TB - Chapter 28 Postpartum Adaptation and Nursing Assessment Chapter 29 The Postpartum Family: Early Care Needs and Home Care Chapter 30 The Postpartum Family at Risk

Assessment 2) 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

. 10 to 12 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 full-term infant weight. 4. A loss of 15 to 20 lb might occur after a multiple birth.

Assessment 14) The nurse documents that a postpartum client's volume of lochia (blood content on a maxi pad) is moderate. What did the nurse most likely assess to make this clinical determination?

Answer: 3 Explanation: 1. This would be estimated as a scant amount of lochia. 2. This would be estimated as a light amount of lochia. 3. This would be estimated as a moderate amount of lochia. 4. This would be estimated as a heavy amount of lochia.

Planning 16) 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 mgExplanation: 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.

Planning 18) Which is the obese postpartum client at a greater risk for experiencing? Select all that apply. 1. Injury 2. Infection 3. Breast engorgement 4. Deep vein thrombosis 5. Respiratory complications

Injury Infection Deep vein thrombosis Respiratory complications Explanation: 1. The obese postpartum client is at a greater risk for injury. 2. The obese postpartum client is at a greater risk for infection. 3. The obese postpartum client is not at a greater risk for breast engorgement. 4. The obese postpartum client is at a greater risk for thromboembolic disease, such as deep vein thrombosis (DVT). 5. The obese postpartum client is at a greater risk for respiratory complications.

Assessment 5) 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

Instructing visitors to leave the room prior to beginning the assessment 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. Page Ref: 659

Assessment 22) Which will the nurse include in the family assessment for the postpartum client? Select all that apply. 1. Parental roles 2. Bonding behaviors 3. Sibling adjustment 4. Signs and symptoms of infection 5. Level of comfort with newborn care

Parental roles Bonding behaviors Sibling adjustment Level of comfort with newborn care Explanation: 1. The nurse assesses parental role adjustment during the family assessment for the postpartum client. 2. The nurse assesses bonding behaviors during the family assessment for the postpartum client. 3. The nurse assesses sibling adjustment during the family assessment for the postpartum client. 4. Clinical manifestations of infection are assessed during the physical assessment, not the family assessment, for the postpartum client. 5. The nurse assesses level of comfort with newborn care during the family assessment for the postpartum client.

2) A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply. 1. methylergonovine maleate (Methergine) 2. butorphanol tartrate (Stadol) 3. misoprostol (Cytotec) 4. betamethasone (Diprolene) 5. fentanyl (Duragesic)

methylergonovine maleate (Methergine) misoprostol (Cytotec) Explanation: 1. Methylergonovine maleate is a drug of choice for postpartum hemorrhage. 2. Stadol is an analgesic, and is not used for postpartum hemorrhage. 3. Misoprostol is commonly administered rectally for postpartum hemorrhage. 4. Betamethasone is a glucocorticoid used for preterm labor in an attempt to decrease respiratory distress in the preterm infant. 5. Fentanyl is an analgesic, and is not used for postpartum hemorrhage

Implementation 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."

"Blood has pooled in the vagina while you were in bed." 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.

Assessment 20) 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."

"I'm not going to let a baby make me fat." "My mother could care less about this baby." "At least help me if you don't want to get a job." "That's fine. Go to work. Leave me here to do all of the work." 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.

Implementation 6) A postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. Which response by the nurse is most appropriate? 1. "Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct." 2. "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." 3. "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area." 4. "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

"Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct." Explanation: 1. A hardened area could indicate a blocked duct. Massage of the blocked duct toward the nipple will help to unplug the duct and relieve stasis of the milk, thereby preventing mastitis. 2. It is not unusual for mothers to develop complications similar to those experienced in prior pregnancies. 3. Warm packs, not cold packs, should be applied to areas that are warm, red, or hardened. 4. The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for detecting early onset of the infection. Massaging the area to unplug the duct and relieve milk stasis is much more effective.

Assessment 4) 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

. The taking-in phase 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.

Caring 7) The hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness? 1. Normal newborn nursery centrally located to all client rooms 2. A kitchen with refrigerator stocked with juice and sandwiches 3. Small, cozy rooms with a client bed and rocking chair 4. A nursing model based on providing couplet care

A nursing model based on providing couplet care Explanation: 1. Rooming-in better promotes family wellness than does having newborns in the nursery. 2. Although having snacks is good for postpartum clients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness. 3. Small rooms can become overly crowded when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better. 4. Couplet care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered.

17) 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

Anger Anorexia Weepiness 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.

Assessment 15) 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 kgExplanation: 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.

Implementation 4) On the second day postpartum, the client who is bottlefeeding experiences engorgement. Which should the nurse encourage to enhance the client's comfort? 1. Removing her bra 2. Applying heat to her breasts 3. Applying ice packs to her breasts 4. Limiting breastfeeding to twice daily

Applying ice packs to her breasts Explanation: 1. Removing her bra will only serve to increase breast milk production. A tight-fitting bra should be worn at all times for 5 to 7 days and only removed when showering. 2. Applying heat will promote breast milk production. 3. Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. 4. Limiting breastfeeding to twice per day actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of the mother.

Assessment 19) The nurse is assessing the abdomen of a client who delivered an infant 1 hour ago. On the diagram, where should the nurse assess the client's uterine level?

Explanation: Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus.

Assessment 3) 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

Type, amount, and consistency of lochia 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.

Assessment 3) The postpartum client who delivered a newborn 2 days ago develops endometritis. Which entry in the medical record would the nurse expect to find when reviewing the client's history? 1. "Cesarean birth performed secondary to arrest of dilation." 2. "Rupture of membranes occurred 2 hours prior to delivery." 3. "External fetal monitoring used throughout labor." 4. "History of pregnancy-induced hypertension."

"Cesarean birth performed secondary to arrest of dilation." Explanation: 1. Cesarean birth is the greatest predictor of postpartum endometritis. The frequent cervical examinations necessary to assess for arrest of dilation are another risk factor for postpartum infection. 2. Prolonged rupture of membranes (longer than 12 hours) is a risk factor for postpartum endometritis. 3. Internal fetal monitoring (both internal fetal scalp electrode and intrauterine pressure catheter) are risk factors for postpartum endometritis. 4. Pregnancy-induced hypertension is not a risk factor for development of postpartum endometritis.

Teaching and Learning 20) The nurse is instructing a postpartum client on the use of perineal pads. Which statements should the nurse include in the teaching session? Select all that apply. 1. "Apply the pad from back to front." 2. "Change the pad after each perineal cleansing." 3. "Place the pad so that it applies pressure to the perineum." 4. "Change the pad each time you use the bathroom." 5. "Your pad should be loose to allow the perineum to 'breathe.' "

"Change the pad after each perineal cleansing." "Change the pad each time you use the bathroom." Explanation: 1. The perineal pad should be applied from front to back, not back to front, to decrease the risk of contamination. 2. The perineal pad should be changed after each perineal cleansing. 3. The perineal pad should be placed snugly against the perineum but should not produce pressure. 4. The perineal pad should be changed after urination and defecation. 5. The perineal pad should be placed snugly against the perineum. If the pad is worn too loosely, it may rub back and forth, irritating perineal tissues and causing contamination between anal and vaginal areas.

Implementation 14) During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate? 1. "Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychologic approach to family bonding. 2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on the stomach." 3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." 4. "Cosleeping is not recommended; however, if you wish to do this, place your baby on a comforter, as opposed to directly on the mattress."

"Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines." Explanation: 1. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for sudden infant death syndrome (SIDS). 2. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Families who practice cosleeping require appropriate teaching measures, which include making sure the baby is sleeping on the back, not on the stomach. 3. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however, may still participate in this practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety guidelines 4. The American Academy of Pediatrics does not recommend cosleeping because it is considered a risk factor for SIDS. Safety guidelines related to cosleeping include placing the infant on a firm mattress, never on comforters, pillows, or a waterbed.

Implementation 9) 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.

Review documentation of the birth experience and discuss it with the client. 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.

Communication and Documentation 13) The nurse is providing care to a postpartum client 24 hours after delivery who has been diagnosed with metritis. Which response by the nurse is accurate when the client asks what made her sick? 1. "Early infections such as this are often caused by group beta strep (GBS)." 2. "Most infections are often caused by a chlamydial infection. Do you practice safe sex?" 3. "You must have already been sick when you came to deliver your baby." 4. "There is no way to knowing why you got sick. Sometimes it just happens."

"Early infections such as this are often caused by group beta strep (GBS)." Explanation: 1. Most early metritis infections are caused by group beta strep (GBS). 2. Most late, not early, metritis infections are caused by chlamydia. Also, it is not appropriate to ask her about safe sex practices at this time. 3. Telling the client that she was sick when she came to deliver the baby is often not true and does not specifically address the client's question. 4. This response is inaccurate as most cases of early metritis are attributed to a GBS infection.

Evaluation 17) The nurse is teaching a postpartum client when light housekeeping can be resumed. Which response by the client indicates accurate understanding of the information provided? 1. "I can resume light housekeeping after the 6-week postpartum checkup." 2. "I can resume light housekeeping during my first week at home." 3. "I can resume light housekeeping during my second day at home." 4. "I can resume light housekeeping after my second week at home."

"I can resume light housekeeping after my second week at home." Explanation: 1. It is not necessary to wait until after the 6-week postpartum checkup to resume light housekeeping. 2. Within the first week is too early to resume even light housekeeping activity. 3. The second day is too early to resume even light housekeeping activity. 4. The postpartum client can resume light housekeeping after the second week at home.

Evaluation 19) The nurse conducts discharge teaching for a postpartum client who is diagnosed with deep vein thrombosis (DVT). Which statements indicate accurate understanding of the information presented? Select all that apply. 1. "I will cross my legs while I sit and watch TV in the evening." 2. "I will wear supportive stockings if I have to stand for long periods of time." 3. "I will only have to continue taking Coumadin for 1 month once I am home." 4. "If I develop bleeding gums, I should contact my healthcare provider." 5. "I should plan to elevate my legs during times of rest."

"I will wear supportive stockings if I have to stand for long periods of time." "If I develop bleeding gums, I should contact my healthcare provider." "I should plan to elevate my legs during times of rest." Explanation: 1. The client would be instructed not to cross the legs while sitting as this can increase venous stasis which further increases the client's risk for more DVTs. This statement indicates the need for further education. 2. The use of supportive stockings if the client has to stand for long periods of time is recommended when diagnosed with DVT. This statement indicates correct understanding of the information presented. 3. Clients diagnosed with a DVT will require warfarin (Coumadin) therapy for 2 to 6 months, not 1 month, after discharge. This statement indicates the need for further education. 4. Bleeding of the gums while on warfarin (Coumadin) therapy can be an indication of a dose that is too large and would be reported to the healthcare provider. This statement indicates correct understanding of the information presented. 5. The postpartum client who is diagnosed with DVT should plan to elevate the legs during times of rest. This statement indicates correct understanding of the information presented.

Teaching and Learning 14) The nurse is conducting discharge instruction for a postpartum client. Which client response indicates accurate understanding of when to notify the healthcare provider? 1. "If I am having trouble getting the baby to latch on, I should call my doctor." 2. "If I continue to have pain after taking my prescribed analgesic, I should call my doctor." 3. "If I saturate one pad every 8 hours, I should call my doctor." 4. "If I don't have a bowel movement within 24 hours of going home, I should call my doctor."

"If I continue to have pain after taking my prescribed analgesic, I should call my doctor." Explanation: 1. Issues with getting the baby to latch on during breastfeeding should be reported but not to the doctor. The client would be instructed to contact a lactation consultant. This statement indicates the need for further education. 2. Pain that is not alleviated by the prescribed analgesic is cause for concern and would require healthcare provider notification. This statement indicates accurate understanding of the information presented. 3. Saturation of one peripad every hour, not every 8 hours, would indicate the need to contact the healthcare provider. This statement indicates the need for further education. 4. The return of bowel function varies with every woman after childbirth. Not having a bowel movement within 24 hours of discharge is not an indication of a problem and would not require the client to contact the healthcare provider. This statement indicates the need for further education.

Implementation 15) A new mother is concerned about spoiling her newborn. Which statement should the home care nurse include in this teaching session with the new mother? 1. "Spoiling occurs when an infant is rocked to sleep every night." 2. "Newborns can be manipulative, so caution is advised." 3. "Crying is good for an infant, and letting them cry it out is advised." 4. "It is important to meet your infant's needs to develop a trusting relationship."

"It is important to meet your infant's needs to develop a trusting relationship." Explanation: 1. The new mother should be taught that an infant cannot be spoiled, especially by rocking the infant to sleep each night. This statement is inappropriate for the nurse to include in the teaching session. 2. Newborns are not manipulative. This statement is inappropriate for the nurse to include in the teaching session. 3. An infant should not be allowed to "cry it out" because this does not meet the infant's needs to develop a trusting relationship. This statement is inappropriate for the nurse to include in the teaching session. 4. Meeting the infant's needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind.

Evaluation 6) The nurse is teaching a postpartum client information regarding weaning her infant from breastfeeding. Which client statement suggests a need for further teaching? 1. "Slow weaning should take place over a period of several months." 2. "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace." 3. "If I wean my baby slowly, I am less likely to develop breast engorgement." 4. "Slowly weaning my baby is recommended to allow time for my psychologic adjustment."

"Slow weaning should take place over a period of several months." Explanation: 1. During slow weaning, over a period of several weeks, the mother substitutes more cup feedings or bottlefeedings for breastfeedings. 2. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 3. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment. 4. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychologic adjustment.

Communication and Documentation 13) The maternal home care nurse, who is orienting a new nurse, discusses maternal psychologic adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential and actual postpartum depression in maternal clients? 1. "Because emotional disorders and imbalances are a very sensitive subject, we try not to offend clients by routinely bringing up the topic of postpartum depression." 2. "For women with a history of depression, we include education about postpartum depression." 3. "Teaching about postpartum depression is a routine part of education for all maternal clients." 4. "If we suspect a woman may have developed postpartum depression, then we provide specialized education about that topic."

"Teaching about postpartum depression is a routine part of education for all maternal clients." Explanation: 1. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 2. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 3. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women. 4. Teaching content should include information on role changes and psychologic adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

Implementation 4) The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is most important for the nurse to make? 1. "Void into this sterile cup without touching the inside of the cup." 2. "Be sure to wipe from back to front after you have a bowel movement." 3. "Call the clinic if you develop nausea and vomiting or constipation." 4. "Decrease your fluid intake for a few days, but eat a lot of vegetables."

"Void into this sterile cup without touching the inside of the cup." Explanation: 1. A clean-catch urine sample will need to be obtained for urinalysis to determine if the client has developed a urinary tract infection. 2. Clients should be taught to wipe from front to back after bowel movements in order to prevent contamination of the urethra and bladder with normal bowel flora. 3. A lower urinary tract infection can progress into pyelonephritis, the signs of which are fever and flank pain. Constipation is not associated with urinary tract infections. 4. Clients should increase their fluid intake but decrease their consumption of carbonated beverages. Cranberries, or cranberry juice, are helpful, as they acidify the urine. Vegetables do not help clear or prevent urinary tract infections.

Implementation 2) During a home care visit, the new breastfeeding mother reports breast engorgement. Which statement by the home care nurse is most appropriate based on this information? 1. "Apply an ice compress to your breast before nursing." 2. "Encourage your baby to suckle for an average of 5 minutes per feeding." 3. "Apply warm compresses to your breast after you finish feeding your baby." 4. "When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep."

"When you are not nursing, wear a well-fitted nursing bra at all times, even when you sleep." Explanation: 1. Warm, not ice, compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. 2. For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours. 3. Cool, not warm, compresses after nursing can help slow refilling of the breasts and provide comfort to the mother. 4. The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

Communication and Documentation 8) The client having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The client states, "I'm wondering what will be different this time compared with my first birth, which was vaginal." Which response by the nurse is most appropriate? 1. "We'll take good care of you and your baby. You'll be home before you know it." 2. "You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." 3. "You will have a lot of pain, but there are medications that we give when it gets bad." 4. "You won't be able to nurse until the baby is 12 hours old because of your epidural."

"You'll be wearing sequential compression devices to prevent blood clots from forming in your legs." Explanation: 1. This response focuses on the nurse, and does not provide specific information to answer the client's question. 2. Sequential compression devices (SCDs) are used until the client is up and walking to prevent thrombus formation. 3. Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained. 4. Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother's ability to breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.

Implementation 19) The nurse is providing care to a lesbian postpartum client and her life partner. Which nursing actions are appropriate when providing care to this couple? Select all that apply. 1. Providing the couple with the same rights and care as those given to heterosexual couples 2. Educating the couple about heterosexual contraception during the postpartum period 3. Teaching the couple about when it is safe to resume sexual relations 4. Encouraging the couple to join a support group of other postpartum lesbian couples 5. Expecting the nonpregnant partner to assume the role of father

- Providing the couple with the same rights and care as those given to heterosexual couples - Teaching the couple about when it is safe to resume sexual relations - Encouraging the couple to join a support group of other postpartum lesbian couples Explanation: 1. Lesbian couples should be given the same rights and care as heterosexual couples in the acute care environment. 2. Contraception teaching during the postpartum period will differ for the lesbian client versus the heterosexual client as there is no need to educate about heterosexual contraception. 3. Lesbian couples require education regarding the safe resumption of sexual relations. 4. Lesbian couples should be encouraged to seek support, including joining a support group with other postpartum lesbian couples. 5. Evidence shows that the nonpregnant partner will assume the comothering role, not the role of the father.

Assessment 6) 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

3. B-breast 4. U-uterus 5. B-bladde 2. B-bowel 1. L-lochia 8. E-episiotomy/laceration/edema 7. H-Homans/hemorrhoids 6. E-emotional 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.

Implementation 5) The nurse is caring for a postpartum client who is 4 hours postoperative following a cesarean birth. Which nursing interventions are appropriate based on these data? Select all that apply. 1. Administering the prescribed analgesics, as needed 2. Encouraging ambulation to the bathroom to void 3. Encouraging leg exercises every 2 hours 4. Encouraging coughing and deep breathing every 2 to 4 hours 5. Encouraging the use of breathing, relaxation, and distraction

Administering the prescribed analgesics, as needed Encouraging leg exercises every 2 hours Encouraging coughing and deep breathing every 2 to 4 hours Encouraging the use of breathing, relaxation, and distraction Explanation: 1. Administering the prescribed analgesics, as needed, addresses the client's nursing care needs, which are similar to those of other surgical clients. 2. Encouraging the client to ambulate to the bathroom to void is not an appropriate intervention for a postpartum client who is 4 hours postoperative for a cesarean birth. 3. Encouraging leg exercises addresses the client's nursing care needs, which are similar to those of other surgical clients. 4. Encouraging coughing and deep breathing every 2 to 4 hours addresses the client's nursing care needs, which are similar to those of other surgical clients. 5. Encouraging the use of breathing, relaxation, and distraction addresses the client's nursing care needs, which are similar to those of other surgical clients.

Implementation 11) The nurse is providing care to a postpartum client who is relinquishing custody of her newborn through an open adoption. Which nursing action is most important? 1. Assigning the client a room on the GYN surgical floor instead of the postpartum floor 2. Preparing to have teaching done in time for discharging the client at 24 hours postdelivery 3. Making an effort not to bring up the topic of the baby, and discuss the mother's health instead 4. Asking the client if she wants to feed her baby, and how much contact she wants to have

Asking the client if she wants to feed her baby, and how much contact she wants to have Explanation: 1. Clients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead. 2. Not all clients who relinquish their infants want early discharge. Make no assumptions, but assess instead. 3. The client's preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead. 4. Assess the client's preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.

12) 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.

Assist the mother in identifying behavior cues of the baby. 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. Planning/Teaching/Learning

Assessment 18) 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

B, A, C, E, D 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. Page Ref: 663

17) The nurse is planning care for a postpartum client. Which data in the client's history increase the risk for postpartum depression? Select all that apply. 1. Type 1 diabetes mellitus (DM) 2. Bipolar disorder 3. Premenstural dysphoric disorder (PMDD) 4. Recent relocation to a new city 5. Family history of hypertension

Bipolar disorder Premenstural dysphoric disorder (PMDD) Recent relocation to a new city Explanation: 1. A personal or family history of type 1 DM is not a risk factor for postpartum depression. 2. A personal or family history of bipolar disorder is a risk factor for postpartum depression. 3. A personal history of PMDD is a risk factor for postpartum depression. 4. Poor support from family and friends, which can occur due to a recent relocation to a new city, is a risk factor for postpartum depression. 5. A family history of hypertension is not a risk factor for postpartum depression.

Assessment 5) Which method of initial assessment would best indicate whether a postpartum client is experiencing a urinary complication? 1. Urine pH 2. Calculation of urine output 3. Urine specific gravity 4. Calculation of intake

Calculation of urine output Explanation: 1. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 2. Calculation of output would provide a better assessment of complete emptying of the bladder, because overdistention can cause trauma to the bladder, displace the uterus, and cause infection. 3. Urine pH and urine specific gravity can be used to identify certain conditions, but would not be part of the initial assessment. 4. Monitoring intake is an intervention that may help prevent urinary complications but calculating the intake itself would not indicate a complication.

Planning 16) Which safety device is most appropriate for the nurse who conducts home care visits to postpartum mothers? 1. Cellular phone 2. Map of the area 3. Personal handgun 4. Can of Mace

Cellular phone Explanation: 1. Cellular phones provide a means of contact, and are advisable for the nurse to carry. 2. A map of the area should be checked before leaving for a visit, and the route traced. 3. Personal handguns are not permissible or legal for nurses to carry on home visits. 4. Mace is not permissible or legal for nurses to carry on home visits.

Assessment 8) The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse? 1. Acute pain 2. Redness 3. Chest pressure 4. Edema

Chest pressure Explanation: 1. Acute pain often accompanies diagnosis of thrombophlebitis. While the pain is important and should be addressed, this finding does not require priority nursing intervention. 2. Redness often accompanies diagnosis of thrombophlebitis. While the redness should be noted and monitored, this does not require priority nursing intervention. 3. A sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention by the nurse. 4. Edema often accompanies diagnosis of thrombophlebitis. While the swelling should be noted and monitored, this does not require priority nursing intervention.

Evaluation 12) The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision? 1. Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis. 2. Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection. 3. Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications. 4. Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care.

Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis. Explanation: 1. Prothrombin time (PT) evaluates the anticoagulation effects of warfarin (Coumadin); the effects of heparin are assessed by way of activated partial thromboplastin time (aPTT). 2. The nurse should inspect the woman's perineum every 8 to 12 hours for signs of early infection. The REEDA scale helps the nurse remember to consider redness, edema, ecchymosis, discharge, and approximation. 3. Misoprostol (Cytotec) is used to prevent and treat uterine atony after failed attempts to control bleeding with oxytocics. 4. Overdistention in the early postpartum period is often managed by draining the bladder with a straight catheter as a one-time measure.

Implementation 12) The nurse is caring for a client who plans to relinquish her baby for adoption. Which nursing actions are appropriate based on this information? Select all that apply. 1. Encourage the client to see and hold her infant. 2. Encourage the client to express her emotions. 3. Respect any special requests for the birth. 4. Acknowledge the grieving process in the client. 5. Allow for access to the infant if the client requests it.

Encourage the client to express her emotions. Respect any special requests for the birth. Acknowledge the grieving process in the client. Allow for access to the infant if the client requests it. Explanation: 1. Encouraging the client to see and hold her infant does not respect the client's right to refuse interaction, and might make her feel guilty for not wanting to see the infant. 2. Encouraging the client to express emotions is an aspect of providing care for the client who decides to relinquish her infant. 3. Respecting any special request for the birth is an aspect of providing care for the client who decides to relinquish her infant. 4. Acknowledging the grieving process is an aspect of providing care for the client who decides to relinquish her infant. 5. Allowing for access to the infant at the client's request is an aspect of providing care for the client who decides to relinquish her infant.

Teaching and Learning 11) The maternal nurse educator is conducting a presentation for antepartum clients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in the teaching content? 1. Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings. 2. Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks. 3. Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. 4. Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.

Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum. Explanation: 1. As many as 50% to 70% of mothers develop adjustment reaction with depressed mood, which is also known as postpartum blues or as maternal or baby blues. Unlike postpartum depression, this condition is characterized by mild depression interspersed with happier feelings. 2. Postpartum blues typically manifest as mild symptoms that are transient and self-limiting. Postpartum depression is severe and poses major threats to the woman and the infant, as well as to the father/partner. 3. Women with a history of postpartum psychosis or depression or other risk factors should be referred to a mental health professional for counseling and biweekly visits between the second and sixth week postpartum for evaluation. 4. Posttraumatic stress disorder, or PTSD (also called posttraumatic stress syndrome), is associated with exposure to an extremely traumatic event involving direct personal experience with actual or threatened death or serious injury, and evokes a reaction of intense fear, helplessness, or horror.

Assessment 15) The nurse is assessing a postpartum client's risk for early postpartum hemorrhage. Which findings in the client's health history place this client at an increase risk for early postpartum hemorrhage? Select all that apply. 1. Microsomia 2. Grand multiparity 3. African American heritage 4. Oxytocin induction of labor 5. History of anorexia nervosa

Grand multiparity Oxytocin induction of labor Explanation: 1. Macrosomia, not microsomia, increases the postpartum client's risk for early hemorrhage. 2. Grand multiparity is one risk factor for early postpartum hemorrhage. 3. Asian or Hispanic, not African American, heritage places the postpartum client at an increased risk for hemorrhage. 4. The use of oxytocin to augment, or induce, labor is a risk factor for early postpartum hemorrhage. 5. Obesity, not a history of anorexia nervosa, is a risk factor for early postpartum hemorrhage.

Implementation 1) The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action? 1. Assist the client to empty her bladder. 2. Help the client back to bed to check her fundus. 3. Assess her blood pressure and pulse. 4. Begin an IV of lactated Ringer infusion.

Help the client back to bed to check her fundus. Explanation: 1. The client might be experiencing a postpartum hemorrhage. Her fundus is not contracting well. Although this might be due to a full bladder, the priority nursing action is to assess and massage the fundus. 2. Massaging the fundus is the priority because of the excessive blood loss. If the fundus is boggy, fundal massage may stimulate toning of the uterus and prevent further blood loss. 3. Massaging the fundus is the top priority because of the excessive blood loss. Blood pressure and pulse do not change until 1000 to 2000 mL of blood has been lost. Massaging the fundus will prevent further blood loss. 4. Massaging the fundus is the top priority because of the excessive blood loss. An IV might need to be started if the client becomes symptomatic.

Assessment 18) The nurse is reviewing the medical record for a postpartum client. Which findings would necessitate the need for the nurse to monitor the client closely for the development of thrombophlebitis? Select all that apply. 1. Vaginal birth 2. 25 years of age 3. History of diabetes mellitus 4. Current smoker 5. Laboratory values indicating anemia

History of diabetes mellitus Current smoker Laboratory values indicating anemia Explanation: 1. A cesarean, not vaginal, birth increases the postpartum client's risk for the development of thrombophlebitis. 2. Advanced maternal age increases the postpartum client's risk for the development of thrombophlebitis. The 25-year-old postpartum client does not have an increased risk for thrombophlebitis. 3. A history of diabetes mellitus is a risk factor for the development of thrombophlebitis during the postpartum period. 4. Cigarette smoking is a risk factor for thrombophlebitis during the postpartum period. 5. Anemia is a risk factor for the development of thrombophlebitis during the postpartum period.

Implementation/Teaching/Learning 8) 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

Lactation suppression 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.

Implementation 3) The postpartum client, who delivered 4 hours ago, has a mediolateral episiotomy and large hemorrhoids. The client currently rates her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to acetaminophen (Tylenol). Which nursing action is most appropriate? 1. Offering 800 mg ibuprofen (Advil) orally with food 2. Providing two oxycodone with acetaminophen tablets (Percocet) by mouth 3. Encouraging use of the prescribed topical anesthetic spray 4. Running very warm water into the tub and assisting her into the bath

Offering 800 mg ibuprofen (Advil) orally with food Explanation: 1. This is the best option because the client is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. 2. This medication is contraindicated because of the client's allergic reaction to acetaminophen. 3. Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a client has moderately severe pain. 4. Ice packs would be better at this stage because they will cause vasoconstriction to reduce edema and pain relief.

Assessment 7) Which assessment data support the nurse's suspicion that a postpartum client has mastitis? Select all that apply. 1. Pain in the nipple during breastfeeding described as "shooting" 2. Late onset of nipple pain 3. Pink, flaking, pruritic skin of the affected nipple 4. Nipple soreness when the infant latches on 5. Breast engorgement prior to each feeding

Pain in the nipple during breastfeeding described as "shooting" Late onset of nipple pain Explanation: 1. The pain associated with mastitis is described as "shooting" pain that occurs during breastfeeding. 2. Mastitis is characterized by late-onset nipple pain. 3. The skin of the affected breast, not nipple, becomes pink, flaking, and pruritic. 4. Nipple soreness often occurs if the infant is not latching onto the breast correctly. This is not a symptom associated with mastitis. 5. Breast engorgement prior to each feeding is not a clinical manifestation associated with mastitis.

Implementation 9) The nurse is caring for a client who delivered by cesarean birth and during which she received a general anesthetic. Which will the nurse encourage to prevent or minimize abdominal distention? Select all that apply. 1. Increasing intake of cold beverages 2. Participating in leg exercises every 2 hours 3. Tightening the abdominal muscles 4. Ambulating as often as possible 5. Eating a high-protein general diet

Participating in leg exercises every 2 hours Tightening the abdominal muscles Ambulating as often as possible Explanation: 1. Increased intake of cold beverages would increase the distention through increase of gas and constipation. 2. Participating in leg exercises every 2 hours serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 3. Abdominal tightening serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 4. Ambulating as often as possible serves to prevent or minimize abdominal distention in a surgical client who received a general anesthetic. 5.Eating a high-protein general diet would increase the distention through increase of gas and constipation

Assessment 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

Primipara, day of delivery, fundus firm 2 cm above umbilicus 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.

Diagnosis 1) The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago. Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ↓ the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client? 1. Acute Pain related to perineal trauma 2. Risk for Deficient Fluid Volume related to uterine bleeding and nausea 3. Readiness for Enhanced Family Coping related to vaginal childbirth experience 4. Knowledge Deficit related to newborn care

Risk for Deficient Fluid Volume related to uterine bleeding and nausea Explanation: 1. Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit. 2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest-priority nursing diagnosis. 3. Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit. 4. Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the physiologic need for adequate fluid volume.

Diagnosis 9) The nurse is revising the care plan of a postpartum client who develops mastitis. Which nursing diagnosis is most appropriate for inclusion in this client's updated plan of care? 1. Ineffective Peripheral Tissue Perfusion related to obstructed venous return 2. Risk for Trauma related to lack of information about appropriate breastfeeding practices 3. Deficient Knowledge related to self-care after discharge on anticoagulant therapy 4. Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction

Risk for Trauma related to lack of information about appropriate breastfeeding practices Explanation: 1. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis. 2. In relation to the client's mastitis, the most appropriate nursing diagnosis is Risk for Trauma related to lack of information about appropriate breastfeeding practices. 3. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis. 4. This nursing diagnosis is more appropriate for a client who develops thrombophlebitis not mastitis.

Implementation 10) 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.

Teach the client how to interact appropriately with the infant. 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 and the mother 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.

Assessment 16) The nurse is assessing a postpartum client who is 36 hours post delivery. Which findings cause the nurse to suspect a reproductive tract infection? Select all that apply. 1. Temperature of 38.0°C (100.4°F) or higher 2. Foul-smelling lochia 3. Uterine tenderness 4. Leg edema and erythema 5. Breast engorgement

Temperature of 38.0°C (100.4°F) or higher Foul-smelling lochia Uterine tenderness Explanation: 1. A temperature of 38.0°C (100.4°F) or higher is an indication that the postpartum client is experiencing a reproductive tract infection. 2. Foul-smelling lochia is an indication that the postpartum client is experiencing a reproductive tract infection. 3. Uterine tenderness is an indication that the postpartum client is experiencing a reproductive tract infection. 4. Leg edema and erythema is an indication of thrombophlebitis, not a reproductive tract infection. 5. Breast engorgement is not an indication of a reproductive tract infection.

Assessment 10) The nurse is performing wellness checks for postpartum clients after hospital discharge via the telephone. Which client should be seen immediately? 1. The client who at 4 weeks postpartum describes feeling sad all the time. 2. The client who at 2 weeks postpartum reports hearing voices talking about the baby. 3. The client who at 1 week postpartum states that she has no appetite and feels tired all the time. 4. The client with a history of depression who states she needs a refill on her sertraline (Zoloft) in 1 week.

The client who at 2 weeks postpartum reports hearing voices talking about the baby. Explanation: 1. While this may indicate postpartum blues or postpartum depression, this client does not require an immediate appointment to be seen. 2. This is an indication the client is experiencing postpartum psychosis, and is the highest priority, because the voices might tell her to harm her baby. 3. While this may indicate postpartum blues or postpartum, this client does not require an immediate appointment to be seen. 4.A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority.

Assessment 13) 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.

The mother points out family traits she sees in the newborn. 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.

Assessment 11) 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.

The mother vocalizes feelings of frustration with her infant. 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.

Caring 10) The nurse is caring for an adolescent client who gave birth to her first child yesterday. Which nursing action indicates accurate understanding of adolescent parenting concepts? 1. The client's mother is included in all discussions and demonstrations. 2. The father of the baby is encouraged to change a diaper and give a bottle. 3. The nurse explains the characteristics and cues of the baby during the assessment. 4. A discussion on contraceptive methods is the first topic of teaching.

The nurse explains the characteristics and cues of the baby during the assessment. Explanation: 1. Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the client desires to have her mother present for teaching and discussions. 2. Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority. 3. This helps the client learn about her baby and understand the baby as an individual, and facilitates maternal-infant attachment. This is the highest priority. 4. Adolescents are statistically more likely to have another child during their adolescence, but establishing a rapport and facilitating understanding of and attachment to the newborn is a higher priority.

Implementation 20) The nurse is conducting teaching for a postpartum client who is approaching discharge. Which topics will the nurse include in the educational session regarding the prevention of postpartum hemorrhage? Select all that apply. 1. Using the peri-bottle 2. Applying ice to the breasts 3. Wearing cotton underwear 4. Performing fundal massage 5. Inspecting the episiotomy site

Using the peri-bottle Performing fundal massage Inspecting the episiotomy site Explanation: 1. The nurse includes education on the use of the peri-bottle during discharge instructions regarding the prevention of postpartum hemorrhage. 2. Application of ice is an appropriate topic when teaching the postpartum client to avoid engorgement. This information is not appropriate when teaching methods to prevent postpartum hemorrhage. 3. The use of cotton underwear is an appropriate topic when teaching the postpartum client to avoid a urinary tract infection (UTI), not postpartum hemorrhage. 4. The nurse includes education on performing fundal massage during discharge instructions regarding the prevention of postpartum hemorrhage. 5. The nurse includes education on inspecting the episiotomy site during discharge instructions regarding the prevention of postpartum hemorrhage.

Teaching and Learning 21) The nurse is conducting discharge teaching for a postpartum client who has an episiotomy. Which client actions indicate correct understanding of the information presented? Select all that apply. 1. Using topical anesthetics regularly 2. Remaining in the sitz bath for 20 minutes 3. Using the peri-bottle to cleanse the site after urination 4. Stating that she will loosen her buttocks prior to sitting down 5. Stating that she will continue to use an ice pack for pain after discharge

Using topical anesthetics regularly Remaining in the sitz bath for 20 minutes Using the peri-bottle to cleanse the site after urination Explanation: 1. The use of topical anesthetics regularly after an episiotomy is a client action that indicates correct understanding of episiotomy care. 2. The postpartum client who remains in a sitz bath for 20 minutes is correctly caring for an episiotomy. 3. The use of a peri-bottle each time the postpartum client urinates indicates correct understanding of episiotomy care. 4. The postpartum client who states she will loosen her buttocks prior to sitting down will require additional education regarding episiotomy care. The client should tighten her buttocks prior to sitting down. 5. The postpartum client who states she will continue to use an ice pack for pain after discharge will require additional education regarding episiotomy care. Ice packs are only used for the first 24 hours.