Post pardum NCLEX
A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: a. encouraging the client to wear a supportive bra. b. having the client stand facing in a warm shower. c. informing the primary care provider that the client is showing early signs of breast infection. e. using a breast pump to facilitate removal of stagnant breast milk.
a. encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? a. 1 week b. 2 weeks c. 3 weeks d. 4 weeks.
b. 2 weeks Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.
The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? a. Reassess the client in 1 hour. b. Document the lochia as scant. c. Stop using a peri-pad. d. Massage the client's fundus.
b. Document the lochia as scant. "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.
A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? a. Percussion reveals tympani. b. Uterus is boggy. c. Lochia is less than usual. d. Bladder is nonpalpable.
b. Uterus is boggy. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.
Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a. when the white blood cell count is less than 10,000/mm³ b. during the first 24 hours after birth owing to dehydration from exertion c. after any period of decreased intake d. when the elevated temperature exceeds 100.4°F (38°C)
b. during the first 24 hours after birth owing to dehydration from exertion Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? a. "Expect to see your 2-year-old become more independent when the baby gets home." b. "Talk to your 2-year-old about the baby when you're driving him to day care." c. "Ask your 2-year-old to pick out a special toy for his sister." d. "Have your 2-year-old stay at home while you're here in the hospital."
c. "Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.
c. Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: a. inspect the perineum for lacerations. b. increase the flow of an IV. c. assess and massage the fundus. d. call the primary care provider or the nurse-midwife.
c. assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? a. infection b. hemorrhage c. normal involution d. atony
d. atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.
A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? a. Apply ice packs directly to the perineal area. b. Apply ice packs for 40 minutes continuously. c. Ensure ice pack is changed frequently. d. Use ice packs for a week after birth.
c. Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: a. scant. b. light. c. moderate. d. heavy.
c. moderate. Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss; light or small- an approximately 4-inch stain or a 10- to 25-mL loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 mL; and large or heavy-a pad is saturated within 1 hour after changing it.
Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? Select all that apply. a. resumption of intercourse b. activity c. resumption of prepregnancy environment d. signs and symptoms of infection e. infant formula selection
a. resumption of intercourse b. activity d. signs and symptoms of infection The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her pre-pregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.
A nurse is assessing a postpartum client. Which measure is appropriate? a. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. b. Instruct the client to empty her bladder before the examination. c. Wear sterile gloves when assessing the pad and perineum. d. Perform the examination as quickly as possible.
b. Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? a. hemorrhage b. infection c. depression d. pulmonary emboli
b. infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.
The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: a. consistency. b. odor. c. specific gravity. d. pH.
b. odor. The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: a. mitral valve collapse. b. thrombophlebitis. c. pulmonary embolism. d. upper respiratory infection.
c. pulmonary embolism. These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? a. talking about how the nurse held her own newborn while on the birthing table b. showing a video of parents feeding their babies c. allowing the mother to pick the best time to hold her newborn d. bringing the newborn into the room
d. bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? a. "I only eat a low-fiber diet." b. "I already have some pads with witch hazel at home." c. "My mom always used dibucaine." d. "Sitz baths worked the last time."
a. "I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? a. touching b. talking c. looking d. feeding
a. touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.
A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition? a. infection b. hemorrhage c. pulmonary embolism d. hypertension
c. pulmonary embolism Pulmonary embolism occurs in up to 3 per 1000 births and is a major cause of maternal mortality
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: a. the client will show no signs of infection. b. discuss methods that the woman will use to prevent infection. c. list signs of infection that she will report to her health care provider. d. maintain previous household routines to prevent infection.
d. maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? a. redness b. temperature c. edema d. drainage
b. temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? a. Inspecting posture, color, and respiratory effort b. Checking for identifying birthmarks or skin injuries c. Auscultating bowel sounds, and measuring urine output d. Determining chest and head circumference
a. Inspecting posture, color, and respiratory effort The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. a. Low self-esteem b. Feeling overwhelmed and out of control c. Low socioeconomic status d. Lack of social support e. Involving family in infant care
a. Low self-esteem b. Feeling overwhelmed and out of control c. Low socioeconomic status d. Lack of social support Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? a. Continue to monitor the woman's temperature every 4 hours; this finding is normal. b.Notify the health care provider about this elevation; this finding reflects infection. c. Obtain a urine culture; the woman most likely has a urinary tract infection. d. Inspect the perineum for hematoma formation.
a. Continue to monitor the woman's temperature every 4 hours; this finding is normal. A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next? a. Determine the newborn's blood type and rhesus. b. Determine if this is the client's first baby. c. Administer Rh immunoglobulins intramuscularly. d. Ask if the client received rH immunoglobulins during the pregnancy.
a. Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? a. one fingerbreadth above the umbilicus b. one fingerbreadth below the umbilicus c. at the level of the umbilicus d. below the symphysis pubis
b. one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.
Which factor puts a client on her first postpartum day at risk for hemorrhage? a. hemoglobin level of 12 g/dl b. uterine atony c. thrombophlebitis d. moderate amount of lochia rubra
b. uterine atony Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? a. "Follow up with your healthcare provider within 3 weeks of being discharged." b. Notify the healthcare provider if your temperature is greater than 99° F (37.2° C)." c. "You should be seen by your healthcare provider if you have blurred vision." d. "Call your healthcare provider if you saturate a peri-pad in less than 4 hours."
c. "You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.
A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? a. The flow contains large clots. b. The flow is over 500 mL. c. Her uterus is soft to your touch. d. The color of the flow is red.
d. The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? a. 500 additional calories per day b. 1,000 additional calories per day c. 250 additional calories per day d. 750 additional calories per day
a. 500 additional calories per day The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.
The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care? a. Symptoms of postpartum depression can easily go undetected. b. Only mental health professionals can detect postpartum depression. c. Postpartum depression only impacts women with two or more children. d. Symptoms occur within a week after giving birth.
a. Symptoms of postpartum depression can easily go undetected. The plan of care should acknowledge that symptoms of postpartum depression are often missed and go undetected (and therefore untreated). Postpartum blues occur within the first week after birth. Postpartum depression can develop after any pregnancy and can be assessed by providers in a variety of settings.
A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? a. an ice pack applied to the perineum b. narcotic pain medication d. a heating pad applied to the perineum c. a sitz bath
a. an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? a. delayed hemorrhage b. bladder distention c. extreme diaphoresis d. uterine atony
a. delayed hemorrhage Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching? a. "Breastfeeding takes time and practice." b. "Some women just can't breastfeed. Maybe I'm one of these women." c. "Some babies latch on and catch on quickly; others take a little more time." d. "Maybe a lactation specialist can help me work through this."
b. "Some women just can't breastfeed. Maybe I'm one of these women." The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.
A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition? a. diabetes b. long-term obesity c. feelings of increased self-esteem d. increased sex drive
b. long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.
During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? a. generally within 3 to 6 weeks b. whenever the couple wishes c. generally after 12 weeks d. usually within a couple weeks
a. generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: a. the level of the umbilicus. b. between the umbilicus and symphysis pubis. c. 1 cm below the umbilicus. d. 2 cm below the umbilicus.
a. the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? a. venous duplex ultrasound of the right leg b. transthoracic echocardiogram c. venogram of the right leg d. noninvasive arterial studies of the right leg
a. venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? a. thromboembolic disorder of the lower extremities b. hormonal shifting of relaxin and estrogen c. infection d. normal response to the body converting back to prepregnancy state
a. thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
