Postpartum Period

The nurse is teaching a client who gave birth to a healthy newborn about the procedures in place to prevent infant abduction. Which information does the nurse include? Select all that apply. "Do not release the newborn to anyone you are unsure about." "Stay with your baby at all times, and maintain visual contact." "Always lock the bassinet's wheels when it is not being moved." "Ask to see the identification badge of anyone entering your room." "Do not remove the identification bands from your baby."

"Do not remove the identification bands from your baby." "Do not release the newborn to anyone you are unsure about." "Ask to see the identification badge of anyone entering your room."

The nurse is teaching a client about oral contraceptive therapy. The client reports missing three doses of the scheduled medication. Which statement made by the client indicates understanding of the teaching regarding oral contraceptives? "If I miss any doses, I will take all the missed doses as soon as I notice the oversight." "I will take two pills for the next 2 days and use an alternative contraceptive method until the next cycle." "I will take three pills for the next 3 days and use an alternative contraceptive method until the next cycle." "I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."

"I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."

One week after giving birth, a client comes to the clinic for a check up. The client tearfully tells the nurse, "I should feel happy, but I don't. What's wrong with me?" Which response by the nurse would be best? "Who do you usually talk to when you have problems?" "It's not unusual to have these feelings after giving birth." "How have you coped with other problems in your life?" "Don't worry. You'll be fine."

"It's not unusual to have these feelings after giving birth."

A client is 2 days postpartum and is experiencing bleeding. She asks the nurse, "Will it always be like this?" Which statement by the nurse would be the most accurate? "This is lochia rubra and will last 3 to 4 days." "This is lochia alba and will last 4 weeks." "This is lochia serosa and will last 2 days." "This is your menstrual cycle and will last 6 weeks."

"This is lochia rubra and will last 3 to 4 days."

The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as: 50 ml 200 ml 100 ml 150 ml

100 ml

The nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? Perform perineal care after voiding or a bowel movement. Drink plenty of fluids. Take a sitz bath. Apply an ice pack to her perineum.

Apply an ice pack to her perineum.

The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. In what order, from first to last, should the nurse perform the listed steps? All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Place one hand on the abdomen just above the symphysis pubis and the other on top of the fundus. 2 Place the client in a supine position. 3 Ask the client to void. 4 Document the findings. 5 Rotate the upper hand to massage the uterus until firm.

Ask the client to void. Place the client in a supine position. Place one hand on the abdomen just above the symphysis pubis and the other on top of the fundus. Rotate the upper hand to massage the uterus until firm. Document the findings.

A nurse enters a postpartum client's room to collect data and observes the perineal pad is completely saturated with lochia rubra. Which action by the nurse is the priority? Have the charge nurse review the finding. Immediately call the health care provider. Ask the client when she last changed her perineal pad. Vigorously massage the fundus.

Ask the client when she last changed her perineal pad.

The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? Close all of the doors on the unit. Permit the mothers and their neonates to continue sleeping. Do nothing because it's most likely a fire drill. Immediately evacuate the unit.

Close all of the doors on the unit.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? Notify security because the neonate's father is demanding to see his baby. Invite everyone into the large conference room to see the neonate. Discuss the unit's policy with the charge nurse. Teach the grandparents how to scrub and gown before entering the nursery.

Discuss the unit's policy with the charge nurse.

The nurse is caring for a breastfeeding client on her second postpartum day. The breast is enlarged, firm, and warm to touch. Which action is the nurse expected to take? Encourage the client to breast feed the baby more frequently and regularly. Assist the client to apply a cold compress to the breast Obtain vital signs Send the breast milk for culture and sensitivity

Encourage the client to breast feed the baby more frequently and regularly.

A nurse is caring for a client who gave birth to a stillborn neonate at 36 weeks' gestation. Which action taken by the nurse is most helpful in helping the client cope with the loss of the baby? Be selective in providing the information that the client seeks. Encourage the client to see, touch, and hold the dead neonate. Provide information about possible causes of the stillbirth only if the client requests it. Let the child's father decide what information the client receives.

Encourage the client to see, touch, and hold the dead neonate.

A couple in the antenatal unit is not satisfied with the care they are receiving. They have spent the past 15 minutes expressing dissatisfaction to the nurse about the care the client is receiving today. What is the most appropriate response by the nurse? Encourage them to talk for 10 more minutes and then remind them that there are other tasks to perform on the unit. Encourage the family to identify their frustrations and fears. Explain that the unit is short staffed and that the nurses are doing the best they can. Call the nurse manager to speak with the couple.

Encourage the family to identify their frustrations and fears.

During the postpartum period, the nurse anticipates normal involution. Which action taken by the nurse promotes involution? Encourage the mother to breast feed. Encourage a sitz bath daily. Increase fluid intake. Encourage bed rest.

Encourage the mother to breast feed.

A nurse is preparing to evaluate a client who gave birth 6 hours ago. Which statement best explains the use of gloves during the postpartum evaluation? Gloves protect the client from the nurse's cold hands. Gloves are an essential part of standard precautions. Gloves provide a barrier for the nurse against infectious organisms. Gloves act as a barrier for the client against infectious organisms.

Gloves are an essential part of standard precautions.

The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What should the nurse monitor during the immediate postpartum period of this client? Heart rhythm via electrocardiogram (ECG) Height of fundus Blood glucose level Stool test for occult blood

Height of fundus

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding? Replace the pad and apply pressure to the vagina. Increase the IV fluids. Massage the fundus. Administer oxytocin as ordered.

Massage the fundus.

A postpartum client with diabetes wants to breast-feed but is concerned about the effects of breast-feeding on her health. Which response would be most appropriate? Mothers with diabetes shouldn't breast-feed because of potential complications. Mothers with diabetes who breast-feed have a hard time controlling their insulin needs. Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding. Mothers with diabetes shouldn't breast-feed; insulin requirements usually are doubled.

Mothers with diabetes may breast-feed; insulin requirements may decrease from breast-feeding.

A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? Performing a pad count Inserting an indwelling urinary catheter Administering packed red blood cells Performing fundal massage

Performing fundal massage

The nurse assesses a client who gave birth 4 hours earlier. Which of the following findings would highlight the need for further evaluation? Thirst and fatigue Chills Scant lochia rubra Temperature of 100.2° F (37.9° C)

Scant lochia rubra

A nurse meets a neighbor and new baby at the local market. The neighbor states that she received outstanding nursing care from one of the nurse's colleagues during her labor and childbirth. What is the best way for the nurse to recognize her nursing colleague's professional efforts? Post accolades to the nurse at the nurses' station. It is a breach of confidentiality to share this information with the colleague. Share the feedback with the nursing colleague directly. Send the colleague an anonymous card.

Share the feedback with the nursing colleague directly.

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his or her mouth. Which of the following actions would enhance latching on to the nipple? Stroke the neonate's lips gently with the nipple. Tilt the bottle so that the nipple fills with formula. Use a nipple with the largest possible opening. Squeeze the baby's lower jaw to open the mouth.

Stroke the neonate's lips gently with the nipple.

A multiparous client with pelvic thrombophlebitis is being treated with bed rest and anticoagulant therapy. The nurse should call for assistance immediately if the client experiences which symptom? Increased blood pressure Sudden onset of shortness of breath Pain in the pelvic area Urine retention

Sudden onset of shortness of breath

The nurse is providing discharge teaching to caregivers of a healthy newborn about the proper usage of a car seat. Which information does the nurse include? Select all that apply. Install the car seat on the passenger side of the back seat so the driver can always see the car seat easily. If the vehicle is equipped with universal anchoring system hooks, these should be used to secure the seat. The child should be rear-facing until the child exceeds the manufacturer's size restrictions for the seat. If the vehicle has no backseat, ensure the passenger seat where the car seat is placed has a working airbag. Ensure the car seat is installed so that the newborn is seated at about a 45-degree angle and not upright.

The child should be rear-facing until the child exceeds the manufacturer's size restrictions for the seat. If the vehicle is equipped with universal anchoring system hooks, these should be used to secure the seat. Ensure the car seat is installed so that the newborn is seated at about a 45-degree angle and not upright.

The nurse is caring for a client on the fourth postpartum day. The nurse is expecting to observe which behavior in the client on the fourth postpartum day? The client asks many questions about the baby's care. The client asks the nurse to help her bathe herself. The client asks the nurse to select her meals for her. The client wants to relate her birth experience.

The client asks many questions about the baby's care.

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor? positioning a rooming-in neonate's bassinet toward the center of room rather than near the door to the hallway affixing matching identification bands to the parents and neonate at birth affixing a security bracelet that monitors movement to a neonate allowing volunteers to return neonates to the nursery

allowing volunteers to return neonates to the nursery

A new mother is discharged 16 hours after a vaginal birth. After reviewing the client's discharge instructions, the nurse determines that the teaching was successful when the client states that she will contact her health care provider if she develops which symptom? vaginal tenderness and dryness during sexual activity increased flow of bright red lochia uterus that is no longer palpable abdominally after 2 weeks fatigue with weight loss

increased flow of bright red lochia

A nurse is collecting data on a client who gave birth yesterday. Where would the nurse expect to find the top of the client's fundus? at the level of the umbilicus below the symphysis pubis one fingerbreadth below the umbilicus one fingerbreadth above the umbilicus

one fingerbreadth below the umbilicus

A client needs to void 3 hours after a vaginal birth. The nurse implements safety precautions when getting the client out of bed based on an understanding that the client is at risk for which condition? chest pain separation of episiotomy incision orthostatic hypotension breast engorgement

orthostatic hypotension

Two days after a cesarean birth, a client is diagnosed with deep vein thrombosis. Which complication is this client at greatest risk for? peripheral venous disease coronary artery disease pulmonary embolism hematoma

pulmonary embolism

A nurse is providing care to a postpartum client on her second day. What appearance does the nurse anticipate the lochia will have on the second postpartum day? red with moderate flow brown and scant amount continuous flow with red clots thin consistency and white in color

red with moderate flow

A community nurse makes their introduction to the family and outlines the purpose of the home visit. The nurse asks permission before sitting on the mattress beside the postpartum mother in the bedroom. Which element of the therapeutic relationship do these behaviors demonstrate? choice genuineness accountability respect

respect

A nurse is providing care to a postpartum client. As part of the client's plan of care, the nurse reinforces the need to perform Kegel exercises based on which reason? to assist with lochia removal to promote the return of normal bowel function to promote blood flow, enabling healing and muscle strengthening to assist the client in burning calories for rapid, postpartum weight loss

to promote blood flow, enabling healing and muscle strengthening