytocin is primarily responsible for UCs during labor. Low levels of estrogen and progesterone lead to abnormally low growth of the uterus. Estrogen and progesterone also increase the blood circulation in the mother. Low levels of these hormones would decrease blood circulation.)

The nurse is caring for a pregnant woman who has low levels of estrogen and progesterone. What does the nurse expect may occur as a result of the low hormone levels? A. Massive growth of the uterus during pregnancy B. Increased uterine contractions (UCs) during labor C. Decreased growth of the uterus during pregnancy D. Increased blood circulation to the uterus during pregnancy

D (Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles.)

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises? A. To prevent urine retention B. To provide relief of lower back pain C. To tone the abdominal muscles D. To strengthen the perineal muscles

B (During the postpartum period, maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to increase the supply of blood. A body temperature of 100.4º F is a normal finding. A respiratory rate of 22 breaths/min indicates that the patient has no internal bleeding. A blood pressure of 120/80 mm Hg does not indicate that the patient has hemorrhage.)

The nurse is monitoring a postpartum patient for signs of hemorrhage. Which observation would indicate excessive blood loss? A. A body temperature of 100.4º F B. An increase in pulse from 88 to 102 beats/min C. An increase in respiratory rate from 18 to 22 breaths/min D. A blood pressure change from 130/88 to 120/80 mm Hg

C (Rubella vaccine is made from duck eggs; therefore women who are allergic to duck eggs can develop a hypersensitivity reaction to the vaccine. As a result, the patient might develop rashes on her skin. The PHP would prescribe adrenaline to combat hypersensitivity reactions. Oxytocin is injected to increase the tone of the uterine muscles but not to combat hypersensitivity. Rh immune globulin suppresses the immune system, which would worsen the condition; therefore this medication is unlikely to be prescribed. Magnesium sulfate is used for preeclampsia and is not used to minimize hypersensitivity reactions caused by rubella vaccine.)

The nurse is preparing to administer rubella vaccine to a patient during the postpartum period. At the follow-up visit, the patient reports to the nurse that she has rashes on her skin. What does the nurse expect the primary health care provider (PHP) to prescribe in this situation? A. Oxytocin (Pitocin) B. Rh immune globulin C. Adrenaline (Epinephrine) D. Magnesium sulfate

D (The patient must not become pregnant for 3 months after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.)

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient? A. "The vaccine is safe even if you have an egg allergy." B. "You cannot breastfeed for 5 days after taking the vaccine." C. "You will not have joint pains or skin rashes after the vaccination." D. "You should use proper contraception for 3 months after the vaccination."

B (In most cases, the patient can continue to breastfeed. If the affected breast is too sore, the patient can pump the breast gently. Regular emptying of the breast is important to prevent the formation of abscess. Use of a supportive bra suppresses milk production and prevents breast engorgement. Additional supportive measures include ice packs, breast supports, and analgesics. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours.)

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching? A. "I need to wear a supportive bra to relieve the discomfort." B. "I need to stop breastfeeding until this condition resolves." C. "I can use analgesics to alleviate some of the discomfort." D. "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

A, B, C (The central nervous system can be affected if a local anesthetic agent is injected accidentally into a blood vessel leading to local anesthetic toxicity . Signs include metallic taste, tinnitus, and slurred speech. Longer stage II labor and increased use of oxytocin are side effects of epidural and spinal anesthesia.)

The nurse is teaching a class on childbirth. What does the nurse teach about signs of local anesthetic toxicity? Select all that apply. A. Tinnitus B. Metallic taste C. Slurred speech D. Long stage II labor E. Increased use of oxytocin

A, D, E (Imagery and visualization are useful techniques in preparation for birth and are often used in combination with relaxation. Imagery involves techniques, such as breathing in light and energy, imagining a walk through a restful garden, or envisaging breathing out worries and tension. Relaxation or reduction of body tension is a technique that involves rhythmic motion that stimulates the mechanoreceptors of the brain. The nurse must recognize the signs of tension, such as clenching of fists when in pain by the laboring patient.)

The nurse is teaching a couple about the use of imagery and visualization in managing pain during labor. What is the patient expected to do during this technique? Select all that apply. A. Imagine breathing in light and energy. B. Maintain clenched fists to drive out pain. C. Engage in dance or rhythmic movements. D. Imagine walking through a restful garden. E. Envisage breathing out worries and tension.

A (The gate-control theory of pain explains the way pain relief techniques work to relieve the pain of labor. Distractions close down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. According to this theory only a limited number of sensations can travel through the sensory nerve pathways to the brain at one time. When the laboring patient engages in motor activity and neuromuscular activity, activity within the spinal cord itself further modifies the transmission of pain. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.)

The nurse is teaching pain relief techniques to a group of expectant patients. What does the nurse teach the patients about the gate-control theory of pain? A. Distractions block the nerve pathways. B. Neuromuscular activity can increase pain. C. All sensations travel together to the brain. D. Motor activity during labor intensifies pain

B (If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage.)

The nurse knows that a measure for preventing late postpartum hemorrhage is to: a. administer broad-spectrum antibiotics. b. inspect the placenta after delivery. c. manually remove the placenta. d. pull on the umbilical cord to hasten the delivery of the placenta.

A (An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase.)

The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is: a. Respiratory depression. b. Bradycardia. c. Acrocyanosis. d. Tachypnea.

B (The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the primary health care providers, who consult with the woman about their findings and recommendations. The needs of each woman are different, and many factors must be considered before a decision is made whether pharmacologic methods, nonpharmacologic methods, or a combination of the two will be used to manage labor pain.)

The nurse should be aware that an effective plan to achieve adequate pain relief without maternal risk is most effective if: a. The mother gives birth without any analgesic or anesthetic. b. The mother and family's priorities and preferences are incorporated into the plan. c. The primary health care provider decides the best pain relief for the mother and family. d. The nurse informs the family of all alternative methods of pain relief available in the hospital setting.

A, D, E (Pressure is usually applied with the heel of the hand, fist, or pads of the thumbs and fingers. Pressure is applied with contractions initially and then continuously as labor progresses to the transition phase at the end of the first stage of labor. Acupressure is said to promote the circulation of the blood, the harmony of yin and yang, and the secretion of neurotransmitters. Thus acupressure maintains normal body functions and enhances well-being. Acupressure is applied over the skin without using lubricants. In acupuncture, the flow of qi (energy) is restored.)

The nurse teaches acupressure methods for pain relief during labor to a couple in the prenatal clinic. What does the nurse teach about acupressure? Select all that apply. A. Blood circulation is enhanced. B. Flow of qi (energy) is restored. C. Lubricants are used over the area. D. Pressure is applied with the fingers. E. Pressure is applied with contractions.

A, C, D (Patterned breathing, controlled relaxation, and biofeedback techniques must be practiced to obtain best results. Patterned breathing and controlled relaxations help to manage pain during labor. Biofeedback is effective when the patient is able to focus and control body responses during labor. The nurse assisting the laboring patient can use methods such as massage and touch and slow-paced breathing successfully without the patient having any prior knowledge about it.)

The nurse teaches the patient nonpharmacologic pain management methods during a prenatal class. Which methods require practice for best results? Select all that apply. A. Biofeedback B. Massage and touch C. Patterned breathing D. Controlled relaxation E. Slow-paced breathing

A (If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. A dose of 400 mcg of intramuscular Rh immune globulin may result in an overdosage. A dose of 100 mcg or 200 mcg of intramuscular Rh immune globulin is not sufficient to prevent maternal sensitization.)

The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient? A. 300 mcg of intramuscular Rh immune globulin B. 400 mcg of intramuscular Rh immune globulin C. 100 mcg of intramuscular Rh immune globulin D. 200 mcg of intramuscular Rh immune globulin

D (Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.)

The obstetric nurse is preparing the patient for an emergency cesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is: a. Respiratory depression. b. Uterine relaxation. c. Inadequate muscle relaxation. d. Aspiration of stomach contents.

B (Almost all instances of acute mastitis can be avoided by proper breastfeeding technique to prevent cracked nipples.)

The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by: A. Washing the nipples and breasts with mild soap and water once a day B. Using proper breastfeeding techniques C. Wearing a nipple shield for the first few days of breastfeeding D. Wearing a supportive bra 24 hours a day

D (NOT: During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.)

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Excessive use of oxytocin is related to: a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours postpartum d. Hypertension e. Hypoventilation

B (NOT: During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.)

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Hypovolemia resulting from hemorrhage is related to: a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours postpartum d. Hypertension e. Hypoventilation

A (NOT: During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.)

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Dehydrating effects of labor is related to: a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours postpartum d. Hypertension e. Hypoventilation

E (NOT: During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.)

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Unusually high epidural or spinal block is related to: a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours postpartum d. Hypertension e. Hypoventilation

C (NOT: During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.)

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Puerperal sepsis is related to: a. Elevated temperature within the first 24 hours b. Rapid pulse c. Elevated temperature at 36 hours postpartum d. Hypertension e. Hypoventilation

B (Degradation of fibrin leads to the accumulation of fibrin split products in the blood.)

What laboratory marker is indicative of disseminated intravascular coagulation (DIC)? A. Bleeding time of 10 minutes B. Presence of fibrin split products C. Thrombocytopenia D. Hyperfibrinogenemia

B (The intensity of afterpains depends on the lactating status of the patient, the number of times a patient has been pregnant, and the type of gestation whether single or multiple. Breastfeeding stimulates uterine contractions (UCs), which increase afterpains. First-time mothers may have only mild uterine cramping, so nulliparous women may have mild afterpains compared with the multiparous women. An overdistended uterus caused by multiple gestation and polyhydramnios makes the afterpains more noticeable. Therefore a patient who is lactating, is multiparous, and had multiple gestation would have more afterpains. If a patient is lactating but is nulliparous and had single gestation, the intensity of afterpains would be less. A patient who is nonlactating, is nulliparous, and has oligohydramnios may have less afterpains. The patient who had multiple gestation but is nonlactating and nulliparous may have less intense afterpains.)

The postpartum patient reports to the nurse, "I am having intolerable pain after the delivery." Which conditions would cause the patient's afterpains? A. Lactating, nulliparous, single gestation B. Lactating, multiparous, multiple gestation C. Nonlactating, nulliparous, oligohydramnios D. Nonlactating, nulliparous, multiple gestation

D, E (After receiving the first dose of Varivax, the patient must take the second dose 4 to 8 weeks later. The patient must use contraception for 1 month after being vaccinated to avoid pregnancy because the vaccine has teratogenic effects. Mothers who receive the varicella vaccine can continue to breastfeed because the vaccine is not transmitted to the fetus through breast milk. Postpartum women usually have low immunity, so one dose is not sufficient. Stopping of all medications is not necessary and can endanger the patient.)

The primary health care provider (PHP) has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine? Select all that apply. A. "Stop breastfeeding after receiving the vaccine." B. "You need not return to the hospital because one dose is enough for you." C. "Stop taking all medications after returning home." D. "You must return for a second dose in 4 to 8 weeks." E. "Use contraception for 1 month to avoid pregnancy."

B (Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the woman's advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the woman of her options, explaining the procedure, and advising the client about potential risk factors. The physician must be present to explain the procedure to the client. However, the nurse's responsibilities go further than simply asking the physician to see the client. The nurse may witness the signing of the consent form. However, depending on the state's guidelines, the woman's husband or another hospital health care employee may sign as witness.)

The role of the nurse with regard to informed consent is to: a. Inform the client about the procedure and have her sign the consent form. b. Act as a client advocate and help clarify the procedure and the options. c. Call the physician to see the client. d. Witness the signing of the consent form.

A (Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpain is caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.)

The self-destruction of excess hypertrophied tissue in the uterus is called: a. Autolysis. b. Subinvolution. c. Afterpain. d. Diastasis.

B, C, D, E (Postpartum hemorrhage often results in anemia, and iron therapy may need to be initiated. Exhaustion is common after hemorrhage. It may take the new mother weeks to feel like herself again. Fatigue may interfere with normal parent-infant bonding and attachment processes. The mother is likely to require assistance with housework and infant care. Excessive blood loss increases the risk for infection.)

The visiting nurse must be aware that women who have had a postpartum hemorrhage are subject to a variety of complications after discharge from the hospital. These include: (Choose those that apply.) a. dehydration. b. anemia. c. exhaustion. d. failure to attach to her infant. e. postpartum infection.

B (The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.)

To assist the woman after delivery of the infant, the nurse knows that the blood patch is used after spinal anesthesia to relieve: a. Hypotension. b. Headache. c. Neonatal respiratory depression. d. Loss of movement.

A (This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage.)

To help clients manage discomfort and pain during labor, nurses should be aware that: a. The predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen. b. Referred pain is the extreme discomfort between contractions. c. The somatic pain of the second stage of labor is more generalized and related to fatigue. d. Pain during the third stage is a somewhat milder version of the second stage.

D (Puerperal sepsis is a condition in which a woman's genital tract becomes infected due to low immunity caused by long labor, severe bleeding, or dehydration. Therefore the nurse should assess the patient for puerperal sepsis if the temperature of the woman after childbirth is raised to 100.4° F. Blood pressure is routinely assessed in postpartum patients to detect hemorrhage. A rapid pulse rate indicates the presence of hypovolemia as a result of hemorrhage. The respiratory rate is measured because hypoventilation can occur after a high subarachnoid block or epidural narcotic following a cesarean birth.)

Twenty-four hours after childbirth, a patient developed a high temperature of 100.4° F. Which monitoring action is most important for the nurse? A. Pulse rate B. Blood pressure C. Respiratory rate D. Assess for puerperal sepsis

C (Within 12 hours of birth women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature would cause chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.)

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is: A. Elevated temperature caused by postpartum infection. B. Increased basal metabolic rate after giving birth. C. Loss of increased blood volume associated with pregnancy. D. Increased venous pressure in the lower extremities.

D (Hematoma formation)

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a) Bladder distention b) Uterine atony c) Constipation d) Hematoma formation

C (The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.)

Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 b. 24, 96 c. 48, 96 d. 48, 120

A (Inversion of the uterus and hypovolemic shock are considered medical emergencies.)

What PPH conditions are considered medical emergencies that require immediate treatment? A. Inversion of the uterus and hypovolemic shock B. Hypotonic uterus and coagulopathies C. Subinvolution of the uterus and idiopathic thrombocytopenic purpura D. Uterine atony and disseminated intravascular coagulation

A (The fundus can rise to approximately 1 cm above the umbilicus within 12 hours after childbirth. By the sixth postpartum day, the fundus is normally located halfway between the umbilicus and the symphysis pubis. At the end of the third stage of labor, the uterus is in the midline, approximately 2 cm below the level of the umbilicus with the fundus resting on the sacral promontory. The uterus is about the same size as it was at 20 weeks' gestation at 24 hours afterbirth, not 12 hours.)

What assessment does the nurse expect to find in a postpartum patient 12 hours after childbirth? A. The fundus is approximately 1 cm above the umbilicus. B. The palpation of the uterus is not possible abdominally. C. The uterus is about the same size as it was at 20 weeks' gestation. D. The fundus is located midway between the umbilicus and the symphysis pubis.

D (Agency policy must be consulted to determine if the approval of the laboring woman's primary health care provider is required. The nurse must ensure that all criteria are met in terms of the status of the maternal and fetal unit. Hydrotherapy is usually initiated when the patient is in active labor, at approximately 5 cm. This reduces the risk of a prolonged labor. FHR monitoring is done by Doppler, fetoscope, or wireless external monitor when hydrotherapy is in use. Use of internal electrodes for monitoring FHR is contraindicated in jet hydrotherapy. The temperature of the water should be maintained at 36° to 37° C (96.8° to 98.6° F). Test-Taking Tip: The night before the examination you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.)

What care must the nurse take when assisting a laboring patient with hydrotherapy? A. Initiate hydrotherapy in the first stage of labor at 3 cm. B. Ensure water is warm at 32.5° to 34° C (90.5° to 93.2°F). C. Check the fetal heart rate (FHR) with internal electrodes. D. Obtain the approval of the primary health care provider.

A (Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis.)

Which measure may prevent mastitis in the breastfeeding mother? a. Initiating early and frequent feedings b. Nursing the infant for 5 minutes on each breast c. Wearing a tight-fitting bra d. Applying ice packs before feeding

B (Certain scents can evoke pleasant memories and feelings of love and security. So, it is helpful if the patient is allowed to choose the scents. The oils must never be applied in full strength directly on to the skin. Most oils should be diluted in a vegetable oil base before use. Inhaling vapors from the oil can lead to unpleasant side effects like nausea or headache. Drops of essential oils can be put on a pillow or on a woman's brow or palms or used as an ingredient in creating massage oil. It is not applied to the hair. STUDY TIP: Do not change your pattern of study. It obviously has contributed to your being here, so it worked. If you have studied alone, continue to study alone. If you have studied in a group, form a study group.)

What care must the nurse take when implementing aromatherapy for a patient in labor? A. Apply oil to the skin and massage. B. Ask the patient to choose the scents. C. Apply a few drops of oil to the hair. D. Allow inhalation of warm oil vapors

B (In the second stage of labor breathing technique is used to increase abdominal pressure and expel the fetus. In the first stage of labor, breathing helps to promote the relaxation of the abdominal muscles, thereby increasing the size of the abdominal cavity. This lessens the discomfort during contraction caused by the friction between the abdominal wall and the uterus. It also relaxes the muscles of the genital area and does not interfere with fetal descent. Test-Taking Tip: Do not panic while taking an exam! Panic will only increase your anxiety. Stop for a moment, close your eyes, take a few deep breaths, and resume review of the question.)

What does the nurse teach the patient about the benefits of breathing techniques in the second stage of labor? A. Does not interfere with fetal descent B. Causes increase in abdominal pressure C. Reduces discomfort during contractions D. Increases the size of the abdominal cavity

C (Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding.)

What infection is contracted mostly by first-time mothers who are breastfeeding? A. Endometritis B. Wound infections C. Mastitis D. Urinary tract infections

B (Notify the physician of any increase in the amount of lochia or a return to bright red bleeding.)

What instructions should be included in the discharge teaching plan to assist the client in recognizing early signs of complications? a. Palpate the fundus daily to ensure that it is soft. b. Notify the physician of any increase in the amount of lochia or a return to bright red bleeding. c. Report any decrease in the amount of brownish red lochia. d. The passage of clots as large as an orange can be expected.

C (The nurse must assist the patient by providing a quiet and relaxed environment. A relaxed environment for labor is created by controlling sensory stimuli, such as light, noise, and temperature, as per the patient's preferences. The nurse must provide reassurance and comfort by sitting rather than standing at the bedside whenever possible. The nurse must not encourage or hurry the patient for rapid birth. The nurse must maintain a calm and unhurried attitude when caring for the patient. Test-Taking Tip: Be aware that information from previously asked questions may help you respond to other examination questions.)

What intervention does the nurse perform to provide a relaxed environment for labor? A. Stand at the bedside. B. Encourage rapid birth. C. Control sensory stimuli. D. Demonstrate excitement

D (Suppression of lactation is recommended in cases of neonatal death. To suppress lactation, the nurse should advise the patient to wear a breast binder continuously for the first 72 hours after delivery. Running warm water over the breast stimulates lactation. Mild analgesics can be administered to reduce breast engorgement, but they are not used to suppress lactation. Administration of oral or intravenous fluids may stimulate lactation.)

What intervention does the nurse perform to suppress lactation in a patient who had a stillbirth? A. Run warm water over the patient's breasts. B. Administer strong analgesics. C. Administer oral and intravenous fluids. D. Advise the patient to wear a breast binder for the first 72 hours after giving birth.

A, B, D (The nurse must immediately notify the primary health care provider, anesthesiologist, or nurse anesthetist. The nurse must administer oxygen by nonrebreather facemask at 10 to 12 L/min or as per health care facility's protocol. The FHR must be monitored every 5 minutes. The patient must be turned to lateral position or a pillow or wedge must be placed under a hip to displace the uterus. Sims' or modified Sims' position may be used when spinal anesthesia is administered. Maternal blood pressure must be monitored every 5 minutes.)

What interventions does the nurse perform for a laboring patient with hypotension and fetal bradycardia? Select all that apply. A. Notify the primary health care provider or anesthesiologist. B. Monitor the fetal heart rate (FHR) every 5 minutes. C. Monitor maternal blood pressure every 10 minutes. D. Administer oxygen using a non rebreather facemask. E. Position the patient in Sims' or modified Sims' position.

A, C, E (The nurse must offer emotional support by complimenting the patient and offering positive reinforcement for efforts during labor. The patient must be involved in decision making regarding own care. The nurse must use a calm and confident approach when assisting the patient during labor. The nurse may offer food and nourishment, if allowed by the primary health care provider. The nurse must encourage participation in distracting activities and nonpharmacologic measures for comfort.)

What interventions does the nurse perform to provide emotional support to a patient in labor? Select all that apply. A. Compliment patient efforts during labor. B. Avoid offering food during labor. C. Use a calm, confident approach. D. Discourage activities that distract. E. Involve the patient in care decisions.

A (General anesthesia may be necessary if indications necessitate rapid birth (vaginal or emergent cesarean), when there is a pressing need for time and/or primary health care providers to perform a block. Pudendal nerve block is administered late in the second stage of labor. It may be required if an episiotomy is to be performed or if forceps or a vacuum extractor is to be used to facilitate birth. Nitrous oxide mixed with oxygen can be inhaled in 50% or less concentration to provide analgesia during the first and second stages of labor. Local infiltration anesthesia may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.)

What kind of anesthesia does the nurse expect the primary health care provider to prescribe to a patient who is to have an emergency cesarean birth due to fetal distress? A. General anesthesia B. Pudendal nerve block C. Nitrous oxide with oxygen D. Local infiltration anesthesia

C (Diazepam (Valium) disrupts thermoregulation in the newborn. Thus the newborn is less able to maintain body temperature. Benzodiazepines, when given with an opioid analgesic, seem to enhance pain relief and reduce nausea and vomiting. Pain is magnified if a barbiturate is given without an analgesic to a patient who is experiencing pain. This is because the normal coping mechanism in the patient may be blunted. Barbiturates should be avoided if birth is anticipated within 12 to 24 hours because it has the potential to cause neonatal central nervous system depression.)

What major side effect does the nurse expect if a patient in labor is administered diazepam (Valium)? A. Severe nausea and vomiting in the mother B. Neonatal central nervous system depression C. Disrupted temperature control in the newborn D. Magnified pain if administered without analgesic

D (All systems of the female body undergo adaptation during pregnancy and childbirth, including the musculoskeletal system. All the joints are completely stabilized 6 to 8 weeks after childbirth, but the joints of the foot do not recover completely to the prepregnant state. Hypotension, bradycardia, and pelvic relaxation are temporary changes and do not last for a long time after childbirth.)

What permanent change does nurse expect the patient to have after childbirth? A Bradycardia B. Hypotension C. Pelvic relaxation D. Increased shoe size

B (Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.)

What statement by a woman who just gave birth indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles." C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after."

B (Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony.)

What woman is at greatest risk for early postpartum hemorrhage? A. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress B. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced C. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor D. A primigravida in spontaneous labor with preterm twins

B (Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.)

When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is: a. Rectal suppositories. b. Early and frequent ambulation. c. Tightening and relaxing abdominal muscles. d. Carbonated beverages.

D (Visceral pain in the first stage of labor occurs in the lower portion of the abdomen. Visceral pain is a result of distention of the lower uterine segment and stretching of cervical tissue as it effaces and dilates. Pressure and traction on uterine tubes, ovaries, ligaments, nerves, and uterine ischemia also cause visceral pain. Pain that originates in the uterus radiates to the gluteal area, iliac crests, abdominal wall, thighs, lumbosacral area of the back, and lower back. This pain is called referred pain.)

When caring for a patient in the first phase of labor, the nurse observes that the patient is experiencing visceral pain. In which area does visceral pain occur? A. Abdominal wall and thighs B. Gluteal area and iliac crests C. Lumbosacral area of the back D. Lower portion of the abdomen

D (Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised, and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion.)

When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is: A. Absence of cyanosis in the buccal mucosa B. Cool, dry skin C. Diminished restlessness D. Urinary output of at least 30 ml/hr

D, E (Rationale: After induction of the anesthetic, maternal blood pressure, pulse, and respirations and fetal heart rate and pattern must be checked and documented every 5 to 10 minutes. If signs of serious maternal hypotension (e.g., the systolic blood pressure drops to 100 mm Hg or less or the blood pressure falls 20% or more below the baseline) or fetal distress (e.g., bradycardia, minimal or absent variability, late decelerations) develop, emergency care must be given.)

When monitoring a woman in labor who has just received spinal analgesia, the nurse should report which assessment findings to the health care provider? (Select all that apply.) A) Maternal blood pressure of 108/79 B) Maternal heart rate of 98 C) Respiratory rate of 14 breaths/min D) Fetal heart rate of 100 beats/min E) Minimal variability on a fetal heart monitor

C (The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action is to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. This is not an expected finding, and emptying the bladder is required.)

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A. Massage the fundus. B. Administer Methergine, 0.2 mg PO, that has been ordered prn. C. Assist the woman to empty her bladder. D. Recognize this as an expected finding during the first 24 hours following birth.

A (The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse.)

Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

D (Postpartum blues affects 50% to 70% of new mothers. It is believed to be related to hormonal fluctuations after childbirth.)

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth? a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues

D (Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition.)

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? A. Varicosities of the legs B. Carpal tunnel syndrome C. Periodic numbness and tingling of the fingers D. Headaches

B (Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.)

Which description of postpartum restoration or healing times is accurate? A. The cervix shortens, becomes firm, and returns to form within a month postpartum. B. Vaginal rugae reappear by 3 weeks postpartum. C. Most episiotomies heal within a week. D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

B (Rugae reappear within 3 to 4 weeks)

Which description of postpartum restoration or healing times is accurate? a) The cervix shortens, becomes firm, and returns to form within a month postpartum b) Rugae reappear within 3 to 4 weeks c) Most episiotomies healh within a week d) Hermorrhoids usually decrease in size within 2 weeks of childbirth

C (The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.)

Which documentation on a woman's chart on postpartum day 14 indicates a normal involution process? A. Moderate bright red lochial flow B. Breasts firm and tender C. Fundus below the symphysis and not palpable D. Episiotomy slightly red and puffy

A (The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours postpartum. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.)

Which finding 12 hours after birth requires further assessment? A. The fundus is palpable two fingerbreadths above the umbilicus. B. The fundus is palpable at the level of the umbilicus. C. The fundus is palpable one fingerbreadth below the umbilicus. D. The fundus is palpable two fingerbreadths below the umbilicus.

D (Pain in left calf with dorsiflexion of left foot)

Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? a) Postural hypotension b) Temperature of 38 C c) Bradycardia- pulse rate of 55 beats/min d) Pain in left calf with dorsiflexion of left foot

C (Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and progesterone levels decrease markedly after expulsion of the placenta and reach their lowest levels 1 week into the postpartum period. Human placental lactogen levels decrease dramatically after expulsion of the placenta.)

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? A. Estrogen B. Progesterone C. Prolactin D. Human placental lactogen

D (For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.)

Which maternal event is abnormal in the early postpartum period? A. Diuresis and diaphoresis B. Flatulence and constipation C. Extreme hunger and thirst D. Lochial color changes from rubra to alba

C (The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage. )

Which measure is least effective in preventing postpartum hemorrhage? A. Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered B. Encouraging the woman to void every 2 hours C. Massaging the fundus every hour for the first 24 hours following birth D. Teaching the woman the importance of rest and nutrition to enhance healing

D (Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. It is unlikely that enough time remains to administer epidural or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn.)

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical dilation? a. Epidural anesthesia b. Narcotics c. Spinal block d. Breathing and relaxation techniques

D (Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder.)

Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder.

C (Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest.)

Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period after a cesarean birth? a. Roll a bath blanket and place it firmly behind the knees. b. Limit oral intake of fluids for the first 24 hours. c. Assist the client in performing leg exercises every 2 hours. d. Ambulate the client as soon as her vital signs are stable.

C (A high pulse rate of 129 beats per minute in a postpartum patient immediately after childbirth may be indicative of hypovolemia caused by blood loss during labor. This is an abnormal assessment finding postdelivery. Labor may cause dehydration, and this may result in a slight increase in body temperature of up to 100.4° F. This is a normal finding associated with labor. Blood pressure may be slightly altered after childbirth. A blood pressure of 126/80 mm Hg would be a normal finding in this patient. The respiratory rate increases during labor and then slowly comes back to normal after labor. Normal respiratory rate is 12 to 14 breaths per minute. Thus, 15 breaths per minute is a normal finding.)

Which postpartum patient finding would the nurse consider abnormal when assessing the patient's vital signs immediately after childbirth? A. Temperature 100.4° F B. Blood pressure 126/80 mm Hg C. Pulse rate 129 beats per minute D. Respiratory rate 15 breaths per minute

D (Venous congestion begins as soon as the woman stands up. The stockings should be applied before she rises from the bed in the morning.)

Which statement by a postpartal woman indicates that further teaching is not needed regarding thrombus formation? a. "I'll stay in bed for the first 3 days after my baby is born." b. "I'll keep my legs elevated with pillows." c. "I'll sit in my rocking chair most of the time." d. "I'll put my support stockings on every morning before rising."

D (Higher endorphin levels help women tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labor pains. Upright positions in labor usually result in improved comfort and less pain. Moving freely to find more comfortable positions is important for reducing pain and muscle tension.)

Which statement correctly describes the effects of various pain factors? a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of childbirth. b. Upright positions in labor increase the pain factor because they cause greater fatigue. c. Women who move around trying different positions are experiencing more pain. d. Levels of pain-mitigating b-endorphins are higher during a spontaneous, natural childbirth.

D (A temperature elevation to greater than 100.4° F on 2 postpartum days not including the first 24 hours indicates infection.)

Which temperature indicates the presence of postpartum infection? a. 99.6° F in the first 48 hours b. 100° F for 2 days postpartum c. 100.4° F in the first 24 hours d. 100.8° F on the second and third postpartum days

B (Afterpains are more common in multiparous women. Afterpains are more noticeable with births in which the uterus was greatly distended, as in a woman who experienced polyhydramnios or a woman who delivered a large infant. Breastfeeding may cause afterpains to intensify.)

Which woman is most likely to experience strong afterpains? A. A woman who experienced oligohydramnios B. A woman who is a gravida 4, para 4-0-0-4 C. A woman who is bottle-feeding her infant D. A woman whose infant weighed 5 pounds, 3 ounces

A (Applying a covered ice pack to the perineum from front to back during first 24 hours decreases edema and increases comfort. Using two or more perineal pads would be helpful in absorbing the heavy menstrual flow but will not reduce the pain or promote perineal healing. Sitz baths and Kegel exercises are important measures to provide pain relief and comfort to the patient with a fourth-degree laceration. Therefore the nurse should not advise the patient to avoid taking sitz baths and performing perineal (Kegel) exercises.)

While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient? A. Apply an ice pack to limit edema during the first 12 to 24 hours. B Instruct the patient to use two or more perineal pads. C. Teach the patient to avoid taking sitz baths. D. Remind the patient to avoid doing perineal (Kegel) exercises.

A, B, C, E (Culture: a woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although the intervention of caregivers may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps, intravenous lines).)

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply): a. Culture. b. Anxiety and fear. c. Previous experiences with pain. d. Intervention of caregivers. e. Support systems.

B (Anxiety and pain reinforce each other in a negative cycle. Mild anxiety is normal for a woman in labor and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labor. Unfortunately, an anxious, painful first labor is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.)

With regard to a pregnant woman's anxiety and pain experience, nurses should be aware that: a. Even mild anxiety must be treated. b. Severe anxiety increases tension, which increases pain, which in turn increases fear and anxiety, and so on. c. Anxiety may increase the perception of pain, but it does not affect the mechanism of labor. d. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity.

C (A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.)

With regard to afterbirth pains, nurses should be aware that these pains are: A. Caused by mild, continuous contractions for the duration of the postpartum period. B. More common in first-time mothers. C. More noticeable in births in which the uterus was overdistended. D. Alleviated somewhat when the mother breastfeeds.

A (Breathing techniques in the first stage of labor is designed to increase the size of the abdominal cavity to reduce friction. First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.)

With regard to breathing during labor, maternity nurses should be aware that: a) Breathing techniques in the first stage of labor is designed to increase the size of the abdominal cavity to reduce friction b) By the time labor has begun, it is too late for instruction in breathing and relaxation c) Controlled breathing techniques are most difficult near the end of the second stage of labor d) The patterned-paced breathing technique can help prevent hyperventilation

A (First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm. Patterned-paced breathing sometimes can lead to hyperventilation.)

With regard to breathing techniques during labor, maternity nurses should understand that: a. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction. b. By the time labor has begun, it is too late for instruction in breathing and relaxation. c. Controlled breathing techniques are most difficult near the end of the second stage of labor. d. The patterned-paced breathing technique can help prevent hyperventilation.

A (Common agents include lidocaine and chloroprocaine. Injections can be repeated to prolong the anesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.)

With regard to nerve block analgesia and anesthesia, nurses should be aware that: a. Most local agents are related chemically to cocaine and end in the suffix -caine. b. Local perineal infiltration anesthesia is effective when epinephrine is added, but it can be injected only once. c. A pudendal nerve block is designed to relieve the pain from uterine contractions. d. A pudendal nerve block, if done correctly, does not significantly lessen the bearing-down reflex.

D (The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium.)

With regard to postpartum ovarian function, nurses should be aware that: A. Almost 75% of women who do not breastfeed resume menstruating within a month after birth. B. Ovulation occurs slightly earlier for breastfeeding women. C. Because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium. D. The first menstrual flow after childbirth usually is heavier than normal.

B (A high incidence of postbirth headache is seen with spinal blocks.)

With regard to spinal and epidural (block) anesthesia, nurses should know that: a) This type of anesthesia is commonly used for cesarean births but it not suitable for vaginal births b) A high incidence of postbirth headache is seen with spinal blocks c) Epidural blocks allow the woman to move freely d) Spinal and epidural blocks are never used together

B (Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.)

With regard to spinal and epidural (block) anesthesia, nurses should know that: a. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. b. A high incidence of after-birth headache is seen with spinal blocks. c. Epidural blocks allow the woman to move freely. d. Spinal and epidural blocks are never used together.

B (Rationale: Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. Effects depend on the specific drug given, the dosage, and the timing. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.)

With regard to systemic analgesics administered during labor, nurses should be aware that: A) systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B) effects on the fetus and newborn can include decreased alertness and delayed sucking. C) IM administration is preferred over IV administration. D) IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

B (Effects on the fetus and newborn can include decreased alertness and delayed sucking.)

With regard to systemic analgesics administered during labor, nurses should be aware that: a) Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier b) Effects on the fetus and newborn can include decreased alertness and delayed sucking c) IM administration is preferred over IV administration d) IV patient-controlled analgesia (PCA) results in increased use of an analgesic

B (Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.)

With regard to systemic analgesics administered during labor, nurses should be aware that: a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. b. Effects on the fetus and newborn can include decreased alertness and delayed sucking. c. Intramuscular administration (IM) is preferred over intravenous (IV) administration. d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

C (Fluid loss through perspiration and increased urinary output accoun for a weight loss of more than 2kg during the puerperium.)

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that: a) Kidney function returns to normal a few days after birth b) Diastasis recti abdominis is a common condition that alters the voiding reflex c) Fluid loss through perspiration and increased urinary output accoun for a weight loss of more than 2kg during the puerperium d) With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth

B (Respirations should decrease to within the woman's normal prepregnancy range by 6 to 8 weeks after birth. Stroke volume increases, and cardiac output remains high for a couple of days. However, the heart rate and blood pressure return to normal quickly. Leukocytosis increases 10 to 12 days after childbirth and can obscure the diagnosis of acute infections (false-negative results). The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth)

With regard to the postpartum changes and developments in a woman's cardiovascular system, nurses should be aware that: A. Cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth. B. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth. C. The lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections. D. A hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

B (After 2 weeks postpartum, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks postpartum the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.)

With regard to the postpartum uterus, nurses should be aware that: A. At the end of the third stage of labor it weighs approximately 500 g. B. After 2 weeks postpartum it should not be palpable abdominally. C. After 2 weeks postpartum it weighs 100 g. D. It returns to its original (prepregnancy) size by 6 weeks postpartum.

C (Rationale: Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. The woman and her partner should experiment with massage before labor to see what might work best. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.)

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: A) either hot or cold applications may provide relief, but they should never be used together in the same treatment. B) acupuncture can be performed by a skilled nurse with just a little training. C) hand and foot massage may be especially relaxing in advanced labor when a woman's tolerance for touch is limited. D) therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations.

C (Hand and foot massage may be especially relaxing in advanced labor when a womans tolerance for touch is limited)

With regard to what might be called the tactile approaches to comfort management, nurses should be aware that: a) Either hot or cold applications may provide relief, but they should never be used together in the same treatment b) Acupuncture can be performed by a skilled nurse with just a little training c) Hand and foot massage may be especially relaxing in advanced labor when a womans tolerance for touch is limited d) Therapeutic touch uses handheld electronic stimulators that produce sympathetic vibrations