TB - Chapter 28
The nurse is assessing the episiotomy of a client who is 2 days postpartum. In which order should the nurse complete this assessment? A. Edema B. Redness C. Ecchymosis D. Approximation E. Discharge/drainage 1. B, A, C, E, D 2. A, B, D, E, C 3. B, A, D, E, C 4. D, E, C, B, A
Answer: 1 Explanation: *1. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for redness, the nurse inspects the wound for edema.* 2. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, the nurse first inspects the wound for redness. 3. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for edema the nurse inspects the wound for ecchymosis. 4. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for discharge/drainage the nurse inspects the wound for approximation. 5. If an episiotomy was done or a laceration required suturing, the nurse assesses the wound. To evaluate the state of healing, after inspecting the wound for ecchymosis the nurse inspects the wound for discharge/drainage.
What amount of weight loss, in pounds, should the nurse expect in an average postpartum client? 1. 5 to 8 2. 10 to 12 3. 12 to 15 4. 15 to 20
Answer: 2 Explanation: 1. A loss of 5 to 8 lb might occur after a preterm birth. *2. A loss of 10 to 12 lb is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.* 3. A loss of 12 to 15 lb does not match the usual weight of placenta, amniotic fluid, and fullterm infant weight. 4. A loss of 15 to 20 lb might occur after a multiple birth.
The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation? 1. The infant grasps the mother's finger while nursing. 2. The mother vocalizes feelings of frustration with her infant. 3. The infant begins to seek out the mother over other individuals. 4. The mother spends more time making eye-to-eye contact with the infant.
Answer: 2 Explanation: 1. Actions that make the infant more attractive to the mother, such as grasping a finger, usually occur during the acquaintance phase. *2. The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship.* 3. When the relationship between mother and infant reaches reciprocity, the infant will seek to interact with the mother more. 4. Holding the infant in the en face position is likely to occur most often in the acquaintance phase.
Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. What action should the nurse take? 1. Answer questions quickly and try to divert attention to other subjects. 2. Review documentation of the birth experience and discuss it with the client. 3. Contact the healthcare provider because of changes in the client's memory. 4. Submit a referral to Social Services because of concerns about obsessive behavior.
Answer: 2 Explanation: 1. Answering questions quickly and trying to divert attention to other subjects trivializes the questions and does not allow the client to sort out the reality from the subjective experience. *2. Reviewing the documentation of the birth experience and discussing it with the client helps the client integrate the experience and talk about perceptions of the labor and delivery experience.* 3. The client is not demonstrating changes in memory. The healthcare provider does not need to be contacted. 4. Submitting a referral to Social Services because of obsessive behavior is not appropriate. The client is demonstrating normal behavior.
On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse? 1. Epidural anesthesia 2. The taking-in phase 3. The taking-hold phase 4. Postpartum hemorrhage
Answer: 2 Explanation: 1. Epidural anesthesia is a pharmacologic approach to pain control. *2. The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest.* 3. The taking-hold phase occurs by the second or third day, when the mother is ready to resume control of life and is open to teaching. 4. Postpartum hemorrhage is a serious complication and will need medical intervention
A postpartum client is not going to breastfeed her newborn. What should the nurse include when teaching this client about breast care? 1. The let-down reflex 2. Lactation suppression 3. The purpose of fundal massage 4. The cause of afterpains
Answer: 2 Explanation: 1. The let-down reflex is an important teaching point for breastfeeding patients. *2. It is important to teach nonbreastfeeding patients about lactation suppression after delivery.* 3. The purpose of fundal massage should be addressed when assessing the uterus and fundus, not when assessing the breasts. 4. Afterpains can be stimulated by breastfeeding. The nurse will not likely teach a nonbreastfeeding primipara about afterpains.
A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient? 1. Contact Social Services with concerns of neglect. 2. Teach the client how to interact appropriately with the infant. 3. Take the infant to the nursery so the baby can receive more consistent care. 4. Provide the care the infant needs while continuing to evaluate the mother's actions.
Answer: 2 Explanation: 1. The mother may only need some education on how to care for her infant. If the nurse consistently teaches the mother and encourages mother-infant interaction continues to ignore the child, then it may be appropriate to contact Social Services in extreme circumstances. *2. New mothers may be hesitant to care for the infant because of feelings of inadequacy. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention.* 3. Instead of encouraging mother-infant bonding, this action may emotionally distance the mother from her child even more. It may also confirm the mother's feelings of inadequacy. 4. While this action does provide for the needs of the newborn during the hospital stay, it does not help the mother know how to care for her child once she returns home.
1) The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first? 1. Multipara, second day postcesarean, moderate lochia serosa 2. Primipara, day of delivery, fundus firm 2 cm above umbilicus 3. Multipara, first postpartum day, 4 cm diastasis recti abdominis 4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants
Answer: 2 Explanation: 1. This client is not experiencing any unexpected findings. *2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.* 3. This finding is normal, especially in a multiparous client. 4. Bowel sounds are often decreased after delivery.
The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene? 1. Asking the client to void before applying clean gloves 2. Instructing visitors to leave the room prior to beginning the assessment 3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment 4. Discussing the effectiveness of comfort measures while performing the perineal assessment
Answer: 2 Explanation: 1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids. *2. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment.* 3. The supine position prevents a falsely high assessment of fundal height. 4. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures
The nurse decides that a family with a newborn would benefit from a Social Services consultation. What statements were made by family members that caused the nurse to make this decision? Select all that apply. 1. "I think we're getting along better." 2. "I'm not going to let a baby make me fat." 3. "My mother could care less about this baby." 4. "At least help me if you don't want to get a job." 5. "That's fine. Go to work. Leave me here to do all of the work."
Answer: 2, 3, 4, 5 Explanation: 1. The statement about getting along would indicate adapting to the new infant. *2. Preoccupation with physical status or weight could indicate adjustment difficulties.* *3. Lack of support systems could indicate adjustment difficulties.* *4. Unemployment could indicate adjustment difficulties.* *5. Marital problems could indicate adjustment difficulties.*
During a home visit the nurse is concerned that a new mother is experiencing postpartum blues. What did the nurse assess to make this clinical determination? Select all that apply. 1. Fear 2. Anger 3. Euphoria 4. Anorexia 5. Weepiness
Answer: 2, 4, 5 Explanation: 1. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Fear is not commonly associated with postpartum blues. *2. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anger.* 3. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. Euphoria is not commonly associated with postpartum blues. *4. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by anorexia.* *5. The postpartum blues consist of a transient period of depression that occurs during the first few days of the puerperium. It may be manifested by weepiness.*
The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex? 1. The mother enfolds the infant in her arms. 2. The mother feeds the infant every 2 to 3 hours as instructed. 3. The mother points out family traits she sees in the newborn. 4. The mother asks questions about how to properly bathe her infant.
Answer: 3 Explanation: 1. This action can be used to assess if the mother is attracted to her newborn and is forming emotional attachments with the newborn. 2. This action can be used to assess the ability of the mother to care for the infant's needs as they arise. *3. This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits.* 4. This action helps assess the mother's willingness to learn how to care for her infant.
7) A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence? 1. "Do not worry. I will make sure everything is fine." 2. "We see this from time to time. It's not a big deal." 3. "Blood has pooled in the vagina while you were in bed." 4. "The gush is an indication that your fundus is not contracting."
Answer: 3 Explanation: 1. This response is not therapeutic because it focuses on the nurse and has a "do not worry" aspect that is demeaning. 2. Although a gush of blood during fundus assessment is fairly common, this response is not therapeutic because it does not address the client's concern. *3. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semisitting in bed, which leads to a gush when fundal massage is performed.* 4. The fundus might be contracting well. The gush is from pooled lochia in the vagina.
In which order should the nurse conduct the examination of a postpartum client? 1. L-lochia 2. B-bowel 3. B-breast 4. U-uterus 5. B-bladder 6. E-emotional 7. H-Homans/hemorrhoids 8. E-episiotomy/laceration/edema
Answer: 3, 4, 5, 2, 1, 8, 7, 6 Explanation: An easy way to remember the components specific to the postpartum examination is to remember the term BUBBLEHE: B-breast, U-uterus, B-bladder, B-bowel, L-lochia, E-episiotomy/laceration/edema, H-Homans/hemorrhoids, E-emotional.
The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important? 1. Determine if father-infant attachment is taking place. 2. Discuss adaptation to grandparenthood by her parents. 3. Describe the likely reaction of siblings to the new baby. 4. Assist the mother in identifying behavior cues of the baby.
Answer: 4 Explanation: 1. Although father-infant attachment is important, the mother is the main client, and teaching her directly is a higher priority. 2. Adaptation to grandparenthood is a task for her parents and not a high priority for teaching the new mother. 3. This is not appropriate because the baby has no siblings. *4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.*
What should the nurse assess to determine healing of the uterus at the placental site? 1. Laboratory values 2. Uterine size 3. Blood pressure 4. Type, amount, and consistency of lochia
Answer: 4 Explanation: 1. Laboratory values are too vague, since the actual values are not identified. 2. Uterine size alone is not enough to assess the placental site. 3. Blood pressure varies slightly in the normal postpartum client and would not affect the placental site. *4. Type, amount, and consistency of lochia determine the stage of healing of the placental site, which occurs by a process of exfoliation.*
A postpartum client weighing 165 lb is prescribed to take 12 mg/kg/day of lysine to help with afterpains. If the client ingests 375 mg of lysine in food, how many additional milligrams of the supplement should the client take? (Calculate to the nearest whole number.)
Answer: 525 mg Explanation: First determine the client's weight in kilograms by dividing the weight in pounds by 2.2, or 165/2.2 = 75 kg. Then determine the amount of lysine that should be taken each day by multiplying the client's weight by 12, or 75 × 12 mg = 900 mg. If the client ingests 375 mg of lysine each day in food, then subtract this amount from the total amount of lysine, or 900 - 375 = 525 mg.
A client weighing 80 kg lost 5 kg of body weight immediately after delivery. In 2 days, another 3 kg has been lost. During a 6-week postpartum examination the client was pleased to learn of returning to her prepregnancy weight of 143 lb. How many kilograms of weight did the client lose during the 6 weeks postpartum? (Calculate to the nearest whole number.)
Answer: 7 kg Explanation: First determine the client's starting weight in pounds by multiplying her weight in kilograms by 2.2, or 80 × 2.2 = 176. Then subtract the prepregnancy weight from the pregnancy weight, or 176 - 143 = 33 pounds. Then divide the weight in pounds by 2.2, or 33/2.2 = 15 kg. Then subtract the total number of kilograms lost after delivery from the total weight of 15 kg. or 15 kg - 5 kg - 3 kg = 7 kg. The client lost 7 kg of weight in 6 weeks.
