Postpartum Period
A 15-year-old primiparous client is being cared for in the hospital's birthing center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a social service agency. Four hours postpartum, the client asks if she can feed her baby. Which response would be most appropriate? "I think we should ask your health care provider if this is a good idea." "It's not a good idea for you to have any contact with the baby." "I'll bring the baby to you for feeding." "I'll check with the social worker to see if the adopting parents will permit this."
Correct response: "I'll bring the baby to you for feeding." Explanation: After birth, the client should make the decision about how much she would like to participate in the neonate's care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The health care provider (HCP) does not need to be contacted about the client's desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.
A client two days postpartum was given a shot of RhoGAM. At the postpartum home visit, the client asks the nurse why she needed RhoGAM. What is the most appropriate response by the nurse? "RhoGAM suppresses antibody formation in women with RH negative blood after giving birth to an Rh negative baby." "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh positive baby." "RhoGAM suppresses antibody formation in women with Rh positive blood after giving birth to an Rh negative baby." "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby."
Correct response: "RhoGAM suppresses antibody formation in women with Rh negative blood after giving birth to an Rh positive baby." Explanation: RhoGAM is indicated to suppress antibody formation in women with Rh negative blood after giving birth to an RH positive baby. It is also given to Rh negative women after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.
After suction and evacuation of a complete hydatidiform mole, the 28-year-old multigravid client asks the nurse when she can become pregnant again. The nurse would advise the client not to become pregnant again for at least how long? 24 months 12 months 6 months 18 months
Correct response: 12 months Explanation: A client who has experienced a molar pregnancy is at risk for development of choriocarcinoma and requires close monitoring of human chorionic gonadotropin (hCG) levels. Pregnancy would interfere with monitoring these levels. High hCG titers are common for up to 7 weeks after the evacuation of the mole, but then these levels gradually begin to decline. Clients should have a pelvic examination and a blood test for hCG titers every month for 6 months and then every 2 months for 1 year. Gradually declining hCG levels suggest no complications. Increasing levels are indicative of a malignancy and should be treated with methotrexate. If after 1 year the hCG levels are negative, the client is theoretically free of the risk of a malignancy developing and could plan another pregnancy.
The nurse is caring for a client 2 days post-cesarean section who is scheduled for discharge today. The client states, "I do not want to go home." What response by the nurse is most appropriate? Ask the client if she has any support in the home. Ask the client the reason she does not want to go home. Inform the healthcare professional (HCP) that the client does not want to go home. Tell the client that she must go home as per hospital policy.
Correct response: Ask the client the reason she does not want to go home. Explanation: It is important for the nurse to identify the client's concerns and reasons for wanting to stay in the hospital. This kind of open-ended questioning facilitates both effective and therapeutic communication and allows the nurse to address the client's concerns appropriately. Asking the client about supports in the home may imply that the nurse is making an assumption about the reason why the client may not want to go home. Informing the HCP or telling the client it is hospital policy is not appropriate at this time because the nurse is unsure of the underlying reason. This is particularly important because the client may have safety-related concerns, may have undisclosed fears, or may require increased support before being discharged. It is imperative that the nurse not make assumptions but further explore the client's concerns.
The clinic nurse is assessing a postpartum client's fundus at the umbilicus 2 weeks after giving birth. Which of the following would the nurse include in the client's plan of care? Assess the client's legs for thrombophlebitis. Ask if the client is bottle feeding. Assess the client's bleeding flow and color. Have the client see the healthcare provider in 2 weeks.
Correct response: Assess the client's bleeding flow and color. Explanation: The client is 2 weeks postpartum and the fundus should be deep in the pelvis. Six to 12 hours after birth, the fundus should be at the umbilicus. Then, each postpartum day, the fundus should decrease one finger breadth under the umbilicus. Bottle feeding will not affect the level of the fundus. Assessment of the client's legs will not affect the client's fundus level. However, bleeding and color will provide further assessment of the client's postpartum healing status. Waiting to 2 weeks for the client to see the healthcare provider is too long.
The nurse is documenting medication administration at the bedside and realizes docusate sodium was administered to the wrong postpartum client. Which action should the nurse take first? Complete an incident report. Complete a head-to-toe assessment. Disclose the error to the client. Retrieve the client's allergy data.
Correct response: Disclose the error to the client. Explanation: Nurses should uphold the standards for safe, competent, and ethical care and ensure personal and professional accountability as per the American Nurses Association (Canadian Nurses' Association) Code of Ethics. The nurse has an ethical obligation to be truthful with the client. The error should be disclosed and explained openly. The nurse can ask the client about allergies at that time as well. Though an incident report will need to be completed, this will take place later. An assessment should be performed, but there will be no effects from swallowing oral docusate sodium in the first few minutes! Even if the error seems benign, the same ethical and policy guidelines apply.
A student nurse is accompanying a community health nurse for the day. The RN asks the parents at the home visit if the student can be present for the breastfeeding assessment. The mother's partner declines this opportunity. What is the nurse's most appropriate response? Ask the partner to leave the premises. Reassure the partner that the student nurse will be professional. Ask the partner about any concerns. Honor the partner's preference.
Correct response: Honor the partner's preference. Explanation: When providing services such as a postpartum visit in someone's home, the nurse needs to respect the culture, values, and personal preferences of the resident family members. The other responses are negating of the family's wishes and could be seen as confrontational and not client centered.
A nurse is teaching a group of clients about birth control methods. When providing instruction about subdermal contraceptive implants, the nurse should cite which feature as the main advantage of this method? The implants can be removed easily if pregnancy occurs. The implants require a lower hormonal dose than other hormonal contraceptive methods. The implants provide effective, continuous contraception that isn't user dependent. The implants cost less over the long term than other contraceptive methods.
Correct response: The implants provide effective, continuous contraception that isn't user dependent. Explanation: Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception that isn't user dependent. The effectiveness of other methods, such as the condom, diaphragm, and oral contraceptives, depends at least partly on the user's knowledge, skills, and motivation.
A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information? Use a warm moist compress over the painful area. Wear a loose-fitting bra to avoid constricting the milk ducts. Stop breast-feeding permanently. Take antibiotics until the pain is relieved.
Correct response: Use a warm moist compress over the painful area. Explanation: Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside.
When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would explain to the parents that the medication is used to prevent which problem? cataracts from beta-hemolytic streptococcus chorioretinitis from cytomegalovirus blindness secondary to gonorrhea strabismus resulting from neonatal maturation
Correct response: blindness secondary to gonorrhea Explanation: The instillation of erythromycin into the neonate's eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate's eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.
A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which symptom should the nurse instruct the client to report to her primary caregiver? breakthrough bleeding within first 3 months of use decreased menstrual flow blurred vision and headache breast tenderness
Correct response: blurred vision and headache Explanation: Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the healthcare provider. Because these two effects in particular may result in cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.
On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most consistent with the client's statement? postpartum psychosis postpartum depression poor coping skills postpartum "blues"
Correct response: postpartum "blues" Explanation: Postpartum "blues" are a normal, expected finding 2 days postpartum. About 50% to 70% of postpartum clients experience transient depression during the first 7 to 10 days after giving birth. Postpartum depression and postpartum psychosis aren't seen until later than the second day postpartum. A statement by the client about not being able to care for her neonate or herself would indicate poor coping skills.
A woman who is Rh negative has given birth to an Rh-positive infant. The nurse explains to the client that she will receive Rho(D) immune globulin. The nurse determines that the client understands the purpose of the treatment when she reports that Rho(D) immune globulin has which action? preventing jaundice in her baby preventing antibody formation in her blood protecting her next baby if it is Rh negative preventing antigen formation in her baby's blood
Correct response: preventing antibody formation in her blood Explanation: Rho(D) immune globulin is given to new mothers who are Rh negative and not previously sensitized and who have given birth to an Rh-positive infant. Rho(D) immune globulin must be given within 72 hours of the birth of the infant because antibody formation begins at that time. The vaccine is used only when the mother has borne an Rh-positive infant—not an Rh-negative infant. Rho(D) immune globulin is not given to a newborn and does not affect antigen formation. Administering Rho(D) immune globulin after birth reduces risk of hyperbilirubinemia in newborns from future pregnancies, but it will not reduce the risk to the current newborn.
Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines that the client understands the instructions when she states which as the purpose of the drug? to prevent further blood clot formation to increase the perspiration for diuresis to increase the lochial flow to thin the blood clots
Correct response: to prevent further blood clot formation Explanation: Heparin therapy is prescribed to prevent further clot formation by inhibiting further thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the puerperium is increased lochia flow, so the nurse must be observant for symptoms of hemorrhage, such as heavy lochial flow. Heparin does not increase diaphoresis, which is normal for the postpartum client.
The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under regional anesthetic. When does the nurse tell the client that the sleeves will be removed? when the client resumes ambulating after sensation returns to the lower extremities just prior to the client's discharge when the platelet levels return to normal
Correct response: when the client resumes ambulating Explanation: A cesarean birth is an independent risk factor for thromboembolic event in pregnant women. Inflatable compression sleeves should be placed on the lower extremities of a client until risk of venous stasis is reduced through ambulation. While return of sensation must happen before the client can safely ambulate, this finding alone does not significantly decrease the risk of venous stasis. Platelets continue to be significantly elevated for at least 3 weeks after birth, which is well after a client would be discharged. It is unnecessary to continue wearing the compression sleeves after ambulation has returned.