PassPoint: PostPartum Period ML8
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? A. "You can continue to breastfeed as long as you want to do so." B. "You will need to discontinue breastfeeding until the antibiotic therapy is stopped." C. "Alternate your breastfeeding with formula feeding to help you rest." D. "You will need to modify your technique by manually pumping your breasts."
A The client can continue to breastfeed as often as desired. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding parents. Manual pumping of the breasts is not necessary.
A nurse is teaching a client how to use a diaphragm. Which statement about using a diaphragm is appropriate? A. "Remove the diaphragm immediately after intercourse." B. "Leave the diaphragm in place for at least 6 hours after intercourse." C. "Insert the diaphragm 4 hours before intercourse." D. "You may use the diaphragm without spermicidal jelly or cream."
B The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn't ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.
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? A. It is a breach of confidentiality to share this information with the colleague. B. Send the colleague an anonymous card. C. Post accolades to the nurse at the nurses' station. D. Share the feedback with the nursing colleague directly.
D It is not a breach of confidentiality for the nurse to share the feedback with the colleague, and by doing so the nurse will recognize the value of the colleague's professional efforts and accomplishments. It is not appropriate to place an announcement at the nurses' station or to send an anonymous card. It is crucial that nurses uphold the standards for professional practice and consider the American Nurses Association (Canadian Nurses' Association) Code of Ethics, in particular surrounding the principles of preserving dignity and maintaining privacy and confidentiality.
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 A. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle. B. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle. C. take all the missed doses as soon as she discovers the oversight. D. discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule.
D A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure effectiveness and can increase the risk of adverse reactions.
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? A. "I will wear a sports bra or a well-fitting bra for several days." B. "When showering, I will direct water onto my shoulders." C. "I will use a breast pump to remove any milk that may appear." D. "I will only use only water to clean my nipples."
C The use of a breast pump to remove milk is contraindicated in bottle-feeding clients. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fitting provides support and decreases stimulation (binders are not suggested). Having the water in a shower land on the shoulders of the client rather than the breasts also decreases stimulation. Only water is necessary to clean nipples when breastfeeding or bottle-feeding.
The nurse is teaching a new parent about the feeding patterns of a newborn infant. Which of the following statements by the parent would the nurse recognize as the correct description of a feeding pattern for a formula-fed infant? A. "Formula-fed infants experience shorter periods between feedings." B. "Formula-fed infants demand to feed every 1.5 to 3 hours." C. "Formula-fed infants digest their milk more rapidly." D. "Formula-fed infants usually feed every 3 to 4 hours."
D Formula is harder to digest than breast milk and therefore, babies typically feed less frequently than breastfed babies. Formula-fed infants should demand feedings every 3 to 4 hours compared to every 2 to 3 hours for breastfed babies.
The nurse caring for a postpartum client recalls which of the following are appropriate instructions for the prevention of a urinary tract infection (UTI)? Select all that apply. A. "Set your phone alarm to remind you to change your peri-pad every one to two hours" B. "Drink at least eight 8-ounce glasses of water daily" C. "Talk with your health care provide about which antibiotic therapy is best for you" D. "Be sure to include lots of probiotics in your diet" E. "Remember to empty her bladder completely every 2-4 hours"
A, B, E The nurse should advise the woman to empty her bladder every 2 to 4 hours while awake to prevent over-distention and trauma to the bladder. Maintaining a good fluid intake is also important. Eating foods high in probiotics or taking probiotic supplements or antibiotics will not PREVENT UTI's. Changing the peri-pad should be done often, as a warm moist environment may contribute to development of a UTI.
Perineal pad changed two times this shift for moderate amount of red discharae. 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? A. lochia alba B. lochia C. lochia serosa D. lochia rubra
D For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.
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. A. Provide an early opportunity for the couple to see the child if desired. B. The nurse should control emotions so as to not upset the parents. C. Offer to stay with the grieving parents. D. Remind the parents that there must have been something wrong with the baby. E. Answer the parents' questions accurately.
A, C, E Seeing the fetus/baby helps parents face the reality of the loss, reduces painful fantasies, and offers an opportunity for closure. Wishes of the parents should be respected either way. Not showing any emotion in front of the parents may not let the parents know that the nurse has also been affected by the loss. Trying to provide a reason for the death of the baby tends to invoke anger in parents who wonder what the reason was and why it had to be them. Some parents are quite anxious about being left alone with the baby and prefer not to have the nurse leave the room. Allowing the parents to ask questions and answering accurately will help the grieving parents understand their loss at their pace.
A client at a follow-up appointment after having a miscarriage 2 weeks previously yells at the nurse, "How could God do this to me? I've never done anything wrong." Which response by the nurse would be most appropriate at this time? A. "I know you're angry. It's so hard to lose your baby." B. "You're a strong person. You'll get through this." C. "God can handle your anger. It's okay." D. "It's not God's fault. It was an accident."
A Acknowledging the anger and its source encourages communication about the client's feelings. Although anger at God is common after a loss, the client is displacing the anger that she needs to deal with more directly. Telling the client that the miscarriage was an accident or that she is a strong person and will get through this ignores the client's feelings of anger and loss, thereby cutting off communication.
When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take? A. Notify the physician. B. Assure the client that such bleeding is normal. C. Apply an ice pack to the perineum. D. Massage the uterus every 15 minutes.
A The nurse should notify the healthcare professional because a continuous flow of bright red blood from the vagina and a firm, contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and would give her a false sense of security.
As she tries to decide on a birth control method, a client requests information about medroxyprogesterone. Which statement represents the nurse's best response? A. "Medroxyprogesterone is effective for only 2 months at a time." B. "Medroxyprogesterone needs to be administered every 12 weeks." C. "Medroxyprogesterone can't be given to breast-feeding women." D. "Medroxyprogesterone has a high failure rate; use a barrier form of protection also."
B Medroxyprogesterone will provide effective birth control for 3 months, and it may be the birth-control method of choice for clients who are breast-feeding because studies haven't established any contraindications. There is no evidence that the drug has a high failure rate.
The community health nurse is providing education to a client who gave birth 74 hours earlier. What would the nurse teach the client is a sign or symptom of hemorrhage? A. foul smelling lochia B. peripad soaked over the course of 1 hour C. backache D. passing a quarter-sized clot
B With a late postpartum hemorrhage (greater than 72 hours), women report heavy bleeding and soaking a peripad in less than 1 hour. The clot could indicate placental fragments but not necessarily a postpartum hemorrhage. Clots larger than a golf ball should be reported. Leukorrhea, backache, and foul lochia may occur if a puerperal infection is the cause.
A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.
500 The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.
Which of the following behaviors would indicate to the nurse that follow-up is needed for a client having difficulty attaching to her newborn? A. talks to the baby in a high-pitched tone when the baby's eyes are open B. holds the baby in the en face position C. lets the baby cry to get to sleep D. responds verbally to any sounds emitted by the baby
C Not responding to the needs of the newborn (e.g., crying) may indicate that the mother is not attaching to her infant. It is normal behavior for the mother to talk to the baby in a high-pitched tone when the baby's eyes are open and to hold the baby in en face position to allow for direct face-to-face and eye-to-eye contact. It is also a positive sign of attachment when the mother verbally and physically responds to noises that the baby makes, such as crying, coughing, sneezing, or grunting.
At which time should the nurse anticipate assisting a client to breastfeed their neonate? A. in about 2 hours, after the baby has been evaluated B. in about 4 hours, after the baby has had some sleep C. after the neonate's first period of reactivity D. during the neonate's first period of reactivity
D A neonate is active and alert soon after birth. If no complications exist, breastfeeding should begin as soon as possible after birth, which coincides with the first period of reactivity. Because colostrum is not irritating if aspirated and is readily absorbed by the neonate's respiratory system, breastfeeding can be initiated immediately after birth.After the first period of reactivity, the neonate goes to sleep, thus making breastfeeding difficult.Maternal/infant bonding will be delayed if breastfeeding is not initiated during the first period of reactivity.
A client is at the end of her first postpartum day. The nurse is assessing the client's uterus. Which finding requires further evaluation? A. uterus in the midline position B. firm, round uterus C. fundus one fingerbreadth below the umbilicus D. fundus two fingerbreadths above the umbilicus
D Fundal height decreases about one fingerbreadth each postpartum day. Therefore, the fundus being two fingerbreadths above the umbilicus requires further evaluation. A firm, round uterus that's in the midline position is normal for a client who is 1 day postpartum.
On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority? A. notifying the physician or nurse-midwife B. administering oxytocin as ordered C. massaging the uterus gently D. reassessing the client in 1 hour
C If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.
A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage the client care assignment? A. Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. B. Refuse to accept the new admission. C. Ask the administrative assistant to complete the new client's paperwork. D. Call the obstetrician and ask to postpone the cesarean birth.
A A nurse in the labor and delivery unit can't safely care for three clients. Therefore, the nurse should notify the charge nurse that an additional staff member is needed to safely meet the needs of the increasing client census. Postponing the cesarean birth isn't the best option. Although asking the administrative assistant to assist with paperwork is appropriate, obtaining an additional nurse is a higher priority. The nurse can't refuse to admit a client in labor.
A postpartum client has a temperature of 99.8° F (37.7.° C) during the first 24 hours after birth. Which nursing intervention is appropriate? A. Check the client's breasts for red, swollen areas. B. Check for signs of puerperal infection. C. Encourage more fluid intake. D. Assess lochia for foul odor.
C A slight temperature elevation from dehydration is common during the first 24 hours after giving birth. Infection should be suspected if the client's temperature exceeds 100.4° F (38° C) for 2 successive days after giving birth, excluding the first 24 hours. A slightly elevated temperature isn't an indication for the nurse to assess for odor in the lochia, breast-abnormalities, or puerperal infection.
Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning their neonate? A. "Eliminate the baby's favorite feeding times first." B. "Gradually eliminate one feeding at a time." C. "Wait until you have breastfed for at least 4 months." D. "Plan to omit the daytime feedings last."
B The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the birth parent desires; they do not have to breastfeed for 4 months. Most infants (and birth parents) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy.
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? A. 24 hours B. 7 days C. 12 hours D. 2 to 4 days
D If the client begins breastfeeding early and often after birth, the breasts begin to fill with milk within 48 to 96 hours, or 2 to 4 days. The breasts secrete colostrum for the first 24 to 48 hours, which is beneficial to the neonate because of the immunoglobulins contained in colostrum.
A breastfeeding primiparous client with a midline episiotomy is prescribed ibuprofen orally. When does the nurse instruct the client to take the medication? A. when providing supplemental formula B. before going to bed C. midway between feedings D. immediately after a feeding
D Taking ibuprofen 200 mg orally immediately after breastfeeding helps minimize the neonate's exposure to the drug because drugs are most highly concentrated in the body soon after they are taken. Most birth parents breastfeed on demand or every 2 to 3 hours, so the effects of the ibuprofen should be decreased by the next breastfeeding session. Taking the medication before going to bed is inappropriate because, although the birth parent may go to bed at a certain time, the neonate may wish to breastfeed soon after the birth parent goes to bed. If the parent takes the medication midway between feedings, its peak action may occur midway between feedings. Breast milk is sufficient for the neonate's nutritional needs. Most breastfeeding parents should not be encouraged to provide supplemental feedings to the infant because this may result in nipple confusion.
A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? A. The implants cost less over the long term than other contraceptive methods. B. The implants provide effective, continuous contraception that isn't user dependent. C. The implants can be removed easily if pregnancy occurs. D. The implants require a lower hormonal dose than other hormonal contraceptive methods.
B Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception that isn't user dependent. The effectiveness of other methods, such as the condom, diaphragm, and oral contraceptives, depends at least partly on the user's knowledge, skills, and motivation.
When caring for a client who has had a cesarean birth, which action by a nurse requires intervention? A. supporting self-esteem concerns about the birth B. monitoring pain status and providing necessary relief C. assisting with parent-neonate bonding D. removing the initial dressing for incision inspection
D Nursing care should never include removing the initial dressing put on in the operating room. Therefore, if a nurse performs this action, intervention is needed. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate and therefore incorrect answers to this question.
A client whose blood type is A- gives birth to a neonate whose blood type is A+. The client is scheduled to have Rho(D) immune globulin administered. Before administering the medication, which action by the nurse is most important? A. documenting administration of the drug in the client's chart B. ensuring that the client understands the procedure and signs a consent for the vaccination C. choosing an injection site that isn't tender D. instructing the client that she won't need an additional vaccination after her next pregnancy
B Before Rho(D) immune globulin administration, the nurse must educate the client about the medication, and the client must sign consent. The nurse should document the procedure after giving the injection. The nurse should advise the client that Rho(D) immune globulin administration will be needed after every pregnancy. Choosing an injection site that isn't tender isn't a priority.
The nurse has been assigned to care for several postpartum clients and their neonates on a birthing unit. Which client should the nurse assess first? A. a multiparous client at 48 hours postpartum who is being discharged B. a primiparous client at 48 hours postpartum after cesarean birth of a term neonate C. a multiparous client at 24 hours postpartum whose infant is in the special care nursery D. a primiparous client at 2 hours postpartum who gave vaginal birth to a term neonate vaginally
D The primiparous client at 2 hours postpartum who gave birth to a term neonate vaginally should be assessed first because this client is at risk for postpartum hemorrhage. Early postpartum hemorrhage typically occurs during the first 24 hours postpartum. Once the nurse has assessed the client's fundus, lochia, and vital signs, a determination about the stability of the client can be made. After this assessment, the nurse can provide care to the other clients, who are of lesser priority than the newly postpartum primiparous client.
A postpartum client tells the nurse that she and her partner had an argument about continuing breastfeeding before the partner left for work in the morning. The partner was up all night, not able to sleep with the baby crying, and wants the client to give the baby formula. What is the most appropriate immediate response from the nurse? A. "Have you considered offering breast milk and formula?" B. "What are your feelings about breastfeeding?" C. "I know an excellent support group for breastfeeding." D. "I will come back in a few days and talk to your husband."
B This response further explores the client's feelings in order to assist her at the time of the nurse's visit. The other responses do not validate her feelings or they take ownership of the situation away from the client and do not build capacity within the family.
While assisting a multiparous client to the bathroom for the first time 1 hour after a vaginal birth, the nurse notes that the client's urine has two small blood clots in the measuring container. What should the nurse do next? A. Massage the client's fundus vigorously. B. Ask the client if they passed clots with their previous births. C. Review the client's records for the length of the third stage of labor. D. Document this observation as a normal finding.
D The passage of two small blood clots from a multiparous woman 1 hour after a vaginal birth is not an unusual occurrence. The nurse should continue to monitor the client and document this as a normal finding.The nurse should never massage a postpartum client's fundus vigorously because of the risk for uterine inversion and discomfort to the birth parent.Asking whether the client passed clots with previous births is irrelevant.The length of the third stage of labor has no relation to whether or not the client passes clots.
Five days postpartum following an uneventful vaginal delivery, a client phones the obstetrician's office stating various symptoms and requesting an appointment. As the nurse is documenting symptoms, which ones indicate a potential puerperal infection? Select all that apply. A. slight edema to perineum B. frequent abdominal pain requiring medication C. reddened area increasing around episiotomy D. serosanguineous drainage on the perineal pad E. temperature of 100.8° F (38.2° C) F. ecchymosis in the perineal area
B, C, E The nurse must analyze normal symptoms following birth (5 days postpartum) and abnormal symptoms that may indicate a puerperal infection. Abnormal symptoms include a temperature over 100.8° F or 38.2° C, abdominal pain, and increasing reddened area around the episiotomy. These symptoms may indicate a postpartum or puerperal infection. Normal findings following birth include pink (serosanguineous) drainage on the fifth postpartum day, edema and ecchymosis to the perineal region.
The nurse is assessing a client who had a cesarean birth 12 hours ago. Findings include a distended abdomen with faint bowel sounds, a firm fundus at the umbilicus, scant lochia rubra, and pain rated as a 2 on a scale of 0 to 10. The intravenous line and Foley catheter have been discontinued, and the client received medication 3 hours ago for pain. The client can have pain medication every 3 to 4 hours. What should the nurse do first? A. Have the client use the incentive spirometry. B. Encourage the client to begin caring for the baby. C. Give the client pain medication. D. Ambulate the client from the bed to the hallway and back.
D The client should have more active bowel sounds by this time after birth. Ambulation will encourage passing flatus and begin peristaltic action in the gastrointestinal tract. A decision on medicating the client should be evaluated prior to ambulating, but it is probably too soon because the last dose was 3 hours ago and the pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incentive spirometry or asking the client to turn, cough, and deep breathe is appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these interventions. Participating in infant care is another way to encourage the client to move about, but the primary goal would be to have them walk on the unit, a more purposeful activity.
Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when they state which effect is the purpose of the drug? A. to increase the perspiration for diuresis B. to prevent further blood clot formation C. to increase the flow of lochia D. to thin the blood clots
B Heparin therapy is prescribed to inhibit further thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the postpartum period is increased lochia flow, so the nurse must observe for symptoms of hemorrhage, such as heavy lochia flow. Heparin does not increase diaphoresis, which is normal for the postpartum client.
A primiparous client who gave birth to a viable term neonate vaginally 48 hours ago has a repair of a third-degree laceration. When preparing the client for discharge, the nurse understands that which assessment would be most important? A. rectal fistulas B. excessive bleeding C. constipation D. diarrhea
C The client with a third-degree laceration should be assessed for constipation because a third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more likely because this condition is extremely painful, possibly causing the client to be reluctant to have a bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum. Rectal fistulas may develop at a later time, but not at 48 hours postpartum.
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? A. The father of the newborn will need to have Rh-factor testing performed. B. The infant will require Rh immunoglobulin injection within 72 hours. C. The newborn will be monitored closely for possible sensitization blood reaction. D. The client will need Rh immunoglobulin injection within 72 hours.
D A mother who is Rh-factor negative should receive Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the client. During birth, the newborn's Rh-positive cells can enter maternal circulation. Ideally, the mother should have received a schedule of RhoGAM to prevent initial isoimmunization against fetal erythrocytes and the formation of antibodies. Since the newborn's Rh factor is known, the father's status is not relevant (but would be positive because Rh negativity is a recessive trait). The newborn is not given the RhoGAM; it is the mother who is at risk for a sensitization reaction.
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? A. Discontinue breastfeeding immediately and replace it with bottle-feeding during the night. B. Express a small amount of breast milk before breastfeeding. C. Take a moderately strong analgesic medication after the infant breastfeeds on both sides. D. Apply ice packs to the breasts for 20 minutes just before breastfeeding the newborn.
B The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breastfeed. Frequent feedings with complete emptying of the breasts should alleviate engorgement.There is no reason why the client needs to discontinue breastfeeding. Rather, more frequent breastfeeding is indicated.Ice packs can be used to relieve edema and pain but should be used between feedings, not immediately before a feeding. Warm compresses may be used to help stimulate milk flow.Although the client's breasts are tender, this tenderness is a result of the engorgement. A strong analgesic medication will not alleviate breast engorgement. Expressing the milk and feeding the neonate are most effective in relieving the problem.
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? A. Client will use a reliable contraceptive method until her follow-up care is complete in 1 year and her hCG level is negative. B. Client will schedule her first follow-up Papanicolaou (Pap) test and gynecologic examination for 6 months after discharge. C. Client will state that she may attempt another pregnancy after 3 months of follow-up care. D. Client will state that she won't attempt another pregnancy until her human chorionic gonadotropin (hCG) level rises.
A After a molar pregnancy, the client should receive follow-up care, including regular hCG testing, for 1 year because of the risk of developing chorionic carcinoma. After removal of a hydatidiform mole, the hCG level gradually falls to a negative reading unless chorionic carcinoma is developing, in which case the hCG level rises. A Pap test isn't an effective indicator of a hydatidiform mole. A follow-up examination would be scheduled within weeks of the client's discharge. The client must not become pregnant during follow-up care because pregnancy causes the hCG level to rise, making it indistinguishable from this early sign of chorionic carcinoma.
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? A. development of Rh-positive antibodies B. development of a future Rh-positive fetus C. a future pregnancy resulting in abortion D. an antibody response to Rh-negative blood
A Rh sensitization can be prevented by Rho(D) immune globulin, which clears the maternal circulation of Rh-positive cells before sensitization can occur, thereby blocking maternal antibody production to Rh-positive cells. Administration of this drug will not prevent future Rh-positive fetuses, nor will it prevent future abortions. An antibody response will not occur to Rh-negative cells. Rh-negative birth parents do not develop sensitivities if the fetus is also Rh negative.
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? A. Encourage the family to identify their frustrations and fears. B. Explain that the unit is short staffed and that the nurses are doing the best they can. C. Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit. D. Call the nurse manager to speak with the couple.
A This response will assist the family in identifying their frustrations and fears so the nurse can work toward resolving their issues. It is inappropriate to tell the client about staffing-related issues or to give them a time limit for which they are able to express their concerns. The nurse manager may need be brought into the situation but first the nurse should try to work toward resolving the issues with the clients.
A nurse observes several interactions between a client and her neonate. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply. A. She takes a nap when the neonate is also sleeping. B. She talks and coos to her neonate. C. She does not make eye contact with her neonate. D. She counts the fingers and toes of her neonate. E. She requests that the nurse take the neonate to the nursery for feedings. F. She cuddles her neonate close to her.
B, D, F Talking to, cooing at, and cuddling with her neonate are positive signs that the client is adapting to her new role as a mother. Eye contact, inspecting the neonate by touching, and speaking help establish attachment with a neonate. Avoiding eye contact is a nonbonding behavior. Feeding a neonate is an important role of a new mother and facilitates attachment. Resting while the neonate is sleeping will conserve needed energy and allow the mother to be alert and awake when her infant is awake; however, it is not evidence of bonding.
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? A. Plan for each parent to spend equal amounts of time with each twin. B. Bottle-feed the twins to prevent exhaustion and fatigue. C. Avoid assistance from other family members until attachment occurs. D. Relate to each twin individually to enhance the attachment process.
D It is believed that the process of attachment is structured so that the parents become attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to each twin individually, rather than as a unit, to enhance the attachment process. Birth parents of twins are usually able to breastfeed successfully because the milk supply increases on demand. However, possible fatigue and exhaustion require that the birth parent rest whenever possible. It would be highly unlikely and unrealistic that each parent would be able to spend equal amounts of time with both twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage assistance from family and friends because caring for twins or other multiple births (e.g., triplets) can be exhausting for the family.
Which measure would the nurse expect to include in the teaching plan for a multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for cystitis? A. avoiding the intake of acidic fruit juices until the treatment is discontinued B. limiting fluid intake to 1 L daily to prevent overload C. washing the perineum with povidone-iodine after voiding D. emptying the bladder every 2 to 4 hours while awake
D The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep their bladder empty. In addition, they should maintain adequate fluid intake; 3000 mL a day is recommended. Intake of acidic fruit juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infection. The client should wear cotton underwear and avoid tight-fitting slacks. The client does not need to wash with povidone-iodine after voiding. Plain warm water is sufficient to keep the perineal area clean.
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? A. increased pulse rate B. uterine atony C. respiratory depression D. hypertension
B Uterine atony is more common in clients who have received oxytocin during labor because the uterine muscle becomes fatigued and does not contract effectively to compress the vessels at the placental site.Respiratory depression, not typically associated with oxytocin induction, may occur with narcotic overdose or excessive magnesium sulfate administration.Increased pulse rate and hypertension are not typically associated with oxytocin induction during labor.
On her third postpartum day, a client complains of chills and aches. Her chart shows that she has had a temperature of 100.6° F (38.1° C) for the past 2 days. The nurse assesses foul-smelling, yellow lochia. What should the nurse do next? A. Call the physician and request an order for antibiotics. B. Assess the client's breasts for engorgement. C. Anticipate that the physician will order laboratory tests and cultures. D. Recheck the client's temperature in 4 hours.
C Signs and symptoms of localized infection include a morbid temperature, chills, malaise, generalized pain or discomfort, and foul-smelling, yellow lochia. The physician may order laboratory tests, including a complete blood count and cultures, to confirm an infection and the causative organisms. Rechecking the client's temperature in 4 hours isn't appropriate because the client requires intervention now. The client's signs and symptoms don't suggest breast engorgement. Laboratory work should be done before starting antibiotics.
A primigravid client at 41 weeks' gestation is admitted to the hospital's labor and birth unit in active labor. After 25 hours of labor with membranes ruptured for 24 hours, the client gives birth to a healthy neonate vaginally with a midline episiotomy. Which problem should the nurse identify as the priority for the client? A. sleep deprivation B. situational low self-esteem C. activity intolerance D. risk for infection
D Birth trauma and prolonged ruptured membranes make the risk for infection the priority problem for this client. Infection can be a serious postpartum complication. Although the client may be fatigued, they should not be experiencing activity intolerance. Clients with heart disease may experience activity intolerance due to excessive cardiac workload. Although the client may be experiencing sleep deprivation, most clients are alert and awake after the birth of a neonate. Situational low self-esteem is not a priority. Clients who undergo a cesarean birth commonly feel a sense of failure because of not having a vaginal birth experience, but this is not the case for this client.
Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. What should the nurse do next? A. Contact the health care provider (HCP) for a prescription for oxytocin. B. Encourage the client to ambulate to the bathroom and void. C. Gently massage the fundus to expel the clots. D. Document this as a normal finding in the client's record.
B At 12 hours postpartum, the fundus normally should be in the midline and at the level of the umbilicus. When the fundus is firm yet above the umbilicus and deviated to the right rather than in the midline, the client's bladder is most likely distended. The client should be encouraged to ambulate to the bathroom and attempt to void because a full bladder can prevent normal involution. A firm but deviated fundus above the level of the umbilicus is not a normal finding, and if voiding does not return it to midline, it should be reported to the HCP. Oxytocin is used to treat uterine atony. This client's fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary because there is no evidence of atony or clots.
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? A. "Any varicosities I had during pregnancy will disappear within 2 weeks." B. "My menstrual flow should resume in approximately 6 to 10 weeks." C. "It's normal for me to have reddish lochia until my 6-week checkup." D. "I can expect to have heart palpitations for several weeks."
B For clients who are bottle-feeding, menstrual flow usually returns in 6 to 10 weeks.Heart palpitations for several weeks are not normal and require further investigation.Reddish lochia at 6 weeks postpartum is not normal and warrants further evaluation.Although varicosities may fade, they rarely disappear completely after childbirth.
On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 0 to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the client for which complication? A. vaginal lacerations B. perineal hematoma C. puerperal infection D. history of drug abuse
B If the client continues to have perineal pain after an analgesic medication has been given, the nurse should inspect the client's perineum for a hematoma because this is the usual cause of such discomfort. Ibuprofen is a nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic agent (such as acetaminophen with codeine). Ice applied to the perineum during the first 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help relieve the discomfort when implemented after the first 24 hours. Typically, hematomas resolve themselves within 6 weeks. A puerperal infection would be indicated if the client's temperature were 100.4°F (38°C) or higher. Also, lochia most likely would be foul-smelling. A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is presented to suggest a history of drug abuse.
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? A. "I will consume 500 more calories each day than if I wasn't breast-feeding." B. "I'll take all the same medications I was taking before my pregnancy." C. "I'll include milk products in my diet." D. "I will drink 10 glasses of fluid every day."
B The client indicates she needs additional teaching when she states she'll resume taking all the medications she was taking before her pregnancy because most drugs are excreted through breast milk and may affect the neonate. The client should consult with her physician before taking any drugs while breast-feeding. She should increase her daily calories by 500, drink 10 glasses of fluid, and include milk products in her diet to increase her milk production and provide adequate nutrition for her neonate and herself.
While assessing the fundus of a multiparous client 36 hours after the birth of a term neonate, the nurse notes a separation of the abdominal muscles. What should the nurse should tell the client? A. to remain on bed rest until resolution occurs B. to perform exercises involving head and shoulder raising in a lying position C. that the separation will resolve on its own with the right posture and diet D. that they will have a surgical repair at 6 weeks postpartum
B The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of the abdomen that is usually palpable on the third postpartum day. An exercise involving raising the head and shoulders about 8 inches (20.3 cm) with the client lying on their back with knees bent and hands crossed over the abdomen is preferred. This exercise helps pull the abdominal muscles together, and the client gradually works up to performing this exercise 50 times per day. However, until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or bend the trunk to one side because further separation may occur. The condition does not need a surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet assist the body to return to its prepregnancy state more quickly but do not resolve the separation of abdominal muscles.
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? A. "Bottle-fed babies generally gain weight faster than breastfed babies in the early months." B. "Your friend may be overfeeding her baby, which is a greater health concern." C. "I hear that you're concerned. Can you tell me more about your baby's growth pattern?" D. "I understand your concern, but all babies gain weight differently, so comparing is discouraged."
C The most helpful response is the one that does not dismiss the new mother's concerns. It is normal for the new mother to seek reassurance and to compare the development of her newborn with others. While such comparisons should be discouraged, the nurse first addresses the client's concerns. By determining whether the growth pattern is within normal limits, the nurse can offer reassurance based on data instead of platitudes. Some academic studies suggest there is variation in weight gain between breastfed and bottle-fed infants, with the former gaining more in early months and the latter gaining more after six months; other studies, however, have found no statistically significant difference between the groups. In general, breastfed babies do tend to be leaner. The nurse has no evidence to support the conclusion that the friend is overfeeding her baby.
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? A. "Feeding the baby for a half-hour on each side will not make my breasts sore." B. "I can put breast milk on my nipples to heal the sore areas." C. "The baby needs to have as much of the nipple and areola in the mouth as possible to prevent sore and cracked nipples." D. "As long as some of my nipple is in the baby's mouth, the baby will receive enough milk."
D As much of the client's nipple and areola as possible need to be in the infant's mouth to establish a latch that does not cause nipple cracks or fissures. Having the nipple and the areola deep in the infant's mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking, and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is correctly placed in the infant's mouth.
The nurse is caring for a client 2 days post-cesarean section who is scheduled for discharge today. The client states, "I do not want to go home." What response by the nurse is mostappropriate? A. Inform the healthcare professional (HCP) that the client does not want to go home. B. Ask the client if she has any support in the home. C. Tell the client that she must go home as per hospital policy. D. Ask the client the reason she does not want to go home.
D It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. This kind of open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address the client's concerns appropriately. Asking the client about supports in the home may imply that the nurse is making an assumption about the reason why the client may not want to go home. Informing the HCP or telling the client it is hospital policy is not appropriate at this time because the nurse is unsure of the underlying reason. This is particularly important because the client may have safety-related concerns, may have undisclosed fears, or may require increased support before being discharged. It is imperative that the nurse not make assumptions but further explore the client's concerns.
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? A. Administer an analgesic medication as prescribed. B. Provide the client with clear liquids. C. Monitor the vital signs every 4 hours. D. Contact the health care provider.
D The nurse should contact the health care provider immediately because the client is demonstrating danger signals of septic shock. Tachycardia, or a pulse rate greater than 120 bpm, and tachypnea, or respirations of 24 breaths/min or higher, are both danger signs of septic shock. Hypotension, changes in the level of consciousness, and decreased urine output are later signs.Analgesic medications can assist the client's comfort but are not critical at this time.Providing the client with clear liquids does not address the life-threatening problem of septic shock.The vital signs should be monitored more frequently than every 4 hours if the client is developing septic shock.
A nurse is walking down the hall in the main corridor of a hospital when the infant security alert system sounds and a code for an infant abduction is announced. The first responsibility of the nurse when this situation occurs is to take which action? A. Go to the obstetrics unit to determine if they need help with the situation. B. Move to the entrance of the hospital and check each person leaving. C. Call the nursery to ask which baby is missing. D. Observe individuals in the area for large bags or oversized coats.
D The process for infant abduction in a hospital system focuses on utilizing all health care workers to observe for anyone who may possibly be concealing an infant in a large bag or under an oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking each individual would be the responsibility of the doorman or security staff within the hospital system. Going to the obstetrics unit to determine if they need help would not be advised as the doors to the unit will be locked and access will not be available. Calling the nursery to ask about a missing baby wastes time, and the nursery staff should not reveal such information.
A 19-year-old primigravid client has decided to breastfeed. The client's 22-year-old spouse supports the decision. The client tells the nurse, "My mother breastfed all of us children, but I'm going to need lots of help with breastfeeding. I'm worried that I won't be able to do this." What additional information should the nurse obtain before teaching the client about breastfeeding? A. Determine the client's level of motivation to breastfeed. B. Perform a complete physical examination to determine the need for help. C. Assess the client's body-to-fat ratio and nutritional status before beginning breastfeeding. D. Ask the client if they have read any literature about breastfeeding.
A Successful breastfeeding depends on the client's willingness and motivation to breastfeed. Clients who have a strong desire to breastfeed tend to continue breastfeeding longer and are often more tolerant of the discomforts of breastfeeding and more accepting of the need for frequent feedings.Although obtaining information about what the client has read about breastfeeding may provide clues about the client's knowledge level, the type of literature is not a significant factor in successful breastfeeding.A complete physical examination is not necessary. The client is asking for support and assistance with breastfeeding. Performing a physical examination does not provide this needed support.Although adequate nutrition during lactation is important, even clients who have had poor nutrition can be taught how to improve their diets. Assessing the client's body-to-fat ratio is not important for breastfeeding because it is not associated with the client's ability to breastfeed nor the amount of breast milk produced.
While caring for a multiparous client 4 hours after the vaginal birth of a term neonate, the nurse notes that the mother's temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are 18 breaths/min. The fundus is firm, midline, and at the level of the umbilicus. What should the nurse do? A. Continue to monitor the client's vital signs. B. Assess the client's lochia for large clots. C. Offer the client an ice pack for their forehead. D. Notify the client's health care provider (HCP) about the findings.
A The nurse needs to continue to monitor the client's vital signs. During the first 24 hours postpartum, it is normal for the client to have a slight temperature elevation because of dehydration. A temperature of 100.4°F (38°C) that persists after the first 24 hours may indicate an infection. Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis, and diaphoresis. The client's respiratory rate is within normal limits. Large clots are indicative of hemorrhage. However, the client's vital signs are within normal limits and the fundus is firm and midline. Therefore, large clots and possible hemorrhage can be ruled out. The HCP does not need to be notified at this time. An ice pack is not necessary because the client's temperature is within normal limits.
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? A. Pregnancy should be avoided for 4 weeks after the immunization. B. The injection will provide immunity against chickenpox. C. The vaccine prevents a future fetus from developing congenital anomalies. D. The client should avoid contact with children diagnosed with rubella.
A After administration of the rubella vaccine, the client should be instructed to avoid pregnancy for at least 4 weeks to prevent the possibility of the vaccine's teratogenic effects on the fetus.The vaccine does not protect a future fetus from infection. Rather, it protects the client from developing the infection if exposed during pregnancy and subsequently causing harm to the fetus.The vaccine will provide immunity to rubella, also known as German measles.The injection immunizes the client against the 3-day or German measles, not chickenpox.
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? A. Stop the flow of urine while urinating. B. Do pelvic squats. C. Lift both legs while lying down. D. Tighten her stomach muscles.
A By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.
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? A. fainting B. bleeding C. hygiene needs D. fatigue
A Clients sometimes feel faint or dizzy when taking a shower for the first time after birth because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes their first shower after birth. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client faints while in the shower, the nurse should cover the client to protect privacy, stay with the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower. The nurse determines a client's risk for bleeding before allowing them to shower. If the client was at high risk for bleeding, the shower should be delayed. Once in the shower, bleeding status would be difficult to determine.
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? A. when the client resumes ambulating B. after sensation returns to the lower extremities C. just prior to the client's discharge D. when the platelet levels return to normal
A A cesarean birth is an independent risk factor for a thromboembolic event in pregnant women. Inflatable compression sleeves should be placed on the lower extremities of a client until the risk for venous stasis is reduced through ambulation. Although a return of sensation must happen before the client can safely ambulate, this finding alone does not significantly decrease the risk for venous stasis. Platelets continue to be significantly elevated for at least 3 weeks after birth, which is well after a client would be discharged. It is unnecessary to continue wearing the compression sleeves after ambulation has returned.
The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is: A. diagnosed with mastitis. B. being treated for active tuberculosis (TB). C. human immunodeficiency virus (HIV) positive. D. currently prescribed lithium.
A A client with mastitis can continue to breastfeed, provided she is not taking antibiotics that are contraindicated in breastfeeding. A mother who has HIV or active TB is strongly discouraged from breastfeeding because of concerns about transmitting the infection to the neonate. Lithium, chemotherapy medications, and amiodarone are some of the few medications that are absolute contraindications to breastfeeding.
A primiparous client who will be bottle-feeding their neonate asks, "What is the best position for the baby to nap after feeding?" What should the nurse recommend? A. Hold the baby upright for 15 to 20 minutes before placing them down for a nap. B. Keep the baby wedged on their left side 20 minutes after feedings. C. Place the baby prone after feedings if they spit up frequently. D. Place the baby in a supine position after feedings.
A The best recommendation is to keep the baby upright for 15 to 20 minutes before placing the baby down for a nap. This helps the stomach empty and decreases the risk for regurgitation. After the short waiting period, the baby should be placed in a supine position. Placing infants on their side or prone in a crib after a feeding is no longer recommended due to the increased risk for sudden infant death syndrome (SIDS).
The nurse has assisted a multigravida with a precipitous birth of a term neonate. Because a precipitous birth can lead to decreased uterine tone, what nursing action should help to prevent this complication? A. Massage the client's fundus continuously. B. Encourage the birth parent to breastfeed the infant. C. Place the neonate on the client's fundus. D. Place the birth parent in a supine position.
B The nurse should encourage the birth parent to breastfeed the infant. Neonatal sucking will induce the release of natural oxytocin, which will help contract the uterus and control uterine bleeding.Placing the neonate on the client's fundus will help keep the neonate warm but will not help to control excessive uterine bleeding.Gentle massage will help contract the fundus. Continuous massage can actually decrease uterine tone and lead to increased bleeding.Placing the birth parent in a supine position has no effect on uterine tone.
The nurse notes a client has produced 1700 mL of dilute urine in the 12-hour period following cesarean birth. What action would the nurse take based on this finding? A. Assess the protein level of the urine using a dipstick at the bedside. B. Elevate the client's legs on two pillows, and restrict fluid intake. C. Request kidney function tests including creatinine and urea levels. D. Document the finding, and complete routine postpartum assessment.
D It is normal for the client to experience diuresis in the first 24 hours after birth (whether vaginal or cesarean). An amount of 3 liters in 24 hours is not unusual. Also, the client will have received IV fluids during labor, which increases input significantly. There is no indication of kidney dysfunction. If preecamplia is suspected, urine output would be decreased, not increased; this makes testing for protein unwarranted. The client may have edema present, for which elevating the legs can encourage further diuresis, but there is not reason to restrict fluid intake.
