1. A nurse discovers a postpartum client with a boggy uterus, displaced above and to the right of the umbilicus. What nursing action is indicated?
1. Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder because cardinal signs of bladder distension are present.
2. Which women experience afterpains more than others?
2. Breastfeeding women, multiparas, and women who experienced over distension of the uterus.
3. Upon admission to the postpartum room, 3 hours after delivery, a client has a temperature of 99.5F. What nursing actions are indicated?
3. Probably elevated d/t dehydration and work of labor; force fluids and retake temperature in an hour; notify physician if above 100.4F
4. A client feels faint on the way to the bathroom. What nursing assessments should be made?
4. Assess BP sitting and lying, assess Hgb and Hct for anemia.
5. What factor places the postpartum client at risk for thromboembolism?
5. Increased clotting factors
6. A breastfeeding mother c/o very tender nipples. What nursing actions should be taken?
6. Have her demonstrate infant position on breast (incorrect positioning often causes tenderness). Leave bra open to air-dry nipples for 15 minutes 3x daily. Express colostrum and rub on nipples.
7. 3 days postpartum, a lactating mother has full, warm, taut, tender breasts. What nursing actions should be taken?
7. She is engorged; have newborn suckle frequently; use measures to increase milk flow; warm water, breast massage and supportive bra.
8. What information should be given to a client regarding resumption of sexual intercouse after delivery?
8. Avoid until postpartum exam. Use water-soluble jelly. Expect slight discomfort due to vaginal changes.
9. A woman has decided to take birth control pills as her contraceptive method. What should she do if she misses taking the pill 2 consecutive days?
9. Take 2 pills for 2 days and use an alternate form of birth control.
10. A woman asks why she is urinating so much in the postpartum period. The nurse bases the response on what information.
10. Up to 3,000 cc per day can be voided due to the reduction of the 40% plasma volume increase during pregnancy.
11. A woman's WBC returns 17,000; she is afebrile and has no symptoms of infection. What nursing action is indicated?
11/ Continue routine assessments; normal leukocytosis occurs during postpartal period because of placental site bleeding.
12. What is the most common cause of uterine atony in the first 24 hours postpartum?
12. A full bladder
13. What is the purpose of giving docusate sodium (Colace) to the postpartum client?
13. To soften the stool in mothers with 3rd of 4th degree episiotomies, hemorrhoids, or C-section delivery.
14. What should the fundal height be at 3 days postpartum for a woman who has had a vaginal delivery?
14. 3 fingerbreaths/cm below the umbilicus.
15. List 3 signs of positive bonding between parents and newborn.
15. Calling infant by name, exploration of newborn head-to-toe, en face position.