Postpartum Quiz
The perinatal nurse routinely screens pregnant women for postpartum depression. Which woman does the nurse screen as the priority? 1. Adolescent 2. Age 35 years or older 3. First pregnancy 4. Ambivalent at first visit
1. Recognized risk factors for postpartum depression include an undesired/unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness. Ambivalence is not unusual, especially in the first trimester. First pregnancy is not a risk factor.
A diabetic patient is 1 day postpartum after an uncomplicated vaginal birth. She wants to know why her blood sugar levels are so much lower than usual. What explanation by the nurse is best? 1. "The levels of hormones that cause an anti-insulin effect are decreased." 2. "The exertion from childbirth is like a massive workout for your body." 3. "Because you are dehydrated, your blood sugar decreases for a few days." 4. "I will call the dietician to see if you are getting enough calories."
1. After childbirth, levels of hormones that exert an anti-insulin effect, such as estrogen, progesterone, human placental lactogen, cortisol, growth hormone, and insulinase, all decline. This leads to a drop in blood glucose in the few days following childbirth.
An infant was born weighing 6 lb (2.72 kg). At the end of 30 days, approximately how much should this infant weigh to demonstrate effective breastfeeding? 1. 6 lb, 4 oz to 7 lb (2.83-3.17 kg) 2. 9 to 11 lb (4-5 kg) 3. 10 to 12 lb, 6 oz (4.5-5.6 kg) 4. 7 to 9 lb (3.17-4 kg)
1. An infant usually loses 5% of body weight during the first few days of life, and then begins gaining weight at the rate of mc028-1.jpg to 1 oz/day. That would result in an infant weighing 6 lb, 4 oz to 7 lb at the end of 30 days.
A nurse is assisting a postpartum woman to get up for the first time after an unmedicated vaginal birth. What action by the nurse is best? 1. Instruct the woman to sit on the edge of the bed prior to standing. 2. Take the patient's blood pressure lying down and then in a standing position. 3. Determine if the woman has normal sensation to her lower extremities. 4. Apply a properly fitting gait belt before assisting the woman.
1. Orthostatic hypotension can occur in the postpartum woman. The nurse should instruct the woman to change positions slowly and sit on the edge of the bed prior to standing up. A gait belt is not necessary. Checking for lower extremity sensation would be important after spinal or epidural anesthetic. Obtaining orthostatic blood pressures is not necessary unless this is an ongoing problem.
A nurse manager has many at-risk mothers in the labor and birth unit. What policy can the manager adapt that would best facilitate mother-baby bonding? 1. Limit separation of mother and baby to exceptional circumstances only. 2. Offer the mother the services of a one-to-one mentor for 1 year. 3. Teach breastfeeding and promote its use exclusively for 1 full year. 4. Encourage attendance at a support group with other at-risk mothers.
1. The most critical action a nurse can take to enhance bonding is to minimize the time the mother and her baby are separated while in the hospital. This policy would be most beneficial to promote bonding. The other ideas are good ones that might be helpful to some new mothers, but the critical action is to minimize separation.
A woman is 1 day post-cesarean birth. The nurse auscultates crackles in her lung bases. Which action by the nurse is best? 1. Have the woman use her incentive spirometer. 2. Notify the provider and document the findings. 3. Facilitate the woman having a chest x-ray. 4. Call respiratory therapy for a breathing treatment.
1. Rales are not uncommon postoperatively and indicate atelectasis. The nurse should have the woman use her spirometer, cough, and deep breathe. The other interventions are not warranted.
A postpartum patient complains of severe perineal pain and a sensation of needing to defecate but cannot pass stool. What action by the nurse is best? 1. Document the findings in the chart. 2. Palpate the perineal area. 3. Administer a stool softener. 4. Offer a warm sitz bath.
2. A perineal hematoma can cause excessive pain and the sensation of needing to defecate. The nurse assesses for this condition by gently palpating the perineal area through sterile gloves while observing for the degree of sensitivity to this touch. If a hematoma is suspected, the provider needs to be notified immediately so that the bleeding can be identified and halted.
A nurse is teaching a postpartum patient about preventing infection after discharge. What action by the patient indicates that she needs additional teaching? 1. Allows milk to dry on her nipples after nursing 2. Removes her peri-pad from back to front 3. Washes her hands prior to using the bathroom 4. Sprays water from the peri-bottle from front to back
2. Removing the peri-pad from back to front increases the likelihood of contaminating the vaginal area with organisms from the rectal area. The other actions are appropriate.
A woman with postpartum depression is being treated with a selective serotonin reuptake inhibitor (SSRI). What statement by the patient requires further action by the nurse? 1. "My baby seemed sleepier so I stopped breastfeeding him." 2. "Adding St. John's wort has really helped my depression." 3. "Increasing my calcium intake seems to have a positive effect." 4. "I have started using aromatherapy and it helps a little."
2. St. John's wort has been used to treat depression but cannot be taken with SSRIs because of the possibility of the patient developing a serious condition known as serotonin syndrome. This herb can also increase the side effects associated with SSRIs. The other statements are appropriate.
A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness and an inability to express milk on the left side when breastfeeding. What nonpharmacological comfort measure does the nurse teach this patient? 1. Expression of milk every 1-2 hours 2. Application of either warm or cold packs 3. Menthol-based lotion to draw the heat out 4. Ice and elevation of the breast when sitting
2. This woman has the manifestations of mastitis and will be treated with antibiotics and analgesics. Comfort measures include applying either warm or cold packs to the breasts. If the woman wishes to continue breastfeeding, she should empty her breasts every 2-4 hours. Elevation and menthol-based lotions are not warranted.
A perinatal nurse is conducting an initial interview and assessment on a new patient in her first trimester of an unplanned pregnancy. The nurse discovers the patient was a victim of child abuse and her husband has left her and returned several times. The nurse should assess this patient for what other issue as the priority? 1. Financial concerns 2. Homelessness 3. Intimate partner abuse 4. Social isolation
3. Although all options are possibilities, this woman has several risk factors for being a victim of intimate partner abuse (unplanned pregnancy, victim of child abuse, marital instability). The nurse should first assess for this (intimate partner abuse) before considering the other situations.
A mother brings her 3-month-old baby to the clinic for a well-baby check. She appears exhausted and when the nurse questions her, the mother explains that she feels that she is the only person who can look after and care for her infant properly, so all of her time is devoted to this task. The nurse should document which of the following? 1. Personal neglect, as evidenced by exhaustion and by not taking care of herself 2. Time management problems, as evidenced by needing the entire day to care for the baby 3. Difficulty with letting-go, as evidenced by excluding her partner from infant care 4. Poor bonding, as evidenced by resentment toward the baby and fatigue.
3. During the letting-go stage, the mother begins to see the baby as separate from herself. The mother should be able to leave the baby with a sitter, make time for herself, and reconnect with her partner. Overprotective mothers have difficulty with this stage due to trouble accepting help and excluding others, especially the partner. There is no evidence that this mother is resentful, is neglecting all of her personal needs, or has time management problems.
A patient is receiving methylergonovine (Methergine) after a vaginal birth. What assessment finding by the nurse warrants immediate intervention? 1. Uterine cramping 2. Headache 3. Palpitations 4. Nausea
3. Methergine can cause headache, dysrhythmias, nausea and vomiting, and other side effects. Palpitations can indicate a cardiac rhythm disturbance and should be reported immediately.
The nursing faculty member explains to a class of nursing students the correct way to assist with perineal care (peri-care) after childbirth. Which action by a student nurse would warrant intervention by the faculty member? 1. Instructs the woman to wash her hands prior to peri-care 2. Washes the hands before assisting woman with her peri-care 3. Removes the peri-pad from back to front and appropriately disposes of it 4. Has woman squirt warm water toward the front of the perineum
3. The peri-pad is removed from front to back to avoid contaminating the vagina with the part of the peri-pad that has come into contact with the rectal area. The other steps are appropriate.
A woman had a cesarean birth after a prolonged trial of labor. When assessing the patient, the nurse notes the patient is lethargic, has a pulse of 130 beats/minute, and states: "I'm glad I have so little lochia; I'm too tired to change my pad." What action by the nurse is most appropriate? 1. Assess the amount of lochia on the peri-pad. 2. Have the woman get up and attempt to void. 3. Cluster the nursing care given to allow uninterrupted sleep. 4. Take a full set of vital signs and call the provider.
4. Signs of puerperal infection include tachycardia, malaise, uterine tenderness, and subinvolution. Lochia can be heavy and foul smelling or scant and odorless, depending on the offending organism. The nurse should take a full set of vital signs, perform a complete assessment, and notify the health-care provider.
An adolescent has vaginally given birth to a healthy baby. What action by the nurse would be most important in developing a plan to help this mother bond successfully? A. Ask the mother about her expectations of the baby and their relationship. B. Determine if the mother plans to keep the baby or give it up for adoption. C. Inquire as to how many family members are available to help care for the baby. D. Refer the mother and her baby to the social worker or to the visiting nurses.
ANS: A Adolescent mothers may have difficulty with bonding and attachment because they have unrealistic ideas of the baby's level of functioning and may not be aware of the baby's level of vulnerability. Asking about the mother's expectations for the baby and their relationship is a good starting point to initiate a discussion about this topic. Plans for keeping or adopting the baby should have already been established. Family members can help give the mother a break from infant care, but the less the mother cares for the baby, the less bonding she will demonstrate. A referral may be needed, but this is not the first action.
The perinatal nurse and student nurse are conducting an assessment on a postpartal woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding sound. How should the nurse document this information? A. A bladder containing about 500 cc of urine B. A full bladder C. An empty bladder D. An overdistended bladder
ANS: C To percuss the bladder, the nurse places one finger flat on the patient's abdomen over the bladder and taps it with the finger of the other hand. A full bladder produces a resonant sound. An empty bladder has a dull, thudding sound.
The perinatal nurse accurately defines postpartum hemorrhage to a group of nursing students by including a decrease in hematocrit levels from prebirth to postbirth by which percentage? A. 5% B. 8% C. 10% D. 15%
ANS: C Postpartum hemorrhage can be defined as a blood loss of greater than 500 mL after a vaginal birth or greater than 1,000 mL after a cesarean birth, a decrease in hematocrit levels by 10% from prebirth to postbirth levels, and the need for transfusion.
A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best? 1. Encourage the woman to drink plenty of fluids. 2. Have the woman cough and deep breathe. 3. Document the findings and notify the provider. 4. Prepare to administer acetaminophen (Tylenol).
1. Dehydration and exertion often cause a transient increase in body temperature up to 100.4°F (38°C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. The findings should be documented, but the provider does not need to be notified. Coughing and deep breathing are good strategies to relieve atelectasis, but this is not the most common cause of elevated temperature after childbirth. The patient may or may not want acetaminophen, but drinking more fluids is the priority over giving an antipyretic medication.
The perinatal nurse describes the need for an assessment for deep vein thrombosis (DVT) in the postpartum patient. Which of the following is one test that can be used as a screening measure for DVT? 1. Homans' sign 2. McBurney's sign 3. Grey Turner's sign 4. Chadwick's sign
1. Homans' sign is often used in the assessment for deep venous thrombosis (DVT) in the leg. To assess for Homans' sign, the patient's legs should be extended and relaxed, with the knees flexed. The examiner grasps the foot and sharply dorsiflexes it. No pain or discomfort should be present. The other leg is assessed in the same manner. If calf pain is elicited, a positive Homans' sign is present. The pain occurs from inflammation of the blood vessel and is believed to be associated with the presence of a thrombosis. Pain on dorsiflexion is indicative of DVT in approximately 50% of patients. A negative Homans' sign does not rule out DVT. Chadwick's sign is a bluish discoloration of the cervix that may indicate pregnancy. Grey Turner's sign is a bruising or bluish discoloration of the flank, often seen in acute pancreatitis. McBurney's sign, an indicator of appendicitis, is a deep tenderness to palpation at McBurney's point.
A nursing student who once lived in the southwest was overheard making disparaging comments about Hispanic immigrants, stating: "They only come here for free medical care." What response by the nursing faculty member is best? 1. "Research actually shows that most immigrants come to find work." 2. "That is a downfall of the Patient Protection and Affordable Care Act." 3. "Why are you only picking one ethnic group about whom to make this statement?" 4. "Most immigrants do not come here for free health care at all."
1. Recent research showed that most undocumented Hispanic immigrants in Texas came to find work as their primary reason. This response is best because it offers factual information and is professional in tone. The Patient Protection and Affordable Care Act does not provide health coverage for undocumented migrants and prohibits them from buying private insurance from the state-sponsored exchanges.
A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best? 1. Call the provider and ask for stronger analgesics. 2. Notify the health-care provider immediately. 3. Document the findings in the patient's chart. 4. Assess if the pain is worse when she sits upright.
4. Headache is not uncommon after childbirth. Patients who received epidural or spinal anesthesia may complain of headaches, especially on assuming an upright position. Because this patient had an epidural, the nurse should first assess for this situation. Asking for stronger pain medication should not be done unless the nurse has completed a comprehensive pain assessment. The health-care provider does not need to be notified right away unless the patient has other symptoms, such as blurred vision. Documentation should be thorough, but the nurse needs to take further action first.
A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, which action by the nurse takes priority? A. Assess sensation in the lower extremities. B. Discontinue the patient's intravenous line. C. Encourage the patient to cough and deep breathe. D. Have the patient sit on the edge of the bed.
ANS: A After a cesarean birth with spinal or epidural anesthesia, the nurse must assess sensation in the woman's legs. She will not be allowed out of bed until sensation returns. Discontinuing the IV line may or may not be appropriate. Coughing and deep breathing are always important for a postoperative patient, but this action is not related to ambulating for the first time. Sitting on the edge of the bed prior to getting up would only be done if the woman had full sensation in her legs.
A postpartum patient is ready for discharge from the hospital with her baby. She describes having some "sad feelings" after her last baby. The perinatal nurse explains that she should seek help in which situation? A. After 2 weeks of continuous sad feelings B. After 3 weeks of continuous sad feelings C. After 1 month of continuous sad feelings D. After 6 weeks of continuous sad feelings
ANS: A Cases of postpartum blues are common. Fifty to 80% of all postpartum women experience some degree of postpartum blues within the first 2 weeks after childbirth. These are usually self-limiting, last several days, and often peak by the end of the first week. After 2 weeks, the woman should seek assistance and have further screening for depression.
A perinatal clinic nurse develops concerns about a postpartum woman and her infant at the first well-baby checkup. The nurse has assessed several risk factors for depression. Which action by the nurse is most appropriate? A. Administer the Edinburgh Postnatal Depression Scale. B. Contact Children and Family Services or Child Protective Services. C. Notify the Visiting Nurses Association and request a home visit. D. Provide information and teaching on the postpartum blues.
ANS: A If the nurse believes that the new mother is demonstrating signs and symptoms of postpartum depression, several depression screening tools are available, including the Edinburgh Postnatal Depression Scale, Postpartum Depression Predictors Inventory, Center for Epidemiological Studiesâ€"Depression, and Beck Depression Inventory II. Because they are highly predictive, these scales are valuable tools that can be combined with the informal interview during a routine post-birth checkup.
A nurse assessing a postpartum woman 12 hours after uncomplicated vaginal birth finds her pulse to be 110 beats/minute. What action by the nurse is best? A. Assess the patient for causes of tachycardia. B. Document the findings and notify the provider. C. Facilitate a blood draw for laboratory studies. D. Place the patient on a 1,000-mL fluid restriction.
ANS: A Postpartum tachycardia can result from several causes, including complications, blood loss, prolonged labor, temperature elevation, and infection. The nurse should assess the patient thoroughly to determine the cause of the tachycardia prior to notifying the provider. A blood draw may or may not be necessary. A fluid restriction would not be helpful, as this would lead to a temperature elevation and further tachycardia.
Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full" and is approximately 4 cm in diameter. The patient describes this area as "tender." What intervention does the nurse anticipate for this situation? A. Application of ice B. Exploratory surgery C. Incision and drainage D. Sitz bath every 12 hours
ANS: A This patient has a perineal hematoma. If the hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative treatments, such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 cm may require incision and drainage with the possible placement of a drain.
A postpartum woman is in the perinatal clinic for a routine follow-up visit with her new infant. The patient seems agitated by the questions the nurse is asking and often looks up at the ceiling apprehensively. What action by the nurse is best? A. Ask the woman if she is hearing voices. B. Assess the woman's sleep and nutrition. C. Determine if the woman has any support. D. Take the baby to another room for assessment.
ANS: A This woman may be displaying signs of postpartum psychosis, which include hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality. The most specific question the nurse can ask is about hallucinations because the woman is looking up at the ceiling. Many new mothers have sleep disturbances, so this would not be the priority question to ask. Assessing the woman's social support is not a priority. Taking the infant away from the mother would only be needed if the infant were in immediate danger, and this action may agitate the woman further. The nurse should alert others, remain with the mother, and conduct further assessments.
The perinatal nurse listens as the patient describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist the patient in doing which of the following? A. Decreasing her ambivalence about her labor and birth B. Developing more positive feelings about her labor and birth C. Initiating her role development in the "letting-go" stage D. Understanding the various demands associated with the maternal role
ANS: B After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth, and for unplanned or emergent cesarean deliveries, the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing the patient to talk about the experience can help her develop a more positive attitude about her own experience.
A new mother is concerned that her 3-year-old child is not adapting well to the birth of a new sibling 1 month ago. What suggestion can the nurse provide to best help this mother? A. Explain to the child that she will always have a special bond with the new sibling. B. Give the 3-year-old a special chore that only she does to help her mom. C. Promise the 3-year-old that she can have a pet if she is good to her new sibling. D. Tell the child she will need to get used to having a new baby in the house.
ANS: B Often siblings have a rough time adapting to the arrival of a new sibling. Some suggestions for the parents are to talk to the child about her feelings, teach the child how to play with the baby, praise age-appropriate behaviors and do not criticize regressive behaviors (regression is common), set aside special time each day for the older child, and give the older child a special chore to be a "big helper for Mommy." A special chore, such as bringing diapers when the baby needs changing, can help boost her self-esteem and make her feel important to the family.
A woman with postpartum depression is in the perinatal clinic for follow-up. The health-care provider tells the nurse that the patient will be prescribed a tricyclic antidepressant. The nurse will instruct the patient about which medication? A. Fluoxetine (Prozac) B. Pamelor (Nortriptyline) C. Sertraline (Zoloft) D. Venlafaxine (Effexor)
ANS: B Pamelor is a tricyclic antidepressant. Prozac and Zoloft are selective serotonin reuptake inhibitors (SSRIs). Effexor is a serotonin-norepinephrine reuptake inhibitor (SNRI).
A woman has painful hemorrhoids after a vaginal birth. Her husband brings her a donut pillow to sit on. What response by the nurse is best? A. "A lot of women get good pain relief from these." B. "Donut pillows actually increase hemorrhoid pain." C. "I will have to get permission for her to use this." D. "That was nice of you, but these don't work well."
ANS: B Soft surfaces and pillows such as donut rings should not be used by the woman with hemorrhoids, as they separate the buttocks when the woman sits down and decrease venous flow, which increases pain. The woman should be instructed to sit on hard surfaces and tighten the buttocks prior to sitting. The other responses do not give accurate information.
A nursing student is preparing to give a pregnant woman heparin for a deep vein thrombosis (DVT). The student questions the dose, as it is higher than what the student has given to other patients. What response by the perinatal nurse is most appropriate? A. Have the student hold the dose and double-check the order with the provider. B. Inform the student that physiological changes in pregnancy require higher doses. C. Remind the student that large doses are needed to dissolve the existing clot. D. Tells the student to administer the dose and check results of the next laboratory draw.
ANS: B The pregnant patient has a greater plasma volume and an increased renal clearance (due to increased blood flow to the kidneys). The combination of normally occurring heparin-binding proteins along with the breakdown of heparin often results in the need for higher doses of heparin during pregnancy.
A woman is 10 hours postpartum after an uncomplicated vaginal birth. She has voided four times, and each time the volume is less than 100 mL. What action by the nurse is best? A. Ask the woman to keep a voiding log for 24 hours. B. Palpate the fundus and assess the amount of lochia present. C. Request an order for a straight catheterization. D. Run the water in the bathroom faucet during voiding attempts.
ANS: B Women who have recently given birth are at risk for urinary stasis and retention, which can lead to a boggy uterus and increased lochia. Frequently voiding 150 mL or less is a sign of urinary stasis and retention. The nurse should assess these factors first. The woman may need assistance when ambulating to the bathroom, or the nurse may need to run the water in the bathroom faucet during voiding attempts. A last resort is straight catheterization for severe urinary retention. Because the woman should be on intake and output assessments, a voiding log will not be helpful.
Two days after an uncomplicated vaginal birth, the nurse notes that the patient's hemoglobin is 13 mg/dL and the hematocrit is 48%. What does the nurse conclude about these values? A. Patient is dehydrated B. Needs further assessment C. Normal for this situation D. Serious anemia
ANS: C After a vaginal birth, the hemoglobin can drop about 1 gram, or 2 grams following a cesarean birth (normal for women is 12.1-15.1 mg/dL). Due to diuresis, hemoconcentration can occur, resulting in a rise in the hematocrit (normal in women is 36.1-44.3%). Therefore, these findings are normal after an uncomplicated vaginal birth.
A G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second-degree laceration was needed following the birth. The nurse assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal bleeding has increased. Which action by the nurse takes priority? A. Assess the vital signs, including blood pressure and pulse. B. Call the health-care provider to examine the woman now. C. Massage the uterine fundus with continual lower-segment support. D. Measure and document each used perineal pad to assess blood loss.
ANS: C As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and to initiate immediate actions. While another member of the team calls the physician or nurse-midwife, the nurse should first locate the uterine fundus and initiate fundal massage.
A husband calls the perinatal clinic because he is worried about his wife's emotional state after giving birth 2 weeks ago. Which question by the nurse would be most helpful? A. "Can you explain specifically what you are worried about?" B. "How is your wife's appetite? Is she eating enough?" C. "Is your wife still able to care for herself and the baby?" D. "When did all the symptoms start, before or after the birth?"
ANS: C Emotional difficulties after birth include the "baby blues," postpartum depression, and postpartum psychosis. The most important determinant rests with the knowledge that postpartum or baby blues do not interfere with the woman's ability to care for herself and her family. This question effectively triages the situation. "Can you..." is a yes-no question and is never a good type of question to use when assessing a situation. In both baby blues and depression, appetite may be diminished.
A postpartum woman is Rho(D)-negative and needs an injection of Rho(D) immune globulin. Which of the following doses would the perinatal nurse expect to be ordered? A. 120 µg B. 250 µg C. 300 µg D. 350 µg
ANS: C Nonsensitized women who are Rho(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 µg of Rho(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations (e.g., hemorrhage, exchange of maternal-fetal blood), a larger dose of RhoGAM may be indicated.
The perinatal nurse is teaching the patient about breastfeeding and explains that which of the following is the most appropriate time to breastfeed? A. Four to 5 hours after the last feeding B. Only when her infant exhibits hunger-related crying C. When her infant is in a quiet alert state D. When her infant is in an active alert state
ANS: C The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.
A nurse is assessing a patient for a perineal hematoma. Which action by the nurse is most appropriate? A. Assist the woman to a knee-chest position with head down. B. Have the patient lie supine and place her legs in frog-leg position. C. Place the patient in a side-lying position and lift the upper buttock. D. Turn the woman side to side and lift the upper leg each time.
ANS: C To correctly assess for a perineal hematoma, assist the woman to a side-lying position and gently lift the upper buttock. Ask the patient to bear down and assess for full or bulging tissue, blue discoloration of tissue, and tenderness.
A nurse has brought a newborn to his mother's room. What action by the nurse takes priority? A. Asking the mother her full name and her birth date B. Comparing the baby to a photograph on the mother's bedside table C. Having the mother wash her hands before taking the baby D. Matching the information on the mother's and baby's wristbands
ANS: D The safety and security of the infant must be maintained at all times. When bringing the baby to the mother, the nurse ensures proper identification by comparing and matching information on both the mother's and the baby's identification band. Having the mother wash her hands before taking the baby is a good practice to reduce the risk of infection, but security takes priority.
A perinatal nurse receives reports from the nurse aide on four patients who all gave birth within the last 4 hours. Which patient should the nurse assess first? A. Blood loss of 850 mL during cesarean birth B. Exhausted mother wanting only to rest after childbirth C. Pulse consistently ranges from 82 to 90 beats/minute D. Systolic blood pressure change from 132 to 110 mm Hg
ANS: D A drop in blood pressure by 15%, maternal heart rate over 110 beats/minute, or an oxygen saturation less than 95% may indicate a postpartum hemorrhage. The nurse should assess the woman whose blood pressure has changed more than 15%. Blood loss of 850 mL during cesarean birth is not considered excessive. A pulse under 100 beats/minute is normal. A mother may well be exhausted and need to rest, particularly if her birthing experience was difficult or traumatic.
A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. The most appropriate nursing action at this time is to do which of the following? A. Ask any visitors to leave now or stay quiet. B. Dim the lights in the patient's room. C. Notify the patient's health-care provider. D. Perform a comprehensive pain assessment.
ANS: D The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort to provide interventions in a timely manner and to enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0-to-10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The other actions are not warranted at this time.
The perinatal nurse demonstrates the correct technique of postpartum uterine palpation for a student nurse. The nurse explains that support for the lower uterine segment is critical, because without it there is an increased risk of which complication? A. Incorrect measurement B. Intensifying the patient's pain C. Uterine edema D. Uterine inversion
ANS: D The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage.
