PostPArdum

A nurse assesses the process of involution by measuring the location of the client's fundus during the postpartum period. Click the location the fundus is expected to be 1 day after birth in a client whose bladder is not distended.

-Place the dot right on the umbilicus One day after birth, the fundus is expected to be at the level of the umbilicus. In the first 12 hours after birth the uterus is expected to be one fingerbreadth above the umbilicus. It is then expected to descend by approximately one fingerbreadth per day until it descends under the pubic bone, usually around day 10.

A 29-year-old gravida 3 para 3, was admitted to the recovery unit 2 hours after the birth of a 9-lb baby girl. The nurse assesses the client an hour later and finds her fundus, which is slightly boggy, three fingerbreadths above the umbilicus and displaced to the right. The peripad, which was changed before the client's transfer, is now saturated. The nurse recognizes: 1 A distended bladder 2 A probable perineal infection 3 Uncontrolled postpartum pain 4 A typical finding in the immediate postpartum period

-A distended bladder Urine retention resulting in a distended bladder will lift and displace the uterus, making it difficult to remain contracted. These findings would not be caused by uncontrolled postpartum pain. It is too early after the delivery for signs of a perineal infection to be noted. The loss of uterine tone (atony) leads to an increase in bleeding.

A registered nurse (RN) on the postpartum unit is providing care to four maternal/infant couplets and is running behind. A licensed practical nurse/licensed vocational nurse (LPN/LVN) and aide are also working on the unit. Which nursing action is best delegated to the LPN/LVN? 1 Discharge teaching for a client who delivered her third infant girl 2 days ago 2 Delivering a clear-liquid dietary tray to a client who had a cesarean section 4 hours ago 3 Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 4 The initial assessment of a client who just delivered an 8 lb 12 oz (3970 g) infant over an intact perineum

-Administering 2 tablets of acetaminophen and oxycodone (Percocet) to a client who rates her pain as 7 of 10 The pain assessment has been performed and the RN will need to evaluate the effectiveness of the pain medication. However, the administration of oral pain medication is within the scope of practice for an LPN/LVN. Initial teaching and assessment are within the scope of practice for only the RN and may only be delegated to another RN. A meal tray may be delivered by an unlicensed person such as an aide or a dietary employee.

A client who is formula feeding her infant complains of discomfort from engorged breasts. What should the nurse recommend that the client do? 1 Use warm, moist towels as compresses. 2 Express milk from each breast manually. 3 Apply cold packs and a snugly fitting bra. 4 Restrict oral fluid intake to less than a quart a day

-Apply cold packs and a snugly fitting bra. Application of cold relieves discomfort, and a snug bra provides support and aids in pressure atrophy of acini cells so that milk production is suppressed. Expressing milk manually is suitable for the breastfeeding mother who is experiencing engorgement, not one who is formula feeding, because it promotes comfort and stimulates milk production. Restriction of fluids will not prevent engorgement and may cause dehydration. Warm, moist compresses are suitable for the breastfeeding mother experiencing discomfort from engorgement because it promotes comfort and stimulates milk production.

A nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her about minimizing breast discomfort? 1 Apply covered ice packs to the breasts. 2 Gently apply cocoa butter to the nipples. 3 Place warm, wet washcloths on the nipples. 4 Manually express colostrum from the breasts

-Apply covered ice packs to the breasts. Covered ice packs promote comfort by decreasing vasocongestion. Nipple stimulation with either cocoa butter application or warm, wet washcloths precipitates the release of prolactin, which leads to more milk production and further engorgement and discomfort. Emptying the breasts stimulates lactation, leading to further engorgement and discomfort.

What is the best nursing intervention to minimize perineal edema after an episiotomy? 1 Applying ice packs 2 Offering warm sitz baths 3 Administering aspirin prn 4 Elevating the hips on a pillow

-Applying ice packs Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides little or minimal perineal relief.

A nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Hispanic woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English, but her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being said? 1 Providing the teaching to all family members and the client 2 Asking the client and her family to nod their heads to verify understanding 3 Asking the client and her family members to say yes to verify understanding 4 Asking the client and family members to repeat, in their own words, what they have been told

-Asking the client and family members to repeat, in their own words, what they have been told The family members should tell the nurse their understanding of what was taught. Nodding or saying yes may be a sign of courtesy rather than of understanding or agreement and is not an effective way to verify understanding. Simply providing the teaching to the family does not ensure understanding.

While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1 Recording these expected findings 2 Obtaining a prescription for an oxytocic medication 3 Asking the client when she last changed the perineal pad 4 Notifying the primary health care provider that the client may be hemorrhaging

-Asking the client when she last changed the perineal pad The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.

A client is bleeding excessively after the birth of a neonate. The health care provider prescribes fundal massage and an IV infusion containing 10 units of oxytocin (Pitocin) at a rate of 100 mL/hr. A nurse's evaluation of the client's responses to these interventions reveals a blood pressure of 135/90 mm Hg, a boggy uterus 3 cm above the umbilicus and displaced to the right, and a perineal pad saturated with bright-red lochia. What is the nurse's next action? 1 Increasing the infusion rate 2 Checking for a distended bladder 3 Continuing to perform fundal massage 4 Continuing to assess the blood pressure

-Checking for a distended bladder A displaced and boggy uterus is usually caused by a full bladder; if the bladder is distended, the nurse should have the client void and then reassess the fundus and, if still boggy, massage until it is firm. The oxytocin (Pitocin) infusion may need to be increased if voiding and fundal massage are ineffective; however, the health care provider must be notified to change the prescription. Continuing to perform fundal massage is necessary if the fundus remains boggy after the client has voided. Continuing to assess the blood pressure is unnecessary at this time; correcting the boggy fundus is the priority.

One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? 1 Encourage the client to void. 2 Notify the practitioner immediately. 3 Massage the uterus and attempt to express clots. 4 Continue periodic assessments and record the findings

-Continue periodic assessments and record the findings Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the health care provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy"; when the uterus is firm and the expected size, it is not necessary to try to express clots.

While palpating the fundus of a postpartum client a nurse identifies separation of the abdominal muscles. How should the nurse document this finding? 1 Split fundus 2 Diastasis recti 3 Abdominus separatus 4 Ruptured abdominal muscle

-Diastasis recti Diastasis recti is the term given to separation of the rectus muscle from the abdominal wall; this may occur during pregnancy as the result of pressure from the enlarging uterus. The fundus is not split; the fundus is the body of the uterus. The abdominal muscle is separated, not ruptured.

A primigravida client gave birth in a vaginal delivery 24 hours ago. Which findings would be considered normal? 1 Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present 2 Fundus firm, one fingerbreadth above the umbilicus; scant lochia alba; voided twice, 500 mL, 400 mL; breasts heavy 3 Fundus firm, two fingerbreadths above the umbilicus; moderate lochia serosa; voided once, 200 mL; colostrum present 4 Fundus firm, 2 fingerbreadths below the umbilicus; moderate serosa alba; voiding quantity sufficient; breasts engorged

-Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present Twenty-four hours after delivery, the fundus is usually at the umbilicus and moderate lochia rubra is expected. Colostrum is present, and the breast milk usually comes in on day 3 after delivery. A fundus two fingerbreadths above the umbilicus may indicate a full bladder, and lochia serosa occurs during days 4 through 10. Voiding just 200 mL since delivery is inadequate. The presence of colostrum is normal. A fundus that is firm at two fingerbreadths under the umbilicus is acceptable, but lochia alba occurs after the 10th postpartum day. The milk would have had to come in for the breasts to be engorged, which does not typically occur until day 3. Scant lochia alba would not occur until day 10; nor would the milk supply be established.

In the second hour after the client gives birth her uterus is firm, above the level of the umbilicus, and to the right of midline. What is the most appropriate nursing action? 1 Having the client empty her bladder 2 Watching for signs of retained secundines 3 Massaging the uterus vigorously to prevent hemorrhage 4 Explaining to the client that this is a sign of uterine stabilization

-Having the client empty her bladder A full bladder elevates the uterus and displaces it to the right. Even though the uterus feels firm, it may relax enough to foster bleeding. Therefore, the bladder should be emptied to improve uterine tone. Watching for signs of retained secundines may be done if emptying the bladder does not rectify the situation. If parts of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding may be evident. Vigorous massage tires the uterus, and even with massage the uterus is unable to contract over a full bladder. Explaining to the client that this is a sign of uterine stabilization is not a sign of uterine stabilization; the uterus will not remain contracted over a full bladder.

A client who has been breastfeeding tells the nurse on the third postpartum day that her breasts are painful and that she is afraid that the baby will hurt her while grasping the nipple and suckling. What is the nurse's best response? 1 Offering the client an analgesic before breastfeeding 2 Recommending that the client limit fluids for several days 3 Suggesting that the client formula feed the baby for 2 days 4 Helping the client express some milk manually before feeding

-Helping the client express some milk manually before feeding The pressure and tenderness resulting from accumulated milk can be relieved by manually expressing some of the fluid before feeding. Pain medication may be offered if other measures are unsuccessful; however, medication can be transferred to the infant through breast milk. Also, giving medication is a dependent function of the nurse that requires a prescription. The mother should not limit fluids, especially if she is breastfeeding. Breastfeeding should continue as a means of limiting engorgement and aiding milk production.

A nurse is assessing clients on the postpartum unit for pain. The client who will have more severe afterbirth pains is one who: 1 Is a grand multipara 2 Is a breastfeeding primipara 3 Had a vaginal birth for a first pregnancy 4 Had a cesarean birth at 43 weeks' gestation

-Is a grand multipara A multipara's uterus tends to contract and relax spasmodically, even if the uterine tone is effective, resulting in pain that may require an analgesic for relief. Although breastfeeding increases the contractile state of the postpartum uterus, the breastfeeding primipara will not have the typical afterbirth pains of a multipara. Primiparas are less likely to have afterbirth pains than are multiparas. A cesarean birth has no effect on the development of afterbirth pains.

A nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this small output of urine during the early postpartum period? 1 It may indicate retention of urine with overflow. 2 It may be indicative of beginning glomerulonephritis. 3 This is common because less fluid is excreted after birth. 4 This is common because fluid intake diminishes after birth.

-It may indicate retention of urine with overflow. Retention of urine with overflow will be manifested in small, frequent voidings. The bladder should be palpated for distention. An increased temperature with urinary alterations would indicate impending infection. More circulating fluid is present, resulting in increased output. The client is usually thirsty and fluid intake increases.

During a home visit the nurse obtains information about a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1 Lethargy 2 Ambivalence 3 Emotional lability 4 Increased appetite 5 Long periods of sleep

-Lethargy, Ambivalence, Emotional lability Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is associated with depression.

After a cesarean birth a nurse performs fundal checks every 15 minutes. The nurse determines that the fundus is soft and boggy. What is the priority nursing action at this time? 1 Elevating the client's legs 2 Massaging the client's fundus 3 Increasing the client's oxytocin drip rate 4 Examining the client's perineum for bleeding

-Massaging the client's fundus Gentle massage stimulates muscle fibers, resulting in firming the tone of the fundus; it also helps expel any clots that may be interfering with contraction of the fundus. Elevating the client's legs will increase return of blood from the extremities but will not improve the tone of the client's fundus. Increasing the client's oxytocin drip rate will be done if uterine massage is ineffective. Examining the client's perineum for bleeding should not be the first action at this time; gentle massage to contract the fundus is the priority.

The priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline is: 1 Massaging the uterine fundus 2 Helping the client to the bathroom 3 Assessing the peripad for the amount of lochia 4 Administering intramuscular methylergonovine (Methergine) 0.2 mg

-Massaging the uterine fundus A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.

A nurse is assigned an adolescent who gave birth 12 hours ago. She continually talks on the phone to her friends and does not respond when her new baby cries. What is the best immediate intervention? 1 Calling social service for a consult 2 Calling the psychiatric team for an intervention 3 Calling her mother and having her speak with the client 4 Modeling appropriate behaviors that encourage infant bonding

-Modeling appropriate behaviors that encourage infant bonding All women go through several phases of adapting to the role of mother. An adolescent may still need time to adjust to her new role, especially if she has just given birth in the past day. By modeling appropriate behavior, the nurse demonstrates appropriate maternal skills to the adolescent. This will assist her as she makes the transition into her new role as a mother. If this behavior continues and does not improving before discharge, social service may need to get involved, but a consult is not needed in this early phase. A psychiatric consult is not necessary because this is not a psychiatric illness. The adolescent's mother is an important part of the plan, especially if the adolescent is going home to her house, but the relationship between the two needs to be assessed to see what role she will play in this new mother-child relationship.

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping because of afterbirth pains? 1 Multipara who has vaginally delivered three children 2 Primipara whose newborn weighed 7 lb 3 Multipara with effectively controlled diabetes 4 Multipara whose second child was small for gestational age

-Multipara who has vaginally delivered three children A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.

A nurse is teaching a client to care for her episiotomy after discharge. What priority instruction should the nurse include? 1 Rest with legs elevated at least two times a day. 2 Avoid stair climbing for several days after discharge. 3 Perform perineal care after toileting until healing occurs. 4 Continue sitz baths three times a day if they provide comfort.

-Perform perineal care after toileting until healing occurs. Prevention of infection is the priority. Resting should be encouraged, but it is not the priority at this time. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.

A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response in language the client will understand? 1 Respirations are enhanced. 2 Bladder tonicity is increased. 3 Abdominal muscles are strengthened. 4 Peripheral vasomotor activity is promoted.

-Peripheral vasomotor activity is promoted. There is extensive activation of the blood clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and to deep-breathe and cough. Bladder tone is improved by the regular emptying and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.

At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client? 1 Planning nursing care activities that provide time for the client to rest and sleep 2 Preparing for the probability of hemorrhage by massaging the client's uterus frequently 3 Arranging an individual session in which the client can learn about successful breastfeeding 4 Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating

-Planning nursing care activities that provide time for the client to rest and sleep After laboring all night the client is tired and needs uninterrupted rest. Massaging the fundus frequently is unnecessary unless the uterus becomes boggy. Providing a lesson on breastfeeding is premature. The client is not ready to learn because she needs to rest and sleep after a long labor. It is necessary for the client to call for assistance only the first time she ambulates; otherwise the client may ambulate ad libitum.

A nurse assesses a new mother who is breastfeeding. The client asks how to care for her nipples. What should the nurse recommend? 1 Putting lanolin cream on the nipples after breastfeeding 2 Applying vitamin E gel to the nipples before breastfeeding 3 Using soap and water to clean the breasts and nipples at least once a day 4 Spreading breast milk on the nipples after the feeding and allowing them to air dry

-Spreading breast milk on the nipples after the feeding and allowing them to air dry Breast milk is a natural lubricant for the nipples and obviously is not toxic for the infant. Products containing lanolin or vitamin E are not advised because they may be ingested by the infant. Soap should not be used on the nipples because it has a drying effect, which may precipitate cracking of the nipples.

The gravida 1 now para 1 woman delivered a 7-lb 6-oz female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks the baby be picked up so she can take a nap. What behavior is the new mother demonstrating? 1 Taking-in 2 Letting-go 3 Taking-hold 4 Bonding failure

-Taking-in During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.

A nurse caring for a client who gave birth to a healthy neonate evaluates the client's uterine tone 8 hours later. How does the nurse determine that the uterus is demonstrating appropriate involution? 1 The amount of lochia rubra is moderate. 2 Numerous clots are being passed vaginally. 3 Bleeding from the episiotomy has stopped. 4 Uterine cramps are absent during breastfeeding.

-The amount of lochia rubra is moderate. Red, distinctly blood-tinged vaginal flow (lochia rubra) is expected during the first few postpartum days and indicates that involution is progressing as it should. Clots indicate uterine atony, which prevents involution of the uterus. The status of the episiotomy is unrelated to the status of the uterus. Uterine cramps during breastfeeding are evidence that the uterus is undergoing appropriate involution.

Before a postpartum client is discharged, the nurse advises her about problems that should be reported and then asks her to recall these problems. Identification of which problem identified by the client indicates that the teaching has been effective? 1 Breast engorgement with feelings of fullness 2 Urgency, frequency, and burning on urination 3 Increased amount of lochia after physical activity 4 Dryness and tenderness when intercourse is first resumed

-Urgency, frequency, and burning on urination These clinical findings are indicative of a urinary tract infection and should be reported immediately. Engorgement is expected and should subside in a few days. An increase in lochial flow or reappearance of lochia after it has ceased is an indication that activity may be too demanding. The client should be advised that this may occur and that rest is indicated; it need not be reported to the practitioner. Dryness and tenderness when intercourse is first resumed are expected; the client may find it helpful to use a water-soluble lubricant initially.

A nurse teaches a postpartum client how to care for her episiotomy to prevent infection. Which behavior indicates that the teaching has been effective? 1 The perineal pad is changed twice daily. 2 The client washes her hands whenever she changes a perineal pad. 3 The client rinses her perineum with water after using an analgesic spray. 4 The client cleanses the perineum from the anus toward the symphysis pubis

-The client washes her hands whenever she changes a perineal pad. Washing the hands after every pad change prevents the transfer of microorganisms from the hands to the genital tract or vice versa. Changing the perineal pad twice daily is an inadequate number of changes; soiled pads promote the growth of microorganisms because they are warm and moist and provide a medium for growth. Rinsing the perineum with water after using an analgesic spray interferes with the analgesic action of the spray and does not prevent infection. Cleansing the perineum from the anus toward the symphysis pubis promotes contamination of the vagina and urethra by organisms from the perianal area.

The postpartum nurse is delegating tasks to unlicensed assistive personnel (UAP). Which task should the nurse delegate to UAP? 1 Evaluation of a postpartum client's lochia 2 Vital signs on a client 4 hours after delivery 3 Assessment of a postpartum client's episiotomy 4 Assisting the postpartum client to breastfeed for the first time

-Vital signs on a client 4 hours after delivery Evaluating the client's lochia, assess the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.

A client who has had a cesarean birth is being discharged. What statement indicates to the nurse that teaching is required? 1 "I may take a Percocet tablet if my incision hurts." 2 "I should take a mild laxative if I don't have a bowel movement." 3 "I can start mild exercises once my incision has stopped hurting." 4 "I don't need perineal care because I didn't give birth through the vagina."

-"I don't need perineal care because I didn't give birth through the vagina." After a cesarean birth, the client has the same vaginal discharge (lochia) as a client who gave birth vaginally. Perineal care is necessary to prevent an ascending infection. Oxycodone/acetaminophen (Percocet) or a similar analgesic usually is prescribed. Mild laxatives are permitted if needed. Mild exercise is not contraindicated if there is no incisional pain.

What should a nurse teach a non-nursing mother to help relieve the discomfort of engorgement? 1 Empty the breasts manually once a day. 2 Apply cold packs to the breasts frequently. 3 Ask the practitioner to prescribe a medication for pain. 4 Loosen the brassiere until the breast swelling has subsided.

-Apply cold packs to the breasts frequently. Application of cold constricts the vessels and numbs the pain caused by the distention of the vessels with lymph and blood. Emptying the breasts manually once a day is contraindicated because the client is not breastfeeding; this action will stimulate the flow of milk. If the discomfort persists even when the client wears a tight brassiere and applies cold packs, an over-the-counter analgesic should be sufficient for relief. A tight brassiere maintains alignment of blood and lymph vessels and prevents further engorgement.

A nurse who is caring for a mother and her newborn infant reviews their record. In light of the data the record contains, what nursing intervention is required? 1 Neonatal blood transfusion 2 Maternal rubella vaccination 3 Maternal RhoGAM injection 4 Neonatal 50% glucose infusion

A rubella titer of 1:2 is inadequate immunization. A titer of 1:8 is considered immunity. Rubella immunization protects the fetuses of future pregnancies from significant birth defects caused by a rubella infection. These laboratory results are borderline for pregnancy but were taken during the prenatal period and do not represent the woman's current status. There is no evidence that the neonate needs a transfusion. A RhoGAM injection is not needed because the infant also is Rh negative. Neonatal 50% glucose infusion is an expected glucose level for a neonate.

The nurse is preparing to discharge a 3-day-old infant who weighed 7 lb at birth. Which finding should be reported immediately to the health care provider? 1 Hemoglobin of 16.2 g/dL 2 Weight of 6 lb 4 oz 3 Total serum bilirubin of 10 mg/dL 4 Three wet diapers over the last 12 hours

-Weight of 6 lb 4 oz A loss of 12 oz since birth, or more than 10%, is higher than the acceptable figure of 5% to 6%. Hemoglobin of 16.2 g/dL, total serum bilirubin of 10 mg/dL, and three wet diapers over the last 12 hours are all normal and expected findings.

An Rh-negative mother who gave birth at 10:30 am on January 7 should receive her Rh immune globulin (RhoGAM) injection no later than: 1 10:30 pm on January 11 2 10:30 pm on January 11 3 10:30 am on January 10 4 10:30 pm on January 10

-10:30 am on January 10 RhoGAM needs to be administered within 72 hours of delivery. Administration at 10:30 pm on January 10 or at any time on January 11 is too late.

Assign an Apgar score to this infant: heart rate 110, crying vigorously, moves all extremities, cries when suctioned, blue extremities with pink body. Apgar score________

-A heart rate above 100 beats/min scores 2 points, vigorous crying scores 2 points, moving all extremities scores 2 points, reflex irritability scores 2 points, and blue extremities with a pink body scores 1 point, for a total Apgar score of 9. http://www.firstaidforfree.com/wp-content/uploads/2016/02/Apgar-score.png

A nurse teaches a multipara who has just given birth to a large baby how she can maintain a contracted uterus. Which statement indicates to the nurse that the teaching was effective? 1 "If I start to bleed, I'll call for help." 2 "I'll massage my uterus regularly to keep it firm." 3 "If I urinate frequently, my uterus will stay contracted." 4 "I'll call you every 15 minutes to massage my uterus."

-"I'll massage my uterus regularly to keep it firm." The uterus responds rapidly to touch, and the mother may be involved in her own care. The uterus must be massaged before there are signs of bleeding. Although frequent urination may be beneficial, the client should be taught to massage the uterus to cause it to contract. Stating that she will call every 15 minutes to have her uterus massaged does not actively involve the mother in her own care and could be unsafe if the uterus becomes boggy during the 15-minute intervals.

A client who is breastfeeding tells a nurse that her breasts are swollen and painful. What can the nurse teach her to do to limit engorgement? 1 "Breastfeed four times a day, then offer water if the baby cries." 2 "Offer just one bottle a day when you're experiencing discomfort." 3 "Nurse at least every 3 hours for at least 10 minutes on each breast." 4 "Limit nursing to 4 to 6 minutes on each breast at least six times a day."

-"Nurse at least every 3 hours for at least 10 minutes on each breast." Frequent nursing reduces engorgement. A 10-minute session permits complete emptying of the breast. Offering water will not decrease engorgement; in addition, the infant will be deprived of nourishment. A relief bottle will prevent emptying of the breasts; it will increase pain and swelling. Limiting nursing does not permit complete emptying of the breasts

A client who just gave birth has three young children at home. She comments to the nursery nurse that she must prop the baby during feedings when she returns home because she has too much to do and, anyway, holding babies during feedings spoils them. What is the nurse's best response? 1 "You seem concerned about time. Let's talk about it." 2 "That's up to you; you have to do what works for you." 3 "Holding the baby when feeding is important for development." 4 "It's not safe to prop a bottle. The baby could aspirate the fluid."

-"You seem concerned about time. Let's talk about it." Asking the client to discuss her concerns about time opens up an area of communication to determine what really is troubling the mother about feeding her baby. The nurse is aware that this is not the best method when using a bottle to feed an infant; the problem of time should be explored with the mother. Holding may be accomplished at times other than feeding periods; telling the client that holding the baby during feedings is important does not explore the client's feelings. Although it is true that it is not safe to prop a baby because of the risk of aspiration, the mother should not be challenged so directly; a gentler explanation should be offered.

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. What is the next nursing action? 1 Checking with the nurse manager to see whether the client may go home 2 Reassessing the client for signs of infection by taking her vital signs 3 Delaying the client's discharge until the practitioner has conducted a complete examination 4 Placing the report in the client's record because this is an expected postpartum finding

-Placing the report in the client's record because this is an expected postpartum finding Leukocytosis (15,000-20,000/mm3 WBC) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention, because the client is exhibiting an expected postpartum leukocytosis.