Passpoint Postpartum period

During a home visit 4 days after birth, the breastfeeding primiparous client tells the nurse that their breasts are hard and tender. The nurse determines the client has breast engorgement and should instruct the client to perform which measure?

Express a small amount of breast milk before breastfeeding.

The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under a regional anesthetic. When does the nurse tell the client that the sleeves will be removed?

when the client resumes ambulating

A client recently gave birth. Two minutes before breast-feeding the baby, she administers one nasal spray (40 units/ml) of oxytocin into each nostril. Why is the client using this drug?

to stimulate lactation

The nurse makes a home visit to a primigravid client on the fourth postpartum day after the birth of a term neonate. When the nurse enters the house, the nurse finds the client sitting in a chair, crying inconsolably, while the neonate is crying in another room. The client tells the nurse that they have not been sleeping well and they have been hearing voices. The nurse determines that the client is most likely experiencing which condition?

postpartum psychosis

The nurse is teaching a client about breastfeeding. The nurse interprets which client statement as indicating correct self-care knowledge on preventing breast engorgement?

"I'll breastfeed as often as the baby is hungry, probably every 1 to 2 hours."

A nurse is teaching a breast-feeding client how to care for her engorged breasts. Which statement by the client indicates the need for further teaching?

"If my breasts are uncomfortable, I'll limit the time I spend breast-feeding."

A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse?

"RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby."

A multiparous client 48 hours postpartum who is breastfeeding tells the nurse, "I'm having a lot of cramping. This didn't happen when I nursed my first baby." Which would be the nurse's best response?

"The cramping is normal and is caused by your baby's sucking, which stimulates the release of oxytocin."

Which client statement indicates effective teaching about burping a breastfed neonate?

"When I switch to the other breast, I will burp the baby."

The client is a 17-year-old single mother who has given birth. On her first postpartum day, the client seems overwhelmed with her new baby and asks the nurse how she is supposed to interact with her baby when all the baby does is eat and sleep. Which of the following actions would be most effective for the nurse to use to facilitate mother-infant attachment?

Show the client how the baby initiates interaction with her and attends to her.

While assessing a primiparous client 8 hours after birth, the nurse inspects the episiotomy site, finding it edematous and slightly reddened. Which interpretation by the nurse is most appropriate?

The client needs application of an ice pack.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours.

A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after birth. What priority outcome criteria should the client achieve?

The client will void more than 30 mL/hour without urinary retention beginning 1 hour after birth.

A postpartum clinic nurse is assessing a client 4 weeks postpartum after a vaginal birth. What finding would indicate to the nurse that the client is experiencing normal hemodynamic changes occurring in the postpartum period?

The hematocrit rises from 34% to 40%.

The nurse is documenting assessment findings of the newborn. When assessing the neonate's head, the above is noted. Upon further examination, swelling is limited to below the scalp on the left side of the head. How does the nurse document this finding most accurately on the admission assessment to the nursery?

a cephalohematoma contained on the left side

A primiparous client with a neonate who is 36 hours old asks the nurse, "Why does my baby spit up a small amount of formula after feeding?" The nurse explains that the regurgitation is thought to result from which factor?

an immature cardiac sphincter

When preparing a multigravid client who has undergone evacuation of a hydatidiform mole for discharge, the nurse explains the need for follow-up care. The nurse determines that the client understands the instruction when they say they are at risk for developing which problem?

choriocarcinoma

A multigravida prenatal client with a history of postpartum depression tells the nurse that they are taking measures to make sure that they don't suffer that complication, including taking St. John's wort. What is the most important assessment for the nurse to make?

current medications

At which time should the nurse anticipate assisting a client to breastfeed their neonate?

during the neonate's first period of reactivity

A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The nurse anticipates remaining near the client to assess for which problem?

fainting

A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation?

fundus two fingerbreadths above the umbilicus

After a client undergoes a dilatation and curettage (D&C) to evacuate a molar pregnancy, it would be most important for the nurse to assess the client for which signs and symptoms?

hemorrhage

A nurse assesses a client who is 16 days postpartum. The nurse finds that the client's left nipple is cracked and bleeding slightly. Her left breast is sore to touch and an area under the breast is firm, painful, and red. The client is also experiencing chills. What is likely causing this breastfeeding problem?

mastitis

A primiparous client who is beginning to breastfeed their neonate asks the nurse, "Is it important for my baby to get colostrum?" When instructing the client, the nurse would explain that colostrum provides the neonate with which factor?

passive immunity from maternal antibodies

Three hours postpartum, a primiparous client's fundus is firm and midline. On perineal inspection, the nurse observes a small, constant trickle of blood. Which condition should the nurse assess further?

perineal lacerations

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into the mouth. In assessing the problem, the nurse should intervene if the mother

pushes only the tip of the nipple into the neonate's mouth.

A client tells a nurse that she's going to breast-feed her neonate but she isn't sure what she should eat. Which client statement requires further teaching?

"I'll take all the same medications I was taking before my pregnancy."

The nurse provides health teaching about physiologic changes that can be expected during the postpartum period to a postpartum client who is bottle-feeding their neonate. Which client statement indicates that this teaching has been effective?

"My menstrual flow should resume in approximately 6 to 10 weeks."

A client in labor is told that they must have a cesarean birth as a result of a prolapsed cord. Which factor(s) in the client's history place them at greater risk for cord prolapse? Select all that apply.

-2 station low-birth-weight infant rupture of membranes breech presentation

The nurse is caring for a new breastfeeding client who is experiencing poor latching and sore nipples. What direction would the nurse offer to best address this breastfeeding issue?

Ensure the baby's mouth is wide open, and angle the nipple toward the roof of the mouth.

A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to

discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.

A woman who is breastfeeding tells the nurse that they plan to return to work in 6 months and will probably wean their baby then. The client asks the nurse, "How will I stop producing milk when I want to wean the baby?" What information should the nurse give the client?

gradual decrease in milk supply as the baby nurses less

A community nurse makes their introduction to the family and outlines the purpose of the home visit. The nurse asks permission before sitting on the mattress beside the postpartum mother in the bedroom. Which element of the therapeutic relationship do these behaviors demonstrate?

respect

As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response?

"Medroxyprogesterone needs to be administered every 12 weeks."

After suction and evacuation of a complete hydatidiform mole, a 28-year-old multigravid client asks the nurse when they can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long?

12 months

When caring for a client who has had a cesarean birth, which action by a nurse requires intervention?

removing the initial dressing for incision inspection

A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate?

"Leave the diaphragm in place for at least 6 hours after intercourse."

A nurse is assisting a grieving client and spouse to deal with the loss of their 24-week-old infant. Which of the following actions would be most appropriate from the nurse? Select all that apply.

-Provide an early opportunity for the couple to see the child if desired. -Offer to stay with the grieving parents. -Answer the parents' questions accurately.

The nurse notices that a client who has just given birth is short of breath, ashen in color, and begins to cough. The client becomes limp on the birthing table. At last assessment 30 minutes ago, the client's temperature was 98°F (36.7°C), pulse was 78 bpm, and respirations were 16 breaths/min. Determine the nursing actions in the order they should occur. All options must be used.

Establish unresponsiveness. Ask staff to activate the emergency response system. Begin compressions. Open the airway using the head tilt-chin lift. Give two breaths.

A client gives birth to a neonate prematurely at 28 weeks' gestation. The neonate is placed in the neonatal intensive care unit (NICU). Three days later, the client's partner seems withdrawn and barely speaks to the staff when visiting the child in the NICU. Which interpretation of this behavior is most appropriate?

The client's partner has depression because of grieving.

The mother of a neonate expresses concern about how to continue breastfeeding when she returns to work in 6 weeks. How should the nurse respond?

"You can develop and practice a plan now for expressing milk and feeding so you're ready."

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and puts on clean gloves. What should the nurse do next?

Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?

hemorrhage

The health care provider (HCP) prescribes an intramuscular injection of vitamin K for a term neonate. The nurse explains to the mother that this medication is used to prevent which problem?

hemorrhage

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which symptom should the nurse instruct the client to report to her primary caregiver?

blurred vision and headache

A nurse completes the initial assessment of a newborn. According to the due date on the antenatal record, the baby is 12 days postmature. Which of the following physical findings contradicts the estimated gestational age of the newborn?

increased amounts of vernix

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra

Carboprost was injected into the uterus of a client to treat uterine atony during a cesarean birth. In preparing to care for this client after birth, the nurse should assess the client for which common adverse effect of the medication?

nausea and diarrhea

A nurse is providing teaching to a client who's being discharged after delivering a hydatidiform mole. Which expected outcome takes highest priority for this client?

Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative.

A primiparous client who is bottle-feeding their neonate asks, "When should I start giving the baby solid foods?" The nurse instructs the client to introduce solid foods no sooner than at which age?

6 months

A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho(D) immune globulin. The nurse should administer the medication within which time frame after birth?

72 hours

A primiparous client planning to breastfeed her term neonate born vaginally asks, "When will my 'real' milk come in?" The nurse explains to the client that after birth, breasts begin to produce milk within what time period?

2 to 4 days

After giving birth to a viable neonate 12 hours ago, the client's fundus is firm at midline, and their breasts are soft. The client has scant lochia and is voiding sufficiently. The client reports pain in the lower back. What action should the nurse take next?

Administer a prescribed mild analgesic medication.

A client is breastfeeding her newborn infant. The client's nipples are red and bruised, and a small crack is visible on the right nipple. Which intervention should the nurse do next?

Assist the client to have the infant create a correct latch to the breast.

The nurse preceptor overhears a student nurse talking to a grieving mother, whose child was stillborn, about her own pregnancy and fears about experiencing a loss. The student nurse and mother make arrangements for the student to pick up the client's maternity clothes and baby furniture on the weekend. What is the preceptor's most appropriate action?

Discuss the situation with the nursing student after the visit has ended.

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth.

A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?

Stop the flow of urine while urinating.

The nurse is caring for a client who has just returned to the postpartum unit after a cesarean birth. Which action is a priority for the nurse to teach the client to perform over the next 24 hours to prevent complications?

deep breathing and coughing exercises every 2 hours

A primiparous client who was diagnosed with hydramnios and breech presentation while in early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client asks, "Why am I bleeding so much?" The nurse responds based on the understanding that the most likely cause of uterine atony in this client is which factor?

overdistention of the uterus from hydramnios

A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse should anticipate the need to include which action in the infant's plan of care?

urine toxicology screening

A client calls the public health nurse with concerns that her one-month-old breastfed infant is not gaining weight as rapidly as her friend's newborn, who is the same age and formula-fed. What is the most helpful response by the nurse?

"I hear that you're concerned. Can you tell me more about your baby's growth pattern?"

After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave birth 4 days ago is to be discharged on oral warfarin. After the nurse teaches the client about the medication and its possible effects, which client statement indicates successful teaching?

"I should use only waxed dental floss when caring for my teeth."

A 30-year-old client with prolonged rupture of membranes is diagnosed with endometritis 36 hours after the birth of a term neonate. While assessing the client after intravenous antibiotic therapy is initiated, the nurse notes that the client's temperature is 100°F (37.8°C), heart rate is 124 bpm, and respirations are 24 breaths/minute. What action should the nurse take?

Contact the health care provider.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse?

Encourage the family to identify their frustrations and fears.

Rho (D) immune globulin is prescribed for a client before they are discharged after a spontaneous abortion. The nurse instructs the client that this drug is used to prevent which condition?

development of Rh-positive antibodies

The nurse evaluates the parenting skills of an adolescent primigravida changing their baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support?

praise and encouragement

The nurse is caring for a client who gave birth to a term neonate vaginally 12 hours ago. The client is diagnosed with class II heart disease. What should the nurse instruct the client to do?

Allow the nursing staff to assist the client with baby care.

A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by

3 full days of elevated basal body temperature and clear, thin cervical mucus.

A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What should the nurse do first?

Catheterize the client.

A 34-year-old client birthed a healthy baby boy 5 days ago. The client is experiencing insomnia and weepiness, lasting for short periods of time each day. What factor/condition does the nurse believe is causing this experience?

postpartum baby blues

A nurse is caring for a breastfeeding client diagnosed with mastitis in one breast and prescribed antibiotics. What actions will the nurse recommend the client take related to breastfeeding?

Apply a warm compress to affected breast prior to feeding.

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate.

A nurse is giving a shift report about a client in labor. Which of the following information is the least important to include to complete the report at the change of shift?

Bottle- or breastfeeding preference.

The nurse is caring for a client who is 2 hours postpartum and who experienced a fourth-degree vaginal laceration. For what intervention will the nurse caution the client could be harmful at this stage of healing and therefore is not part of the current plan of care?

Kegel exercises

Which information would the nurse include in the primiparous client's discharge teaching plan about measures to provide visual stimulation for the neonate?

Maintain eye contact while talking to the baby.

The nurse is caring for a multiparous client after vaginal birth of a set of twins 2 hours ago. What should the nurse should encourage the client and their partner to do?

Relate to each twin individually to enhance the attachment process.

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts?

Share the feedback with the nursing colleague directly.

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.

The nurse is caring for a multigravida client who is 1 day postpartum following a vaginal birth. Which finding indicates a need for further assessment?

temperature of 100.8°F (38.2°C)

A postpartum primiparous client is having difficulty breastfeeding their infant. The infant latches on to the breast, but the mother's nipples are extremely sore during and after each feeding. The client needs further instruction about breastfeeding when they make which statement?

"As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."

Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning their neonate?

"Gradually eliminate one feeding at a time."

An adolescent primiparous client 24 hours postpartum asks the nurse how often they can hold their newborn without "spoiling" the baby. Which response would be most appropriate?

"Hold them as much as you want to hold them."

A client gave birth 2 days ago and has been given instructions on breast care for bottle-feeding birth parents. Which statement indicates that the nurse should reinforce the instructions to the client?

"I will use a breast pump to remove any milk that may appear."

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client?

"You can continue to breastfeed as long as you want to do so."

A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth. The client, who is breastfeeding, is diagnosed with mastitis of the right breast. The client asks the nurse, "Can I continue breastfeeding?" What should the nurse should tell the client?

"You can continue to breastfeed, feeding your baby more frequently."

The nurse from the nursery is bringing a newborn to a client's room. The nurse took care of the client yesterday and knows the client and baby well. The nurse should implement which action to ensure the safest transition of the infant to the birth parent?

Complete the hospital identification procedure with birth parent and infant.

A primiparous client, 20 hours after giving birth, asks the nurse about starting postpartum exercises. What instructions would be most appropriate to include in the plan of care?

Flex the knees while supine, and then inhale deeply and exhale while contracting the abdominal muscles.

A client had a complicated pregnancy and childbirth and has just experienced the loss of her infant. The postpartum nurse assigned to care for the client is preparing for the client's care. What is the nurse's most appropriate initial action?

Gather pertinent information and enter the room, asking the client and her family how the staff can be most helpful.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma.

During a home visit to a breastfeeding primiparous client 1 week after birth, the client tells the nurse that their nipples have become sore and cracked from the feedings. Which instruction should the nurse give the client?

Position the baby with as much of the areola as possible in the baby's mouth.

When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse should include which information?

Pregnancy should be avoided for 4 weeks after the immunization.

A breastfeeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The client is reporting a warm, red, painful breast, a temperature of 100°F (37.7°C), and flulike symptoms. What should the nurse do?

Refer the client to their health care provider (HCP).

When assessing a client who gave birth 12 hours ago, the nurse measures an oral temperature of 99.6° F (37.5° C), a heart rate of 82 beats/minute, a respiratory rate of 18 breaths/minute, and a blood pressure of 116/70 mm Hg. Which nursing action is most appropriate?

encouraging increased fluid intake

A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription for vitamins with iron because they are anemic. To maximize absorption of the iron, the nurse instructs the client to take the medication with which liquid?

orange juice

During a home visit with a primipara who gave birth 7 days ago, the client tells the nurse that her lochia serosa has been profuse and foul smelling and they are experiencing chills. During palpation of the uterus, the client indicates that they are very sore. The nurse should further assess the client for which problem?

puerperal infection

On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described?

rubra

A woman who has given birth to a healthy neonate is being discharged. As part of discharge teaching, the nurse should instruct the client to observe vaginal discharge for postpartum hemorrhage and notify the health care provider (HCP) of which finding?

saturating a pad in less than an hour

A primiparous client who gave birth 3 days ago is to be discharged on heparin therapy. After teaching the client about the possible adverse effects of heparin therapy, the nurse determines that the client needs further instruction when they state that the adverse effects include which symptom?

slow pulse

In which phase of postpartum psychological adaption would discharge teaching regarding infant care most likely be successful?

taking hold

During the second day postpartum, the nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with a little assistance from her partner. According to Reva Rubin's "phases of bonding," which of the following is the appropriate phase the woman is experiencing?

the taking-hold phase

During the immediate postpartum period, the nurse is caring for a primipara who gave birth to a postterm neonate after an oxytocin induction. When the nurse is developing the client's plan of care, which problem should the nurse expect to assess for frequently?

uterine atony