Postpartum AQ – Flashcards
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A nursing student is learning about expected postpartum anatomic and physiologic changes. Which statement made by the nursing student indicates a need for further learning? "The capacity of the bladder increases postpartum." "The uterus involutes to approximately 350 g by two weeks after birth." "The cervical dilation decreases to 2 to 3 cm by the second or third postpartum day." "After birth, the vagina gradually decreases in size and returns to its pre-pregnancy state."
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"After birth, the vagina gradually decreases in size and returns to its pre-pregnancy state." (During the postpartum period, normal anatomic and physiological changes occur. After a birth, the vagina gradually decreases in size; however, does not return to its pre-pregnancy state. The capacity of the bladder increases postpartum, which may lead to a decreased urge to void. The uterus returns to a nonpregnant state after birth in a process known as involution. The uterus involutes to approximately 350 g by two weeks after birth. During labor, the cervix dilates to approximately 10 cm; the dilation decreases to 2 to 3 cm by the second or third postpartum day.)
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The nurse instructs a multipara who has just given birth to a large-for-gestational-age (LGA) infant how best to maintain a contracted uterus. Which statement indicates to the nurse that the teaching was effective? "If I start to bleed, I'll call for help." "I'll massage my uterus regularly to keep it firm." "If I urinate frequently, my uterus will stay contracted." "I'll call you every 15 minutes to massage my uterus."
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"I'll massage my uterus regularly to keep it firm." (The uterus responds rapidly to touch, and the mother may be involved in her own care. The uterus must be massaged before there are signs of bleeding. Although frequent urination may be beneficial, the client should be taught to massage the uterus to cause it to contract. Stating that she will call every 15 minutes to have her uterus massaged does not actively involve the mother in her own care and could be unsafe if the uterus becomes boggy during the 15-minute intervals.)
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The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment? Drink fluids Empty her bladder Perform the Valsalva maneuver Assume the semi-Fowler position
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Empty her bladder (Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.)
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The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains? Multipara who has vaginally delivered three children Primipara whose newborn weighed 7 lb Multipara with effectively controlled diabetes Multipara whose second child was small for gestational age
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Multipara who has vaginally delivered three children (A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.)
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The nurse is assigned to care for an adolescent who gave birth 12 hours ago. The client continually talks on the phone to her friends and does not respond when her new baby cries. What is the priority intervention at this time? Calling social service for a consult Calling the psychiatric team for an intervention Calling her mother and having her speak with the client Modeling appropriate behaviors that encourage infant bonding
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Modeling appropriate behaviors that encourage infant bonding (All women go through several phases of adapting to the role of mother. An adolescent may still need time to adjust to her new role, especially if she has just given birth in the past 24 hours. By modeling appropriate behavior, the nurse demonstrates appropriate maternal skills to the adolescent. This will assist her as she makes the transition into her new role as a mother. If this behavior continues and does not improve before discharge, social service may need to get involved, but a consult is not needed in this early phase. A psychiatric consult is not necessary because this is not a psychiatric illness. The adolescent's mother is an important part of the plan, especially if the adolescent is going home to her house, but the relationship between the two needs to be assessed to see what role she will play in this new mother-child relationship.)
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When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? There is a slow rate of involution. There are retained placental fragments. The bladder has become overdistended. The uterine ligaments are overstretched.
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The bladder has become overdistended. (A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.)
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The nurse notes that a client is voiding frequently in small amounts 8 hours after giving birth. What should the nurse conclude about this minimal output of urine during the early postpartum period? It may indicate retention of urine with overflow. It may be indicative of beginning pyelonephritis. This is common because less fluid is excreted after birth. This is common because fluid intake diminishes after birth.
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It may indicate retention of urine with overflow. (Retention of urine with overflow will be manifested in small, frequent voidings. The bladder should be palpated for distention. An increased temperature with urinary alterations would indicate impending infection. More circulating fluid is present, resulting in increased output. The client is usually thirsty and fluid intake increases.)
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Twelve hours after delivery the nurse is checking the client. Where does the nurse expect to find the fundus once the woman has voided?
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At 12 hours after delivery, the uterus should be midline, slightly above the umbilicus.
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While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats per minute, and respirations are 16 breaths per minute. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? Recording these expected findings Obtaining an order for an oxytocic medication Asking the client when she last changed the perineal pad Notifying the primary healthcare provider that the client may be hemorrhaging
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Asking the client when she last changed the perineal pad (The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported or recorded without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.)
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What is the optimal nursing intervention to minimize perineal edema after an episiotomy? Applying ice packs Offering warm sitz baths Administering aspirin as needed (prn) Elevating the hips on a pillow
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Applying ice packs (Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides minimal perineal relief.)
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During the postpartum period a client tells a nurse that she has been having leg cramps. Which foods should the nurse encourage the client to eat? Liver and raisins Cheese and broccoli Eggs and lean meats Whole-wheat breads and cereals
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Cheese and broccoli (The leg cramps may be related to low calcium intake; cheese and broccoli each have a high calcium content. Although liver and raisins, eggs and lean meats, and whole-wheat breads and cereals are recommended as part of a high-quality nutritional intake, they are inadequate sources of calcium.)
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A client required an extensive episiotomy because her newborn was large. What is a priority nursing intervention that minimizes edema and lessens discomfort at the episiotomy site? Applying ice packs to the perineum Positioning the client off the incisional area Administering an oral analgesic to the client Spraying the perineum with a local anesthetic
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Applying ice packs to the perineum (Application of cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site. Cold also deadens nerve endings and lessens the pain. A side-lying position will not lessen pain or reduce edema. Analgesia may diminish the pain but will not lessen the edema. An anesthetic spray is not recommended after an episiotomy.)
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The nurse teaches a postpartum client how to care for her episiotomy in order to prevent infection. Which behavior indicates that the teaching has been effective? The perineal pad is changed twice daily. The client washes her hands before and after she changes a perineal pad. The client rinses her perineum with water after using an analgesic spray. The client cleanses the perineum from the anus toward the symphysis pubis.
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The client washes her hands before and after she changes a perineal pad. (Washing the hands before and after every pad change prevents the transfer of microorganisms from the hands to the genital tract or vice versa. Changing the perineal pad twice daily is an inadequate number of changes; soiled pads promote the growth of microorganisms because they are warm and moist and provide a medium for growth. Rinsing the perineum with water after using an analgesic spray interferes with the analgesic action of the spray and does not prevent infection. Cleansing the perineum from the anus toward the symphysis pubis promotes contamination of the vagina and urethra by organisms from the perianal area.)
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A primigravida client gave birth by vaginal delivery 24 hours ago. Which findings would be considered normal? Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present Fundus firm, one fingerbreadth above the umbilicus; scant lochia alba; voided twice, 500 mL, 400 mL; breasts heavy Fundus firm, two fingerbreadths above the umbilicus; moderate lochia serosa; voided once, 200 mL; colostrum present Fundus firm, two fingerbreadths below the umbilicus; moderate serosa alba; voiding quantity sufficient; breasts engorged
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Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present (Twenty-four hours after delivery, the fundus is usually at the umbilicus and moderate lochia rubra is expected. Colostrum is present, and the breast milk usually comes in on day 3 after delivery. A fundus two fingerbreadths above the umbilicus may indicate a full bladder, and lochia serosa occurs during days 4 through 10. Voiding just 200 mL since delivery is inadequate. The presence of colostrum is normal. A fundus that is firm at two fingerbreadths under the umbilicus is acceptable, but lochia alba occurs after the 10th postpartum day. The milk would have had to come in for the breasts to be engorged, which does not typically occur until day 3. Scant lochia alba would not occur until day 10; nor would the milk supply be established.)
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A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. (16 X 109/L) What is the next nursing action? Checking with the nurse manager to see whether the client may go home Reassessing the client for signs of infection by taking her vital signs Delaying the client's discharge until the practitioner has conducted a complete examination Placing the report in the client's record because this is an expected postpartum finding
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Placing the report in the client's record because this is an expected postpartum finding (Leukocytosis (15,000 to 20,000/mm3 WBC) (15 to 20 X 109/L) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention because the client is exhibiting an expected postpartum leukocytosis.)
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Which information should the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. The episiotomy sutures will be removed at the first postpartum visit. She may not have a bowel movement for up to a week after the birth. She should schedule a postpartum checkup as soon as her menses returns.
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The prenatal Kegel tightening exercises should be continued. (Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.)
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One hour after a birth a nurse palpates a client's fundus to determine whether involution is taking place. The fundus is firm, in the midline, and two fingerbreadths below the umbilicus. What should the nurse do next? Encourage the client to void. Notify the practitioner immediately. Massage the uterus and attempt to express clots. Continue periodic assessments and record the findings.
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Continue periodic assessments and record the findings. (Immediately after birth the uterus is 2 cm below the umbilicus; during the first several postpartum hours the uterus will rise slowly to just above the level of the umbilicus. These findings are expected, and they should be recorded. Encouraging the client to void is unnecessary; if the bladder is full, the uterus will be higher and pushed to one side. Notifying the healthcare provider is unnecessary; involution is occurring as expected. Massage is used when the uterus is soft and "boggy.")
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A client who has had a cesarean birth is being discharged. Which statement indicates to the nurse that further teaching is required? "I may take a Percocet tablet if my incision hurts." "I should take a mild laxative if I don't have a bowel movement." "I can start mild exercises once my incision has stopped hurting." "I don't need perineal care because I didn't give birth through the vagina."
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"I don't need perineal care because I didn't give birth through the vagina." (After a cesarean birth, the client has the same vaginal discharge (lochia) as a client who gave birth vaginally. Perineal care is necessary to prevent an ascending infection. Mild laxatives are permitted if needed. Oxycodone/acetaminophen (Percocet) or a similar analgesic usually is prescribed. Mild exercise is not contraindicated if there is no incisional pain.)
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The nurse on the postpartum unit is providing postpartum care instructions to a 21-year-old Inuit woman who delivered her first baby yesterday without complications. Her husband, mother, and other family members have been with her since delivery. The mother speaks and understands very little English; however, her husband and sister speak some English. What is the best way to ensure that the client and her family understand what is being taught? Providing the teaching to all family members and the client Asking the client and her family to nod their heads to verify understanding Asking the client and her family members to say yes to verify understanding Asking the client and family members to repeat, in their own words, what they have been told
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Asking the client and family members to repeat, in their own words, what they have been told (The family members should tell the nurse their understanding of what was taught. Simply providing the teaching to the family does not ensure understanding. Nodding or saying yes may be a sign of courtesy rather than of understanding or agreement and is not an effective way to verify understanding.)
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Which behavior indicates to the nurse that a new mother is in the taking-hold phase? Calling the baby by name Talking about the labor and birth Touching the baby with her fingertips Being involved with the infant's need to eat and sleep
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Calling the baby by name (The mother has moved into the taking-hold phase when she takes control and becomes actively involved with her infant and calls the infant by name. She has completed the taking-in phase when her own needs no longer predominate. Talking about the labor and birth occur in the taking-in phase when she has the need to integrate the experience. Touching the baby with her fingertips is the initial early action of the taking-in phase. Being involved with the infant's need to eat and sleep is part of the taking-in phase.)
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Which statements regarding the involution process are correct? Select all that apply. Involution begins immediately after expulsion of the placenta. Involution is the self-destruction of excess hypertrophied tissue. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth. Involution may be caused by retained placental fragments and infections.
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Involution begins immediately after expulsion of the placenta. Involution progresses rapidly during the next few days after birth. Involution is the return of the uterus to a nonpregnant state after birth. (The involution process is the return of the uterus to a nonpregnant state after birth; it begins immediately after expulsion of the placenta and contraction of the uterine smooth muscle. This process progresses rapidly during the first few days after birth. Subinvolution is the self-destruction of excess hypertrophied tissue; this process may be caused by retained placental fragments or infection.)
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A nurse assesses the process of involution of the uterus by measuring the location of the client's fundus during the postpartum period. Click on the location the fundus is expected to be 1 day after birth in a client whose bladder is not distended.
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One day after birth, the fundus is expected to be at the level of the umbilicus. In the first 12 hours after birth, the uterus is expected to be one fingerbreadth above the umbilicus. It is then expected to descend by approximately one fingerbreadth per day until it descends under the pubic bone, usually around day 10.
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At 5 am, 2 hours after a long labor and vaginal birth, a client is transferred to the postpartum unit. What is the nurse's priority when planning morning care for this client? Planning nursing care activities that provide time for the client to rest and sleep Preparing for the probability of hemorrhage by massaging the client's uterus frequently Arranging an individual session in which the client can learn about successful breastfeeding Anticipating safety needs by instructing the client to remain in bed and call for assistance whenever ambulating
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Planning nursing care activities that provide time for the client to rest and sleep (After laboring all night the client is tired and needs uninterrupted rest. Massaging the fundus frequently is unnecessary unless the uterus becomes boggy. Providing a lesson on breastfeeding is premature. The client is not ready to learn because she needs to rest and sleep after a long labor. It is necessary for the client to call for assistance only the first time she ambulates; otherwise the client may ambulate ad libitum.)
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What type of lochia should the visiting nurse expect to observe on a client's pad on the fourth day after a vaginal delivery? Scant alba Scant rubra Moderate rubra Moderate serosa
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Moderate serosa (On the third to fourth day the uterine discharge becomes pink to brown; it continues until approximately the 10th day. After about 10 days the uterine discharge becomes yellow to white (alba); alba may continue until 2 to 6 weeks after the birth. It is unusual to have scant lochia rubra. Lochia rubra lasts from the first to about the third day; it is usually heavy but may be moderate after a few days.)
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After the birth of her baby a client tells the nurse, "I'm so cold, and I can't stop shaking." How should the nurse respond? "I'm going to take your temperature right now." "Let me check your uterus to see whether it's firm." "Turn on your side so I can check the amount of lochia." "I'll get you some warm blankets to help make the chill go away."
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"I'll get you some warm blankets to help make the chill go away." (A postpartum chill is an expected vasomotor reaction. Covering the client with warm blankets will ease the discomfort. Taking the client's temperature, palpating the uterus, and monitoring the lochial flow are all parts of the routine postpartum assessment; however, they do not need to be done in response to the sensation of a chill.)
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Which interventions are included in the care plan of a postpartum client with a fourth-degree laceration? Select all that apply. Pain management with oral analgesics Continuous application of a warm pack Assessment of the site every 15 minutes Gentle cleansing with antibacterial cleanser Application of an ice pack for 20-minute intervals Instructing the client in how to promote normal bowel function
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Pain management with oral analgesics Assessment of the site every 15 minutes Application of an ice pack for 20-minute intervals (Providing pain management will prevent the client's pain from reaching an unmanageable level. Assessment of the site will identify any abnormal changes. Application of ice will decrease pain and edema. Warmth applied to newly traumatized tissue will increase pain and edema. Antibacterial cleanser would be caustic and painful to the laceration. Teaching regarding bowel function would be more appropriately presented after the client has completed the fourth stage and resumed normal intake.)
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A client on the postpartum unit asks the nurse why the nurses are always encouraging her to walk. What should the nurse consider when forming a response? Respirations are enhanced. Bladder tonicity is increased. Abdominal muscles are strengthened. Peripheral vasomotor activity is promoted.
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Peripheral vasomotor activity is promoted. (There is extensive activation of the blood-clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and deep-breathe and cough. Bladder tone is improved by regular voiding and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.)
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What does the nurse expect to find when checking the vital signs of a client in the early postpartum period? Bradycardia with no change in respirations Tachycardia with a decrease in respirations Increased basal temperature with a decrease in respirations Decreased basal temperature with an increase in respirations
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Bradycardia with no change in respirations (In the postpartum period a slow pulse rate may result from a combination of factors, including decreased cardiovascular workload, emotional relief and satisfaction, and rest after labor and birth. Bradycardia is more likely; respirations generally are unchanged. The temperature may rise slightly, but usually respirations are unchanged.)
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What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline? Massaging the uterine fundus Helping the client to the bathroom Assessing the peripad for the amount of lochia Administering intramuscular methylergonovine (Methergine) 0.2 mg
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Massaging the uterine fundus (A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.)
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A client delivered a 7-lb 6-oz (3345 g) female infant at 11 pm yesterday after a labor of 14 hours. After breakfast the nursery staff brings the baby to the new mother. The mother smiles at the baby, then asks that the nurse take the baby back to the nursery because she has not had a shower yet. One hour later the nurse returns with the infant. Again the mother smiles at the baby; then she holds her, kisses her, and feeds her a bottle. Immediately after feeding the baby, the mother calls the nursery and asks if the baby be picked up so she can take a nap. Which behavior is the new mother demonstrating? Taking in Letting go Taking hold Bonding failure
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Taking in (During the taking-in period the mother focuses on her needs rather than the baby's. During this period the mother needs to be "mothered" so she can assume the role of mother. The letting-go period is when the mother wants to take control and "mother" the infant. The taking-hold period is when the mother is anxious to learn about the infant and how to care for it. This mother shows positive behaviors, including smiling, kissing, and holding. There is no evidence of a failure to bond.)
