Postpartum NCLEX questions

The nursing student is assigned to care for a client in the postpartum unit. The coassigned registered nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method?

"I should weigh the perineal pad before and after use and note the amount of time between each pad change." To gather accurate data for comparison, the perineal pads must be weighed both before and after use. Once these weights are gathered, the amount of lochia flow can be accurately determined. Noting the time frame between pad changes and the number of pads used also is an important factor. Gauging the amount of staining does not provide accurate data. Asking the client to obtain the information also may not provide accurate data.

A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client

Begin feeding on the less sore nipple.

The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?

My left breast is sore, so I will offer only my right breast frequently for breastfeeding."

The nursing instructor is reviewing the plan of care for a postpartum client with a student. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which responses made by the student indicate an understanding of this phase? Select all that apply.

"The client may complain of lack of sleep and fatigue." "The client is self-focused and talks to others about labor." Rubin has identified 3 phases of regeneration during the postpartum period. The taking-in phase occurs in the first 3 days postpartum, and the taking-hold phase occurs between days 3 and 10. During the taking-in phase, the new mother is attempting to integrate her labor and birth experience. She tends to need sleep and feels fatigued, talks about labor, and is self-focused and dependent. In the taking-hold phase, the client is more active and independent, initiates activities, and partakes in mothering tasks. In the letting-go phase, the mother may grieve over the separation of the baby from part of her body.

The nurse is monitoring a postpartum client who is at risk for developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, supports a diagnosis of postpartum endometritis?

Abdominal tenderness and chills Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104º F (37.9º C). This intrauterine infection may lead to further maternal complications, such as infections of the fallopian tubes, ovaries, and blood (sepsis). Increased diuresis and appetite, slight elevation in temperature, and firm fundus, midline below the umbilicus represent normal maternal physiological responses in the immediate postpartum period.

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis?

Ambulate frequently. Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. The other options may be interventions for the client diagnosed with thrombophlebitis. In addition, bed rest promotes stasis.

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client?

Maternal overexertion The immediate postpartum period is associated with increased risks for the cardiac client. Hormonal changes and fluid shifts from extravascular tissues to the circulatory system cause additional stress on cardiac functioning. Although infection, maternal attachment, and bonding are appropriate nursing concerns during the postpartum period, the primary concern for the cardiac client is to maintain a safe environment because of the potential for cardiac compromise.

Which instructions should the nurse provide to a client following delivery on care of the episiotomy site to prevent infection? Select all that apply.

Report a foul-smelling discharge. Take a warm sitz baths 3 times a day. Use warm water to rinse the perineum after elimination. Wipe the perineum from front to back after voiding and defecation. Warm sitz baths and cleansing with warm water are helpful for relieving pain, and these measures will promote cleanliness in the perineal area to prevent infection. Lochia should not have a foul smell; if it does, this should be reported immediately to the primary health care provider. The client also should be instructed that the perineal pad should be changed after each elimination and may be changed in between. Warm water should be used to rinse the perineum after elimination. The client should also be instructed to wipe the perineum from front to back after voiding and defecation to decrease the risk for contamination with microorganisms from the anus to the vagina.

The nurse is reinforcing instructions to the mother following delivery regarding care of the episiotomy site to prevent infection. Which statement by the mother indicates a need for further teaching?

I will change the perineum pads three times a day."

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement?

Massage the breasts before feeding to stimulate let-down.

The nurse is caring for a client during the immediate recovery phase or fourth stage of labor. Which action is most important for the nurse to take at this time?

Check the uterine fundus and lochia.

The nurse is preparing to care for a woman in the immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the woman's vital signs at which time intervals?

Every 15 minutes for the first hour and then every 30 minutes for the next 2 hours

The nurse is checking lochia discharge on a client in the immediate postpartum period and notes that the lochia is bright red and contains some small clots. Which interpretation should the nurse make about this finding?

The finding is normal.

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching?

"Foods and fluids that will increase urine alkalinity should be consumed."

The nurse has reinforced instructions to a new mother about how to perform postpartum exercises. The nurse determines that the client understands the instructions when she makes which statement?

"I should alternately contract and relax the muscles of the perineal area."

The postpartum unit nurse has provided discharge instructions to a client planning to breast-feed her normal, healthy infant. Which statement by the client indicates an understanding of the instructions?

"If I notice any pain, redness, or swelling in my breasts, I should contact the primary health care provider." Signs and symptoms of infection include pain, redness, heat, and swelling of a localized area of the breast. If these signs or symptoms occur, the client needs to contact the primary health care provider. Sweating, experiencing uterine pains with breast-feeding, and lochia after 7 days are normal changes that occur in the postpartum period.

The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?

500 calories per day If the client is breast-feeding, her calorie needs increase by approximately 500 calories/day. The client should also be instructed on the need for increased fluids and the need for prenatal vitamins and iron supplements.

The nurse is assisting in developing a plan of care for a client preparing to breastfeed. In planning care, which factor is most significant in teaching a client to breastfeed?

A positive nurse-client relationship

A postpartum nurse reinforces information provided to a new mother following a vaginal delivery regarding a sitz bath. The nurse determines that the client understands the purpose of the sitz bath when the client makes which statement?

A sitz bath will promote healing of the perineum."

The nurse is monitoring a client at risk for postpartum endometritis. Which observation noted during the first 24 hours after delivery supports this diagnosis?

Abdominal tenderness and chills

A postpartum client is at high risk for infection. A goal has been developed that states, "The client will not develop an infection during her hospital stay." Which data support that the goal has been met?

Absence of fever

The nurse is performing a postpartum fundal assessment on a client 6 hours after delivery. The nurse finds the fundus above the umbilicus and displaced to the right. Which intervention should the nurse do first?

Assist the client to the bathroom to void and then reassess the fundus.

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity?

Breast-feeding Afterpains are a normal occurrence and result from contractions of the uterus as it reduces in size during involution. Afterpains may be especially noticeable during breast-feeding because oxytocin is released in response to the infant's sucking. Ambulating, taking sitz baths, and increasing activity do not affect afterpains.

In order to prevent mastitis, which discharge instructions should the breastfeeding postpartum client receive from the nurse? Select all that apply.

Change breast pads frequently. Avoid the use of soap on your nipples. Intermittently expose your nipples to the air.

The nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which assessment finding most likely indicates a hematoma?

Changes in vital signs

The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?

Checks the calf areas for redness or swelling

A pregnant client experienced a uterine rupture with subsequent fetal death. After ensuring that the client is physiologically stable, the nurse should take which approach as the first step to support the client psychologically?

Collect data regarding how the client perceived the event.

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action is appropriate?

Cover the client with a warm blanket. In the postpartum period, a woman may experience a shaking, uncontrollable chill immediately after birth. The exact cause of this fairly common event is not known; however, it is thought to be associated with a nervous system reaction such as a vasovagal response. If the chill is not associated with an elevated temperature, it is of no clinical significance. The appropriate nursing action is to provide a warm blanket to the client and a warm drink if oral intake is not contraindicated.

The nurse suspects that the client has a pulmonary embolism when the client exhibits which signs and symptoms?

Dyspnea, tachypnea, and tachycardia

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client?

Encouraging fluid intake Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.

The nurse is reinforcing instructions to a postpartum cesarean delivery client who is preparing for discharge. Which statement by the client indicates a need for further teaching?

I can start doing abdominal exercises as soon as I get home.

The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?

I should avoid wearing a bra at this time."

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?

Instruct the client to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a primary health care provider's prescription. Option 4 is unnecessary.

The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider?

Pain, redness, or swelling in the breasts

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?

Red

A client is admitted to the labor and delivery suite with an intrauterine fetal demise. The nurse determines that the discussion with the parents was effective in preparing them for the delivery when the parents make which response?

Request to hold the infant following delivery

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

Rest during the acute phase. Wear a supportive, nonunderwire bra. .Maintain a fluid intake of at least 3000 mL. .Continue to breastfeed if the breasts are not too sore.

As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?

She should alternately contract and relax the muscles of the perineal area.

The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement?

Tell me about the delivery of your baby."

Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?

The mother constantly complains of tiredness and fatigue.

The nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red and has a foul odor. The nurse determines that this finding indicates which?

The presence of infection

The nurse provides instructions to a breastfeeding mother who is experiencing breast engorgement about measures that will provide comfort. Which statement by the mother indicates an understanding of these measures?

"I will massage the breasts before feeding to stimulate let-down."

The nurse in a maternity unit is providing emotional support to a client and her significant other who are preparing to be discharged from the hospital after the birth of a dead fetus. Which statement made by the client indicates a component of the normal grieving process?

"We want to attend a support group." A support group can help the parents work through their pain by nonjudgmental sharing of feelings. The correct option identifies a statement that indicates positive, normal grieving. Although the other options may indicate reactions of the client and significant other, they are not specifically a part of the normal grieving process.

A stillborn was delivered in the birthing suite a few hours ago. After the birth, the family has remained together, touching the baby. Which statement by the nurse should further assist the family in their initial period of grief?

"Would you like to hold your baby?"

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? Select all that apply.

A mother who had 10 vaginal exams during labor A mother with a history of previous puerperal infections A mother who experienced prolonged rupture of the membranes Risk factors associated with puerperal infection include a history of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, and retained placental fragments.

The parents of a neonate who is not circumcised asks the nurse why the foreskin should not be retracted. The nurse explains that retracting the foreskin should be avoided because which complication may occur?

Adhesions

The goal for the postpartum client with deep thrombophlebitis is to prevent the complication of pulmonary embolism. In planning care to assist in meeting this goal, the nurse should perform which action?

Administer anticoagulants as prescribed.

The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider?

Administration of a subcutaneous rubella virus vaccine

The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding

Encourage her to hold the infant even when the infant is crying

The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding?

Encourage her to hold the infant even when the infant is crying.

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs?

Every 4 hours During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

vThe nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action?

Keep the client and her family members informed of her progress.

A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.

Lengthening of the umbilical cord udden gush of dark blood from the vagina Appearance of fetal membranes at the introitus

A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.

Less pain Less blood loss More likely to extend with birth of LGA infant

The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

Massage the fundus until it is firm. If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.

When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

Notify the obstetrician (OB). Normally, a few small clots may be noted in the lochia in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.

A second-day postpartum client diagnosed with a stable cardiac condition has scant lochia with a foul odor and a temperature of 102.2° F. The primary health care provider suspects infection and writes prescriptions to treat the client. Which prescription written by the primary health care provider should the nurse implement first?

Obtain culture and sensitivity of lochia and urine.

Which additional daily dietary intake will most closely match the number of additional calories needed by the breast-feeding mother?

Peanut butter and jelly sandwich and glass of 2% milk If the client is breast-feeding, her calorie needs increase by approximately 500 calories/day. Adding only an apple and an orange will be too few calories. The hamburger meal and the chicken breast meal contain significant calories over the required 500 calories.

Which nursing actions should decrease the discomfort of an episiotomy? Select all that apply.

Performing sitz baths Applying ice packs to the perineum for the first 12 to 24 hours

The nurse is caring for a woman who has delivered a baby after a pregnancy complicated with placenta previa. Which complication is the client most at risk for developing?

Postpartum hemorrhage

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?

Prepare the client for surgery.

A client experiences subinvolution during the puerperium. The nurse recalls that which factors are the most common causes for this occurrence? Select all that apply.

Retained placental fragments .Maternal reproductive tract infections

After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery?

Support the mother in her reaction to the newborn infant. Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings.

The postpartum nurse is caring for a mother following delivery of a newborn infant. The nurse performs a perineal assessment on the mother and notes a trickle of bright red blood coming from the perineum. The nurse checks the mother's fundus and notes that it is firm. On review of the mother's record, the nurse also notes that an episiotomy was performed. Which determination should the nurse make based on this information?

The bright red bleeding is abnormal and should be reported.

A 45-year-old woman delivered her first baby by cesarean section 5 days ago. The postpartum recovery has been complicated by thrombophlebitis in her left leg. She cries frequently and requests to have her newborn infant stay in the nursery. The nurse recognizes that the mother may have intensified "postpartum blues" because of which situation?

The client is required to stay on bed rest.

The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

The client with lochia that is red and has a foul-smelling odor Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.

The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn?

The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding. Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission. Option 1 will not affect disease transmission since hepatitis B does not spread through airborne transmission. Options 2 and 3 are appropriate feeding techniques for bottle-feeding but do not minimize disease transmission for hepatitis B.

After surgical evacuation and repair of a vaginal hematoma, a 3-day postpartum mother is discharged. The nurse determines that the mother needs further teaching if the new mother makes which statement?

The only medications that I will take are prenatal vitamins and stool softeners."

The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?

The spouse lacks hope because of the loss of the baby and illness of his wife.

The nurse in the postpartum unit is assigned to care for a client who delivered a full-term, healthy baby. The nurse receives the report and is told that the mother had lost 500 mL of blood during the delivery. When checking the vital signs, the nurse notes that the woman's pulse is 90 beats per minute and is weak and thready. This finding should indicate which accurate interpretation to the nurse?

This may be a sign of hemorrhage or shock.

The nurse is caring for a client who is being treated with antibiotics for mastitis. To reinforce instructions, what does the nurse tell the client?

To complete the entire antibiotic regimen

A postpartum client diagnosed with gestational diabetes is scheduled for discharge. During the discharge, the client asks the nurse, "Do I have to worry about this diabetes anymore?" The nurse should make which response to the client?

You will be at risk for developing gestational diabetes with your next pregnancy and developing overt diabetes mellitus."

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching?

I can resume sexual activity at any time."

The nurse is monitoring a postpartum client who is bleeding for signs of shock. Which indicates an early sign of shock?

An increased pulse rate of 80 to 120 beats/min During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure is not the earliest sign of shock. An increase in the respiratory rate from 18 to 120 breaths/min is not a concern and is within normal range. Complaints of abdominal cramping, feeling tired, and feeling hungry is normal in the postpartum period.

The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?

An increase in the pulse rate from 88 to 102 beats per minute

The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initialnursing action when performing this assessment?

Ask the client to urinate and empty her bladder.

The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate?

Have the mother place the infant in the bassinet and assist the mother in dressing the baby.

When the client has been given instructions about postoperative complications following cesarean delivery, the nurse interprets that the client requires clarification of the information when the client identifies which situation as a reason to notify her primary health care provider?

Her temperature is 99° F.

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note?

At the level of the umbilicus

The nurse has a prescription to give a dose of Rho(D) immune globulin to a client who has delivered an infant. Which criteria need to be met in order to administer this medication? Select all that apply.

Rh negative mother Negative Coombs' test

A postpartum client suspected of having an infection is informed that she will be unable to have the newborn present in the room with her. The nurse plans care, knowing that which problem is the highest priority at this time?

Risk of ineffective bonding between the mother and newborn

The nurse in the newborn nursery is collecting data on a neonate who was born of a mother addicted to cocaine. Which signs/symptoms should the nurse expect to note in the neonate? Select all that apply.

Tremors Irritability Hypertension Exaggerated startle reflex

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

You will need to bottle-feed your newborn." Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is monitoring the client for signs of postpartum depression. Which behavior indicates the need for further assessment related to this form of depression?

The client constantly complains of tiredness and fatigue. Postpartum depression is not the normal depression that many new mothers experience from time to time. The client experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The client also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The client often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating also are present. The client would have little interest in food and experience sleep disturbances.

The nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on these data, the nurse should make which interpretation?

The client is experiencing normal lochia discharge. Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, the client is not hemorrhaging, not in need of increased fluids, and there is no need to contact the PHCP.

The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include?

The diet should include additional fluids. The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. Breast-feeding is not a method of contraception, so birth control measures should be resumed.

The nurse has provided instructions for a postpartum client at risk for thrombosis regarding measures to prevent its occurrence. Which statement, if made by the client, indicates a need for further education?

"I should apply my antiembolism stockings after breakfast." The nurse should instruct the client to apply antiembolism stockings before the client rises in the morning to prevent the venous congestion that will begin as soon as the mother gets up. Circulation can be improved with a regular schedule of activity, preferably walking, and the mother should be instructed to avoid prolonged standing or sitting in 1 position and avoid placing pillows under the knees because of the risk for venous stasis in the lower extremities. The mother also should be encouraged to maintain a fluid intake of at least 2500 mL/day to prevent dehydration and consequent sluggish circulation.

The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply.

"I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily." The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or other medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding, but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers.

The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

"I will begin abdominal exercises immediately." A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery.

A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief?

"What can I do for you?" When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their primary health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious/spiritual practices and beliefs. The correct option provides a supportive, giving, and caring response. Options 2, 3, and 4 are blocks to communication and devalue the parents' feelings.

The rubella vaccine has been prescribed for a new mother. Which statements should the postpartum nurse make when providing information about the vaccine to the client? Select all that apply.

"You need this vaccine because you are not immune to the rubella virus." "You should not become pregnant for 1 to 3 months after the administration of the vaccine." Rubella vaccine is a live attenuated virus that provides immunity for 15 years. A second vaccination is not required to attain immunity. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. If not immune (titer less than 1:8) then the client should be vaccinated in the postpartum period. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 1 to 3 months after its administration. Abstinence from sexual intercourse is unnecessary. Warmth and extreme changes in temperature have no effect on the client who has been vaccinated.

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

3 Within 12 hours after delivery, the fundus may be approximately 1 cm above the umbilicus. Involution progresses rapidly during the next few days after delivery, decreasing approximately 1 cm per day. By the sixth postpartum day, the fundus normally is located 6 cm below the 12 hours after delivery location.

The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?

3 days postpartum After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions. Options 2, 3, and 4 are incorrect.

The clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects the uterine fundus to be located at which area? Click on the image to indicate your answer.

4 Within 12 hours after delivery, the fundus may be approximately 1 cm above the umbilicus. Involution progresses rapidly during the next few days after delivery, decreasing approximately 1 cm per day. By the sixth postpartum day, the fundus normally is located 6 cm below the 12 hours after delivery location.

The nurse has determined that a postpartum client has uterine atony. The nurse should take actions in which priority order? Arrange the actions in the priority order that they should be done. All options must be used.

4. Massage the uterus attempting to achieve firmness. 2. Monitor vital signs. 1. Contact the primary health care provider. 3. Check the amount of drainage on the peripad. When uterine atony occurs, the first nursing action would be to massage the uterus until firm. If this does not assist in controlling blood loss, the primary health care provider is notified. In addition, once bleeding is under control, the nurse should monitor the vital signs and then estimate the amount of blood loss.

The nurse who is employed in a prenatal clinic is performing prenatal assessments on clients who are in their first trimester of pregnancy. The nurse is concerned with identifying clients who may be at risk for the development of postpartum complications. Which client would be at most risk for development of postpartum thromboembolic disorders?

A 39-year-old woman who reports that she smokes Certain factors create a risk for the development of thromboembolic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than 3 pregnancies, and women who have had a cesarean birth.

The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage?

A multiparous client who delivered a large baby after oxytocin induction The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage.

The nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis?

An adolescent experiencing an emergency cesarean delivery for fetal distress Endometritis is an acute infection of the uterine mucous lining immediately after delivery. Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures. Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and an excessive length of labor. The other options provided do not describe the client most at risk for developing endometritis following delivery.

A client has just had surgery to deliver a nonviable fetus resulting from abruptio placentae. As a result of the abruptio placentae, the client develops disseminated intravascular coagulation (DIC) and is told about the complication. The client begins to cry and screams, "God, just let me die now!" Which client problem should be the priority for the client at this time?

Concern about the loss of the baby and personal health The client expresses that there is no way out of the situation except for death; therefore, the client exhibits concern about the loss of the baby and personal health. The data given do not support lack of power. Grieving is a possible client problem at a later time; however, at this time the concern over the loss should take priority. Lack of knowledge is a possible problem later, but not enough data support it at this point, and it is not the priority.

The nurse suspects the presence of uterine atony and massages the uterus, but this action does not assist in controlling blood loss. Which is the next nursing action?

Contact the primary health care provider (PHCP). When uterine atony occurs, the initial nursing action should be to massage the uterus until it is firm. If this does not assist in controlling blood loss, the nurse should contact the PHCP. In addition, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss. Blood administration needs to be prescribed by the PHCP.

The nurse is caring for a client who has just delivered a newborn following a pregnancy with placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa?

Hemorrhage Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The other options are not risks that are specifically related to placenta previa.

The home care nurse's assignment is to visit a new mother at home 24 to 48 hours after discharge. What should the nurse expect to note in a healthy mother who is breast-feeding her newborn infant?

The mother is breast-feeding with the infant in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking, followed by a pause and swallow. The infant should be positioned completely facing the mother with head, neck, and spine aligned. Poor positioning increases the number of attempts for latching on. The infant's head turned toward the breast and the body flat in the mother's arms is incorrect because it demonstrates improper positioning. Cracked nipples, breast engorgement, and sore nipples are all complications that are the result of improper positioning.

A client is diagnosed with placenta previa. The nurse plans care with the understanding that which is associated with placenta previa?

The placenta is implanted in the lower uterine segment. In placenta previa, there is one placenta that is normal size but is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus; therefore, the greatest risk associated with this condition is bleeding.

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal?

The saturation of more than 1 peripad per hour Saturation of more than 1 peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.

Oxytocin is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client monitors for which effectiveresponse from the medication?

Uterine contractions

The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.

Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore. Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client?

Wear a supportive brassiere continuously for 72 hours. Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant.

The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching?

"I need to isolate my infant for 48 hours after starting the antibiotics

A new mother is seen in a health care clinic 2 weeks after giving birth to a healthy newborn infant. The mother is complaining that she feels as though she has the flu and complains of fatigue and aching muscles. On further assessment, the nurse notes a localized area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the nurse about the condition. The nurse should make which response?

"Mastitis can occur at any time during breast-feeding." Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. Mastitis is more common in mothers who are nursing for the first time and usually affects 1 breast only. A supportive bra will not cause mastitis; however, constriction of the breasts from a bra that is too tight may interfere with the emptying of all ducts and may lead to infection.

The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?

Encouraging the client to take pain medication as prescribed

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How should the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used.

1. A 12-hour post-cesarean section delivery gravida 3, para 3 who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks. 2. A 24-hour post-vaginal delivery gravida 4, para 4 who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen. 3. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR). 4. A 48-hour post-cesarean section delivery gravida 1, para 1 who reports not yet having a bowel movement since delivery and requests a stool softener. The 12-hour post-cesarean section delivery client should be assessed first because she is reporting a sensation of wetness; this could be excessive bleeding. The 24-hour post-vaginal delivery client is complaining of pain, which can be treated easily with oral medications; therefore, this client should be assessed next. The 8-hour post-vaginal delivery client who is scheduled for a bilateral tubal ligation has an IV infusion. A baseline assessment must be conducted preoperatively for a bilateral tubal ligation; however, the scheduled operative time is 5 hours away. The client who had a cesarean section delivery 48 hours ago is assessed last, as she is the farthest out from delivery and the effectiveness of a stool softener will be achieved over time with continued administration.

A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?

Breastfeeding is allowed once the baby has been vaccinated."

The nurse is assisting in preparing a plan of care for a client who just delivered a dead fetus. Which initial intervention in meeting the emotional needs of the client and her spouse is appropriate

Gather data from the client and spouse about the perception of the event.

The nurse provides a list of discharge instructions to a client who has delivered a healthy newborn by cesarean delivery. Which statement by the client indicates the need for further teaching?

"A fever on and off is expected and is nothing to worry about." A fever in the postpartum period is not expected, and if this occurs the client should contact the primary health care provider because fever is an indication of infection. Women may ovulate in the postpartum period even without menstruating, so breast-feeding should not be considered a form of birth control. Abdominal exercises should not start until 3 to 4 weeks after abdominal surgery to allow for healing of the incision. Postpartum depression is a concern, and the client should contact her primary health care provider if she is having any depressed feelings.

On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction?

"Foods and fluids that will increase urine alkalinity should be consumed." A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.

A woman infected with the human immunodeficiency virus (HIV) has given birth to an infant who appears normal, and the nurse provides instructions about newborn infant care. Which statement by the mother indicates an understanding of the instructions? Select all that apply.

"I am going to need to bottle-feed my baby." "I need to wash my hands before and after bathroom use." "I can transmit the infection to my baby when I breast-feed." "I am going to contact some support groups to help me cope and learn ways to deal with things when I get home." Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding; therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Note that in the United States HIV infection is considered a contraindication for breast-feeding. However, this may not be the practice in other countries. In developing countries where HIV is prevalent, the benefits of breast-feeding for infants outweigh the risk of contracting HIV from infected mothers. Frequent hand washing is encouraged. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life. Support groups and community agencies can be identified to assist the parents with the newborn's home care, the impact of the diagnosis of HIV infection, and available financial resources.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement made by the client indicates an understanding of the instructions?

"I can use ice packs to assist in alleviating some of the discomfort." Mastitis is an inflammation of breast tissue that sometimes involves an infection. Possible causes are a blocked milk duct or bacteria entering the breast. It usually occurs within the first three months of breast-feeding. Symptoms include breast pain, swelling, warmth, fever, and chills. Antibiotics are required. Mild pain relievers can help with discomfort. In most cases, the client can continue to breast-feed with both breasts. If the affected breast is too sore, the client can pump that breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

A pregnant woman who is infected with the human immunodeficiency virus (HIV) delivers a newborn infant, and the nurse provides instructions to help the mother regarding care of the infant. Which statements by the client indicate the need for further instruction? Select all that apply.

"I need to breast-feed, especially for the first 6 weeks postpartum." "My baby has no symptoms so it is not likely that he has gotten the infection from me." Perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore, HIV-positive clients should be encouraged to bottle-feed their neonates. Currently, in the United States, HIV infection is considered a contraindication for breast-feeding. Note that this may not be the practice in other countries. In developing countries where HIV is prevalent, the benefits of breast-feeding for infants may outweigh the risk of contracting HIV from infected mothers. Frequent hand washing is encouraged. It is recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life. The infant born to a mother with HIV may be asymptomatic for the first several years of life and should be monitored for immunodeficiency. Infants at risk need to receive all recommended vaccines at the regular schedule; however, no live vaccines should be administered.

The home care nurse visits a client who has delivered a healthy newborn infant via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the client regarding care related to the infection. Which statement, if made by the mother, indicates a need for further instruction?

"I need to isolate the infant for 48 hours after beginning the antibiotics." The infant is not isolated routinely from the mother with a wound infection, but the mother must be taught good hand-washing techniques and how to protect the infant from contact with contaminated articles. If the mother has a wound infection, broad-spectrum antibiotics will be prescribed for the mother, and she should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and sitz baths or warm compresses may be used to provide comfort in the area. There is no need to isolate the infant.

The nurse is providing instructions to a client who has been diagnosed with mastitis. Which statement, if made by the client, indicates a need for further instruction?

"I need to stop breast-feeding until this condition resolves." Mastitis is an infection of the lactating breasts and occurs most often during the second and third weeks after birth, although it may develop at any time during breast-feeding. In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

The discharge nurse is discussing mastitis with a postpartum client. Which statement made by the client indicates a need for further instruction?

"If I develop a fever, chills, or body aches at any time after discharge, I should stop breast-feeding immediately." The mother should not discontinue breast-feeding even if mastitis occurs. Mastitis, a breast infection, is best characterized by a sudden onset of flu-like symptoms; localized breast pain and tenderness; and a hot, reddened area on the breast that often resembles the shape of a pie wedge. Treatment usually includes antibiotics, but the mother should be instructed to feed the baby or pump frequently to adequately empty the affected breast. The remaining options are correct statements.

A postpartum client develops a urinary tract infection. The nurse instructs the new mother on measures to take for treatment of the infection. Which statements, if made by the mother, would indicate a need for further instruction? Select all that apply.

"The prescribed medication needs to be taken until I feel better." "I need to try to hold my urine as long as I can and urinate 3 to 4 times a day." The woman should be encouraged to urinate frequently throughout the day, instructed to take the medication for the entire time it is prescribed, and encouraged to drink at least 3000 mL of fluid each day to flush the infection from the bladder. Foods and fluids that acidify the urine should be encouraged. A follow-up urinalysis may be prescribed to ensure that the infection is resolved.

The rubella vaccine has been prescribed for a new mother. Which statement should the postpartum nurse make when providing information about the vaccine to the client?

"You should not become pregnant for 2 to 3 months after administration of the vaccine." Rubella vaccine is a live attenuated virus that provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as a virus and is potentially harmful to the organogenesis phase of fetal development. Informed consent for rubella and varicella vaccination in the postpartum period includes information about possible side effects and the risk of teratogenic effects. The client should be informed about the potential effects of this vaccine and the need to avoid becoming pregnant for 2 to 3 months (or as indicated by the primary health care provider) after administration of the vaccine. Abstinence from sexual intercourse is unnecessary. Heat or extreme changes in temperature have no effect on the person who has been vaccinated. The vaccine is not known to cause anaphylactic reactions.

The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?

"You will need to bottle-feed your newborn." Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?

An increase in the pulse rate from 88 to 102 beats per minute During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?

Ask the client to urinate and empty her bladder. Before fundal assessment is started, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The nurse can then assess the bladder for complete emptying and accurately assess uterine involution. When performing fundal assessment, the woman is asked to lie flat on her back, with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm.

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take?

Assess for hypovolemia and notify the primary health care provider (PHCP). Symptoms of hypovolemia include cool, clammy, pale skin; sensations of anxiety or impending doom; restlessness; and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the PHCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.

A type 1 diabetic mother delivered a 4400-gram newborn 3 hours ago. She has already initiated breast-feeding. What should the nurse plan to do to maintain euglycemia in this client?

Assess her blood glucose before administering any glucose-lowering medications. Frequently, after delivery blood glucose is maintained for several days at a relatively low level, especially when the mother is breast-feeding, as the placental hormones have been depleted. It is not necessary to keep this mother NPO, and not feeding her may actually be harmful to her. No medications to alter her blood glucose should be administered to this mother without having assessment data about her current blood glucose level.

The postpartum unit nurse has provided information on performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that it will promote which action?

Assist in healing and provide comfort. Warm, moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort, promote healing, and reduce the incidence of infection. This warm, moist heat is provided via a sitz bath. Ice is used in the first 24 hours to numb the tissue and reduce edema. Promoting a bowel movement is best achieved by ambulation.

The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma?

Changes in vital signs Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

Client pain level The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.

Which nursing intervention is appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care?

Encourage the client to take pain medication as prescribed. Nursing responsibilities for the care of the client with endometritis include maintaining adequate hydration (3000 to 4000 mL/day), bed rest in Fowler's position to facilitate drainage and lessen congestion, providing appropriate analgesia to lessen the pain, and administering antibiotics as prescribed. If the client's pain is relieved, she will be more likely to participate in newborn care. Asking family members to care for the newborn will not facilitate client participation in newborn care.

The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding.

On assessment of a client who is 30 minutes into the fourth stage of labor, the nurse finds the client's perineal pad saturated with blood and blood soaked into the bed linen under the client's buttocks. Which is the nurse's initial action?

Gently massage the uterine fundus. The most frequent cause of excessive bleeding after childbirth is uterine atony. A major initial intervention to restore adequate tone is stimulation of the uterine muscle via gently massaging the uterine fundus. In addition, a prescription is needed to administer a medication. Calling the obstetrician, assessing the client's vital signs, and administering a bolus of oxytocin may be necessary, but they are not initial actions.

When planning care for a postpartum client who plans to breast-feed her infant, which important piece of information should the nurse include in the teaching plan to prevent the development of mastitis?

Massage distended areas as the infant nurses. Massaging the distended areas as the infant nurses will encourage complete emptying of the breast and prevent milk stasis. Each breast should be offered at each feeding to prevent milk stasis and ensure adequate milk supply. There is no need to discard breast milk. If early signs of mastitis occur, the client usually will be instructed to nurse the infant more frequently because infant sucking is thought to empty the breast more completely. Soap should not be used on the nipples because of the risk of drying or cracking.

On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action?

Massage the fundus. If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Documenting the findings is an appropriate action but is not the initial action. Contacting the obstetrician is not an initial action; however, the obstetrician would be contacted if the massage does not contract the uterus. Ambulating the client could be harmful and cause bleeding.

The nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and not firmly contracted. The nurse should prepare to implement which interventions? Select all that apply.

Massaging the uterus Assisting the woman to urinate Checking for a distended bladder If the uterus is soft and spongy and not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. The nurse should then check for a distended bladder and assist the woman to urinate. Pushing on an uncontracted uterus could invert it, potentially causing massive hemorrhage and rapid shock. Waiting for 1 hour without intervention could result in excessive blood loss. The primary health care provider (PHCP) will need to be notified if uterine massage is not helpful. Pharmacological measures may be necessary to maintain firm contraction of the uterus. An abdominal hysterectomy may need to be performed for massive hemorrhage that is uncontrollable. The question presents no data indicating that hemorrhage is a problem. In addition, the nurse should not schedule an operative procedure.

The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery?

Prepare an ice pack for application to the area. A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent.

A postpartum client is attempting to breast-feed for the first time. The nurse notes that the client has inverted nipples. What nursing action should the nurse take to assist the client in breast-feeding the newborn infant?

Provide breast shells and assist the mother with using a breast pump before each feeding to make the nipples easier for the newborn infant to grasp. Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple. Massaging the breast is an appropriate instruction for the mother with engorgement but will not help with resolving inverted nipples. True inverted nipples will retract if the areola is pressed between the thumb and forefinger. Having the client take a cool shower will only make the mother cold, and it has no effect on inverted nipples.

The postpartum nurse is caring for a woman who just delivered a healthy newborn. The nurse should be most concerned about the presence of subinvolution if which occurs?

Retained placental fragments from delivery Retained placental fragments and infection are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0° F after delivery and the presence of afterpains are expected findings following delivery. Option 4 is not a cause of subinvolution and is unrelated to the subject of the question.

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, indicates a need for follow-up or further assessment related to this form of depression?

The mother constantly complains of tiredness and fatigue. Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty concentrating are also present. The mother would have little interest in food and would experience sleep disturbances.

The nurse caring for a client with a diagnosis of subinvolution should recognize which conditions as causes of this diagnosis? Select all that apply.

Uterine infection Retained placental fragments from delivery Infections and retained placental fragments are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Hormonal levels are not causes of subinvolution.

The nurse is creating a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed?

Elevation of the affected extremity Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. There is usually no need for anticoagulants or anti-inflammatory agents unless the condition persists. Bed rest or limited activity may be prescribed depending on primary health care provider preference. Warm packs may be prescribed to be applied to the affected area to promote healing.

The nurse provides explanation to a client prescribed methylergonovine maleate in the immediate postpartum period. Which statement made by the client demonstrates understanding of the rationale for administration?

It will help prevent bleeding and control bleeding if it occurs."

A postpartum client is diagnosed with a urinary tract infection. Which measures should the nurse instruct the client to take regarding treatment and the prevention of a future infection?

Urinate frequently throughout the day. A client with a urinary tract infection should be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. The client is also taught to wipe the perineal area from front to back after urinating or having a bowel movement. A woman with a urinary tract infection must be encouraged to take medication for the entire time it is prescribed; medication should not be stopped once the client is feeling better.

The nurse visits at home a client who delivered a healthy newborn 2 days ago. The client is complaining of breast discomfort. The nurse notes that the client is experiencing breast engorgement. Which instructions should the nurse provide to the client regarding relief of the engorgement? Select all that apply.

Wear a supportive bra between feedings. Apply moist heat to both breasts for about 20 minutes before a feeding. Feed the infant at least every 2 hours for 15 to 20 minutes on each side. Massage the breasts gently during a feeding, from the outer areas to the nipples. With breast engorgement, the client should be instructed to wear a supportive bra between feedings. In addition, the client should be advised to feed the infant frequently, at least every 2 hours, for 15 to 20 minutes on each side. The infant will have an easier time latching on if the client softens her breast and expresses her milk before a feeding. Instruct the client to apply moist heat to both breasts for about 20 minutes before a feeding. This can be done in the shower or with warm wet towels. During a feeding, it is helpful to massage the breast gently from the outer area to the nipple. This helps stimulate the let-down and flow of milk. Avoiding breast-feeding will promote additional complications.

The nurse is caring for a client with placenta previa who is at high risk for infection and hemorrhage. The nurse plans care based on which information related to the condition?

Fewer muscle fibers in the lower segment of the uterus will result in poor contractions.

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor?

Postpartum infection Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hot flashes. Anxiety and low self-esteem are unrelated to physiological integrity.

The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?

"I should wash my nipples daily with soap and water." Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breast-feed every 2 to 3 hours.

Rho(D) immune globulin is prescribed for a client after delivery of a full-term infant. Before administering the medication, the nurse reviews the client's history, recognizing which circumstance as a contraindication for administering this medication?

Experiencing a severe reaction to prior administered human globulin