Olds Maternal-Newborn Nursing ch 37
The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? 1. Purulent, foul-smelling lochia 2. Decreased blood pressure 3. Flank pain 4. Breast is hot and swollen
Answer: 1 Explanation: 1. Assessment findings consistent with endometritis are foul-smelling lochia, fever, uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills.
The home health nurse is visiting a new mother whose baby was delivered by emergency cesarean after a car accident. The mother seems dazed, irritable, and unaware of her surroundings. She tells the nurse she has had trouble sleeping. What would the nurse suspect that the mother has? 1. Post-traumatic stress disorder 2. Postpartum blues 3. Postpartum psychosis 4. Disenfranchised grief
Answer: 1 Explanation: 1. Because of the traumatic nature of the birth and the client's symptoms, this condition is most likely post-traumatic stress disorder (PTSD). At particular risk for PTSD are women who have histories of prior trauma and/or prior psychiatric histories and women who undergo emergency cesarean sections.
The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? 1. "Cesarean birth after extended labor with ruptured membranes." 2. "Unassisted childbirth and afterbirth." 3. "External fetal monitoring used throughout labor." 4. "The client has history of pregnancy-induced hypertension."
Answer: 1 Explanation: 1. Cesarean birth is the single most significant risk of postpartum endometritis as well as prolonged premature rupture of the amniotic membranes (PPROM).
The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."
Answer: 1 Explanation: 1. If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses.
The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? 1. "If your incision becomes increasingly painful, call the doctor." 2. "It is normal for the incision to ooze greenish discharge in a few days." 3. "Increasing redness around the incision is a part of the healing process." 4. "A fever is to be expected because you had a surgical delivery."
Answer: 1 Explanation: 1. The client should call the doctor if the incision becomes increasingly painful. After cesarean delivery, wound infection is most often associated with concurrent endometritis. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. Some women have cellulitis without actual purulent drainage.
The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? 1. Assist the client to the bathroom in 2 hours to void. 2. Place a Foley catheter now. 3. Apply warm packs to the perineum three times a day. 4. Allow the client to rest for the next 8 hours.
Answer: 1 Explanation: 1. This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention.
The client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? 1. "Sometimes the uterus relaxes and excessive bleeding occurs." 2. "The blood collected in the vagina and poured out when your partner stood up." 3. "Bottle-feeding prevents the uterus from getting enough stimulation to contract." 4. "The placenta had embedded in the uterine tissue abnormally."
Answer: 1 Explanation: 1. Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases.
A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Shooting pain between breastfeedings 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Pain radiating to the underarm area from the breast
Answer: 1, 2, 3 Explanation: 1. Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast becomes pink, flaking, and pruritic. Page Ref: 983
A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Avoid crossing the legs. 2. Avoid prolonged standing or sitting. 3. Take frequent walks. 4. Take a daily aspirin dose of 650 mg. 5. Avoid long car trips.
Answer: 1, 2, 3 Explanation: 1. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 2. Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. 3. Women should be advised to avoid a sedentary lifestyle and to exercise as much as possible (walking is ideal).
Which interventions can the nurse utilize to provide continuity of care for the postpartal client who experienced a complication and is now ready to return home? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Encourage the client to take advantage of home visits. 2. Make telephone calls as a follow-up to check on the client and newborn. 3. Provide information about postpartal support groups. 4. Refer to mental health professionals to help screen the client for any mental health problems as a result of the complications experienced in the hospital. 5. Supply information about postpartum expectations designed to meet the specific needs of a variety of families.
Answer: 1, 2, 3, 5 Explanation: 1. Home visits, especially for early discharge families, are invaluable in fostering positive adjustments for the new family. 2. Telephone follow-up at 2 to 3 weeks postpartum to ask whether the mother is experiencing difficulties is also helpful. 3. Support groups in which child care is available can be an invaluable community service for the postpartum client. 5. Social support teaching guides are available to assist in helping postpartum women explore their needs for postpartum support.
Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Redness 2. Tender at the margins 3. Vaginal bleeding 4. Hardened tissue 5. Purulent drainage
Answer: 1, 2, 4, 5 Explanation: 1. Redness is a classic sign of a perineal wound infection. 2. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 4. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 5. Purulent drainage is a classic signs of a perineal wound infection.
Risk factors associated with increased risk of thromboembolic disease include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Diabetes mellitus 2. Varicose veins 3. Hypertension 4. Adolescent pregnancy 5. Malignancy
Answer: 1, 2, 5 Explanation: 1. Diabetes mellitus is a risk factor for thromboembolic disease. 2. Varicose veins are a risk factor for thromboembolic disease. 5. Malignancy is a risk factor for thromboembolic disease.
A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Methergine 2. Coumadin 3. Misoprostol 4. Serotonin reuptake inhibitors (SSRIs) 5. Nonsteroidal anti-inflammatory drugs
Answer: 1, 3 Explanation: 1. Methergine is commonly used orally for postpartum hemorrhage. 3. Misoprostol is commonly used rectally for postpartum hemorrhage.
Clinical features of posttraumatic stress disorder (PTSD) include which of the following? 1. Difficulty sleeping 2. Acute awareness 3. Flashbacks 4. The need to be constantly around others 5. Irritability
Answer: 1, 3, 5 Explanation: 1. A clinical feature of PTSD is difficulty thinking. 3. A clinical feature of PTSD is intrusive thoughts and flashbacks to the threatening event. 5. A clinical feature of PTSD is irritability.
) The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the client to void if the fundus is displaced upward or to one side.
Answer: 1, 4 Explanation: 1. Weighing the perineal pads will indicate whether the client is bleeding more than anticipated. 4. The nurse reviews hemoglobin and hematocrit levels when available, and compares them to the admission baseline.
The nurse is assessing a client who has been diagnosed with an early postpartum hemorrhage. Which findings would the nurse expect? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A boggy fundus that does not respond to massage 2. Small clots and a moderate amount of lochia rubra on the pad 3. Decreased pulse and increased blood pressure 4. Hematoma formation or bulging/shiny skin in the perineal area 5. Rise in the level of the fundus of the uterus
Answer: 1, 4, 5 Explanation: 1. A boggy fundus indicates that the uterus is not contracted and will continue to bleed. 4. Shiny or bulging skin could indicate the presence of a hematoma. 5. The uterine cavity can distend with up to 1000 mL or more of blood causing the fundus to rise.
A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? 1. Decreased bladder capacity 2. Inhibited neural control of the bladder following the use of anesthetic agents 3. Increased bladder sensitivity 4. Abnormal postpartum diuresis
Answer: 2 Explanation: 2. A postpartum woman is at increased risk for developing urinary tract problems because of inhibited neural control of the bladder following the use of anesthetic agents.
To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? 1. Address pain early 2. Change peri-pads frequently 3. Avoid overhydration 4. Report symptoms of uterine cramping
Answer: 2 Explanation: 2. Changing peri-pads frequently decreases skin contact with a moist medium that favors bacteria growth.
The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? 1. The client who describes feeling sad all the time 2. The client who reports hearing voices talking about the baby 3. The client who states she has no appetite and wants to sleep all day 4. The client who says she needs a refill on her sertraline (Zoloft) next week
Answer: 2 Explanation: 2. Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby.
Which of the following would be considered a clinical sign of hemorrhage? 1. Increased blood pressure 2. Increasing pulse 3. Increased urinary output 4. Hunger
Answer: 2 Explanation: 2. Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage.
The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? 1. Assist the client to empty her bladder 2. Help the client back to bed to check the fundus 3. Assess her blood pressure and pulse 4. Begin an IV of lactated Ringer's solution
Answer: 2 Explanation: 2. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts.
The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. High fever 2. Frequency 3. Suprapubic pain 4. Chills 5. Nausea and vomiting
Answer: 2, 3 Explanation: 2. Frequency is characteristic of acute cystitis. 3. Suprapubic pain is characteristic of acute cystitis.
The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? 1. "This condition is called parametritis." 2. "Gonorrhea is the most common organism that causes this type of infection." 3. "My Beta-strep culture's being positive might have contributed to this problem." 4. "If I had walked more yesterday, this probably wouldn't have happened."
Answer: 3 Explanation: 3. Clinical findings of metritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS).
The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? 1. Postpartum psychosis 2. Postpartum infection 3. Postpartum depression 4. Postpartum blues
Answer: 3 Explanation: 3. Postpartum depression can impair maternal-infant bonding and can cause developmental and cognitive delays in the child.
The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? 1. One visit from a homecare nurse, to take place in 2 days 2. Two visits from a public health nurse over the next month 3. An appointment with a mental health counselor 4. Follow-up with the obstetrician in 6 weeks
Answer: 3 Explanation: 3. Postpartum depression has a high recurrence rate. Women with a history of postpartum psychosis or depression or other risk factors may benefit from a referral to a mental health professional for counseling during pregnancy or postpartum.
A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? 1. Nipple soreness 2. Engorgement 3. Mastitis 4. Letdown reflex
Answer: 3 Explanation: 3. Signs of mastitis include late-onset nipple pain, followed by shooting pain between feedings, often radiating to the chest wall. Eventually, the skin of the affected breast may become pink, flaking, and pruritic.
The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion? 1. Facial petechiae 2. Large, soft hemorrhoids 3. Tense tissues with severe pain 4. Elevated temperature
Answer: 3 Explanation: 3. Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas.
The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? 1. The client reports she had this condition after her last pregnancy. 2. The client develops pain and swelling in her left lower leg. 3. The client appears anxious, and describes pressure in her chest. 4. The client becomes upset that she cannot go home yet.
Answer: 3 Explanation: 3. The most common clinical findings of a pulmonary embolism include dyspnea, pleuritic chest pain, cough with or without hemoptysis, cyanosis, tachypnea and tachycardia, panic, syncope, or sudden hypotension and require immediate intervention.
Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? 1. Urge ambulation 2. Apply ice to the leg 3. Elevate the affected limb 4. Massage her calf
Answer: 3 Explanation: 3. Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents.
The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? 1. Wearing a tight-fitting bra 2. Limiting breastfeedings 3. Frequent breastfeedings 4. Restricting fluid intake
Answer: 3 Explanation: 3. Treatment of mastitis includes frequent and complete emptying of the breasts.
The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? 1. The client who was overdue and delivered vaginally 2. The client who delivered by scheduled cesarean delivery 3. The client who had oxytocin augmentation of labor 4. The client who delivered vaginally at 36 weeks
Answer: 3 Explanation: 3. Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor.
A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? 1. The client can douche every other day. 2. Sexual intercourse can be resumed when the client feels up to it. 3. Light housework will provide needed exercise. 4. The baby's mouth should be examined for thrush.
Answer: 4 Explanation: 4. A breastfeeding mother on antibiotics should check her baby's mouth for signs of thrush, which should be reported to the physician.
A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? 1. That the client would be encouraged to ambulate freely 2. That the client would be given aspirin 650 mg by mouth 3. That the client would be given Methergine IM 4. That the client would be placed on bed rest
Answer: 4 Explanation: 4. These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose.
The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? 1. "If I start to have burning with urination, I need to call the doctor." 2. "Drinking 8 glasses of water each day will help prevent another UTI." 3. "I will remember to wipe from front to back after I move my bowels." 4. "Voiding 2 or 3 times per day will help prevent a recurrence."
Answer: 4 Explanation: 4. Voiding only 2 or 3 times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). The woman needs to empty her bladder whenever she feels the urge to void at least every 2 to 4 hours while awake.
Which of the following is a risk factor for urinary retention after childbirth? 1. Multiparity 2. Precipitous labor 3. Unassisted childbirth 4. Not sufficiently recovering from the effects of anesthesia
Answer: 4 Explanation: 4. Women who have not sufficiently recovered from the effects of anesthesia and cannot void spontaneously are at risk for urinary retention after childbirth.
