Chapter 17 Questions

A postpartum client overhears the nurse tell the HCP that she has a positive Homan's sign and asks what it means. Which is the nurse's best response?
a. you have pitting edema in your ankles
b. you have deep tendon reflexes rate 2+
c. you have calf pain when the nurse flexes your foot
d. you have a fleshy odor to your vaginal drainage.
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A postpartum client overhears the nurse tell the HCP that she has a positive Homan's sign and asks what it means. Which is the nurse's best response?
a. you have pitting edema in your ankles
b. you have deep tendon reflexes rate 2+
c. you have calf pain when the nurse flexes your foot
d. you have a fleshy odor to your vaginal drainage.
c. you have calf pain when the nurse flexes your foot
rationale: discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis.
Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic
a. Gravida 5, para 5
b. primipara who delivered a 7 lb boy
c. client who is bottle feeding her first child
d. Client who wishes to breastfeed as soon as her baby is out of the NICU
A. gravida 5, para 5
rationale: The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone.
Which maternal event is abnormal in the early postpartal period
a. diuresis and diaphoresis
b. flatulence and constipation
c. extreme hunger and thirst
d. lochial color changes from rubra to alba.
a. lochial changes from rubra to alba
rationale: For the first 3 days after childbirth, lochia is termed rubra
Which fundal assessment finding at 12 hours after birth requires further assessment
a. The fundus is palpable at the level of the umbilicus
b. the fundus is palpable two finger breadths above the umbilicus
c. The fundus is palpable one finger breadth below the umbilicus
d. The fundus is palpable two fingerbreadths below the umbilicus
b. the fundus is palpable two finger breadths above the umbilicus
rationale: the fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus above the umbilicus may indicate uterine atony and urinary retention.
If the clients WBC is 25,000 on her second post partum day, which action should the nurse take
a. document the finding
b. tell the HCP
c. begin antibiotic therapy immediately
d. have the lab draw blood for reanalysis.
a. document the finding.
rationale: an increase in WBC to 25,000 during the postpartum period is considered normal and not a sign of infection.
Postpartal overdistention of the bladder and urinary retention can lead to which complication
a. fever and increased blood pressure
b. postpartum hemorrhage and eclampsia
c. urinary tract infection and uterine rupture
d. postpartum hemorrhage and urinary tract infection
d. postpartum hemorrhage and urinary tract infection
rationale: incomplete emptying and overdistention of the bladder can lead to urinary tract infection.
A postpartum clients asks, "will these stretch marks go away". Which is the nurses best response.
a. No, never
b. yes, eventually
c. the will fade to silvery lines but wont disappear completely
d. they will continue to fade and should be gone by your 6 week checkup
c. they will fade to silvery lines but wont disappear completely.
A pregnant client asks when the dark line on her abdomen will go away. The nurse knows the pigmentation will decrease after birth because of
a. increased estrogen
b. increased progesterone
c. decreased human placental lactogen
d. decreased melanocyte-stimulating hormone
d. decreased melanocyte-stimulating hormone
rationale: melanocyte-stimunlating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth.
if the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which?
a. Distended bladder
b. normal involution
c. been lying on her right side too long
d. stretched ligaments that are unable to support the uterus.
A. distended bladder.
rationale: the presence of a full bladder will displace the uterus.
The center for disease control and prevention recommends the use of which personal protective equipment with which the nurse is likely to come into contact?
a. any body fluids
b. any client at any time
c. blood and blood products
d. any client suspected of being HIV positive
c. blood and blood products
rationale: possible contamination of medical personnel can result from contact with blood, blood products, and only certain body fluids.
Rho(D) immune globulin will be ordered postpartum if which situation occurs. a. mother Rh-negative, baby Rh-positive b. mother Rh-neg, baby Rh-neg c. mother Rh-pos, baby Rh-pos d. Mother Rh-positive, baby Rh-negA. mother Rh-neg, baby Rh-pos rationale: An Rh-negative mother delivering an Rh positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated.If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included. a. No specific instructions b. drinking plenty of fluids to prevent fever c. recommendation to stop breastfeeding for 24 hours after the injection. d. Explanation of the risks of becoming pregnant within 28 days following injection.d. explanation of the risks of becoming pregnant within the 28 days following the injection rationale: potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration.Which is the best measure to prevent abdominal distention following a cesarean birth. a. rectal suppositories b. carbonated beverages c. early and frequent ambulation d. tightening and relaxing abdominal muscles.c. early and frequent ambulation. rationale: activity can aid the movement of accumulated has in the GI tract.Which documentation in the clients chart on the 14th postpartum day indicates a normal involution process. a. breasts firm and tender b. episiotomy slightly red and puffy c. moderate bright red lochial flow d. fundus below the symphysis and not palpable.d. fundus below the symphysis and not palpable rationale: the fundus decends 1cm/day, so buy postpartum day 14, it is no longer palpable.To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform a. Assess locial flow rather than palpating the fundus b. palpate forcefully through the abdominal dressing c. place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveriesd. gently palpate, applying the same technique used for vaginal deliveries. rationale: assessment of the fundus is the same for vaginal and cesarean deliveries.The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount a. saturated peripad. b. 4 to 6 inch stain on the peripad c. 1 to 4 inch stain on the peripad d. less than 1 inch stain on the peripad.b. 4 to 6 inch stain on the peripad rationale: because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in the following lables. scant - less than 1 inch light - 1 to 4 inch moderate - 4 to 6 inch heavy - saturated excessive - saturated peripad in 15 minsThe postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed. a. I may not have a bowel movement until the 2nd postpartum day. b. if I breastfeed and supplement with formula, I wont need any birth control c. I know my normal pattern of bowel elimination wont return until about 8 to 10 days d. If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband.b. If i breastfeed and supplement with formula, I wont need any birth controlThe nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the HCP a. pulse rate of 50 b. temo of 100.4 c. firm fundus, but excessive lochia d. lightheaded when moving from a lying to standing position.c. firm fundus, but excessive lochia. rationale: excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal.The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take a. decrease IV fluid rate b. document the finding c. Encourage the use of an incentive spirometer. d. ambulate the client around the nurses stationc. encourage the use of an incentive spirometer. rationale: incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations.Which of the following would indicate an abnormal finding during the postpartum period. a. lochia flow changing from alba to rubra b. unable to palpate uterine fundus at 6 week postpartum checkup c. presence of afterbirth pains d. lochia flow heavier in the early morning 2 days following vaginal birth.a. lochia changing from alba to rubra rationale: lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding.Vaginal exam findings reveal a slitlike opening of the cervix. what is the correct interpretation of this finding with regard to obstetric history. a. client has not been pregnant b. client has had a c-section as a method of birth c. client has been treated for an STP with resultant scarring of the cervix d. client has a history of pregnancyd. client has a history of pregnancyTo facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care. a. Have the client drink carbonated beverages to promote urinary excretion b. tell the client that because of postpartum diuresis there is less risk to develop dehydration c. limit fluid intake to prevent polyuria d. teach the client to do pelvic floor exercises to combat potential stress incontinence.d. teach the client to do pelvic flow exercises to combat potential stress incontinence.In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth. a. quantity of lochia rubra b. pain management techniques c. frequency of vital signs and fundal checks d. assessment of infection risk from loss of skin integrity.b. pain management techniques. rationale: a cesarean section is major surgery. Pain relief is provided in various ways, including patient controlled anesthesia and oral and intramuscular analgesics.When assessing the A of the acronym REEDA, the nurse should assess the a. skin color b. degree of edema c. edges of the episiotomy d. episiotomy for discharge.c. edges of the episiotomy rationale: A refers to the approximation of the edges of the episiotomy R - reddness E - Edema E - ecchymosis D - drainage A - approx edgesWhich assessment finding 24 hours after vaginal birth would indicate a need for further intervention a. pain level is 5 on a scale of 0 to 10 b. saturated pad over a 2 hour period c. urinary output of 500 mL in one voiding d. uterine fundus 2 cm above the umbilicus.d. uterine fundus 2 cm above the umbilicus. rationale: by the second postpartum day, the fundus decends and should be 1 cm below the umbilicus.The nurse is providing care to a patient who delivered a 3535g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurses priority action related to this finding. a. inform the HCP b. encourage the patient to urinate c. massage the uterus to expel clots d. document the finding in the patients chart.d. document the finding in the patients chart.The nurse is providing care to a patient 2 hours after a cesarean section. In the hand off report, the preceding nurse indicated that the patients lochia was scant rubra. On initial assessment, the oncoming nurse notes the patients peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurses priority action with this finding. a. weigh the peripad b. replace the peripad c. contact the HCP d. document the finding in the patients chart.c. contact the HCP rationale: the lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced.the nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates that the treatment has been effective. a. no swelling or edema to the perinal area b. patient complains that the sitz bath is too cold c. patient reports she took two sitz baths in 12 hours d. edges of the perineal laceration are well approximated.a. no swelling or edema to the perineal area.The term reciprocal attachment behavior refers to which of the following a. Behavior during the sensitive period when the infant is in the quiet alert stage b. Positive feedback an infant exhibits toward parent during the attachment process c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of falling in love from the parents.B. positive feedback an infant exhibits toward parent during attachment process rationale: In this definition, reciprocal refers to the feedback from the infant during the attachment periodThe postpartum client who continually repeats the story of her labor, birth, and recovery experiences is doing which ? a. making the birth experience "real" b. Accepting her response to labor and birth c. Providing others with her knowledge of events d. taking hold of the events leading to her labor and birtha. making the birth experience real rationale: reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and the infant is born and is now a separate individual.During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant. a. Formal b. informal c. personal d. anticipatorya. formal rationale: a major task of the formal stage of role attainment is getting acquainted with the infant. Informal: begins once the parents have learned appropriate responses to their cues. The personal stage is attained when parents feel a sense of harmony in their role. The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes.The nurse observes a client on her first postpartum day sitting in bed while her newborn lies awake in the bassinet. Which appropriate action should the nurse take a. hand the baby to the woman b. explain "taking-in" to the woman c. offer to hand the baby to the woman d. No action, because this situation is perfectly acceptable.a. hand the baby to the woman rationale: during the taking in phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage.A postpartum nurse is observing a client holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4 yr old big brother is punching his mother on the back. Which action should the nurse take? a. Report the incident to the social services department b. Advise the parents that the older son needs to be reprimanded. c. No action; this is a normal family adjusting to family change. d. report to oncoming staff that the mother is probably not a good disciplinarian.c. no action. this is a normal family adjusting to family change. rationale: the observed behaviors are normal variations of families adjusting to change.During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby. a. Letting go b. taking in c. taking on d. taking holda. letting go rationale: accepting the real infant and relinquishing the fantasy infant occurs during the letting go phase. taking in - mother is primarily focused on her own needs taking hold - mother assumes responsibility for her own care and shift her attention to the infant.A 25 year old gravida 1, para 1, who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry, Which should be your initial action. a a. assess her for pain b. Allow her time to express her feelings c. point out how lucky she is to have a healthy baby. d. explain that she is experiencing postpartum blues.b. allow her time to express her feelings. rationale: although many women experience transient postpartum blues, they need assistance in expressing their feelings.A husband calls the nurses station stating that his wife who delivered last week is happy one minute and crying the next. He says "she was never like this before the baby was born". Which should be the nurses initial response. a. Reassure him that this behavior is normal b. advise him to get immediate psychological help for her. c. Tell him to ignore the mood swings because they will go away d. instruct him in the signs, symptoms, and duration of postpartum blues.a. reassure him that this behavior is normal rationale: before providing further instruction, inform family members of the fact the postpartum blues are a normal process to allay anxieties and increase receptiveness.To promote bonding and attachment immediately after birth, which action should the nurse take? a. assist the mother in feeding her baby b. allow the mother quiet time with her infant c. teach the mother about the concepts of bonding and attachment. d. Assist the mother in assuming an en face position with her newbornd. assist the mother in assuming an en face position with her newborn rationale: assisting the mother in assuming an en face position with her newborn will support the bonding process.While the nurse is demonstrating a baby bath, the client states "the other nurse told me to do it a different way". Which response should the nurse make a. tell her to do the procedure whichever way works best for her b. confront the other nurse about her knowledge of the procedure. c. reassure her that procedures are based on standard principles and may vary d. tell her that the other nurse does not have much experience in caring for newborns.c. reassure her that procedures are based on standard principles and may vary. rationale: procedures may vary as long as basic principles are included.A new mother states "my mother in law will be here from out of town for a few weeks. I am afraid she will take over the care of the baby". Which response should the nurse make a. tell the client that everything will be okay b. tell the client how lucky she is to have someone to help her c. encourage the client to allow her mother in law to take care of the newborn d. encourage the client to tell her mother in law that she (the new mother) wants to care for her infant.d. encourage the client to tell her mother in law that she wants to care for her infant. rationale: before the mother in law has the opportunity to take over, the mother needs to state her own desire to care for the infant.Which client is most likely to have the least stress adjusting to her role as a mother. a. A 26 yr old woman who is returning to work in 10 weeks b. a 35 yr old anxious mother who has had no contact with babies or children. c. A 16 yr old teenager who lives with her parents and has a strained relationship with her mother. d. A 25 yr old woman who knew at 16 weeks of gestation that she was pregnant with twins, who delivered by cesarean birhta. a 26 yr old woman who is returning to work in 10 weeks rationale: the woman who has the least amount of stress in her life will adjust more quickly to her role as a mother.Which anticipatory guidance action by the nurse makes role transition to parenthood easier. a. Helps the new parents identify resources b. Recommends employing babysitters frequently c. Tells the parents about the realities of parenthood d. Offers a home phone number and tells the parents to call if they have questions.a. helps the new parents identify resources. rationale: available resources within the community can assist the parents in role transition.Which action should the nurse do to provide support and encouragement to the new postpartum client. a. Recount how she solved her own problems b. Correct the new mother at every opportunity. c. Praise the mothers early attempts at infant care d. Explain to the new mother that everything will be finec. praise the mothers early attempts at infant care rationale: positive reinforcement of the mothers attempt to provide care to the newborn will promote a healthy self concept.Which should the nurse do to provide support to a new client who must return to full time employment 6 weeks after a vaginal birth. a. Discuss child care arrangements with her. b. Allow her to solve the problem on her own. c. reassure her that she'll get used to leaving her baby d. Allow her to express her positive and negative feelings freely.d. allow her to express her positive and negative feelings freely. rationale: allowing the client to express feelings will provide positive support in her process of maternal adjustment.A new father states, "I know nothing about babies" but he seems to be interested in learning. The nurse should take which action a. Include him in teaching sessions b. tell him when he does something wrong c. show no concern because he will learn on his own d. Continue to observe his interaction with the newborna. include him in teaching sessions.The postpartum nurse is reviewing dietary practices for an Asian client. Which should the nurse expect to observe as a dietary practice for this culture. a. Food brought from home b. Preference for fresh fruits c. preference for cold foods d. request for ice water instead of hot water.a. food brought from home rationale: food brought from home is a welcome sign of caring in many cultures. Some Asians believe that after birth the woman should eat only "hot" foods such as chicken, meat, and fish. Fresh fruit would be considered a "cold" food.The nurse is teaching new parents about behavior cues that indicate their infant has had enough stimulation. Which cues should the nurse include in the teaching session. a. The infant kicks his legs b. the infant is quiet and alert c. the infant splays his fingers d. the infant looks at their faces.c. the infant splays his fingers. rationale: nurses should help parents recognize signals that indicate when their infant has had enough interaction and wants to avoid further stimulation.An example of binding in during the postpartum period is a a. new mother telling her friends all about her labor and birth experience. b. Father looking at his newborn and stating that he "looks like I did when I was a baby" c. Mother reporting increasing anxiety during the postpartum period because she feels like she is all alone d. Mother wanting some time alone so that she can catch up on needed sleepB. father looking at his newborn and stating that he looks like I did when I was a babyA postpartum client who is a gravida 4, para 4, comes to the office for her 6 week postpartum checkup. Her presentation is untidy and unkept. The client states that she is not sleeping well and related that she feels overwhelmed at times. According to the client, family members responses have been non-supportive. What recommendations would you advise to help the client at this time. a. Tell the client that this is a normal reaction to an increase in family size and that listening to music can help relieve anxiety. b. tell the client to increase her exercise pattern because that ill promote a sense of well-being c. Make appropriate referrals for psychological intervention counseling because the client is exhibiting high risk symptoms. d. record the clients vital signs as part of the ongoing assessment and offer relaxation strategies as a method of support.c. make appropriate referrals for psychological intervention counseling because the client is exhibiting high risk symptoms. rationale: the client exhibiting symptoms that are consistent with postpartum depression, so she should be given priority intervention to maintain client safetyWhich of the following behaviors would be applicable to a nursing diagnosis of risk for impaired parenting. a. en face behavior is observed between father and infant b. mother related that she feels exhilarated post birth c. mother states that she feels excessive fatigue as a result of the childbirth experience. d.father displays finger tipping behavior toward infant.c. mother states that she feels excessive fatigue as a result of the childbirth experience rationale: fatigue can contribute to altered parenting because it may affect the level of interaction between parent and child.A family is concerned about how their 2 yr old son is going to react to the new baby. What intervention would help facilitate sibling attachment. a. Have the mother and father spend individual time with their son to allay potential anxiety over the new baby coming in and displacing his position in the family as the only child. b. make sure that their son is supervised at all times when the baby is brought home from the hospital and is in his presence. c. include the son in helping to take care of the baby and reinforce the label of "big brother" as a special role d. observe the sons reaction to the baby and let him decide when he wants to be introduced to his new sibling.c. include the son in helping to take care of the baby and reinforce the label of big brother as a special role.The nurse is developing a plan of care for the patients fourth stage of labor. One nursing intervention is to promote bonding. Specifically, which nursing action will facilitate the bonding process. a. Encourage the patient to call the baby by his or her name b. stimulate the grasp reflex by placing the patients finger in the infants palm. c. ask the patient if she wants her baby placed on her chest immediately after birth. d. assess for familial characteristics and remark on the resemblance to the patient of the father.c. ask the patient if she wants her baby placed on her chest immediately after birth. rationale: bonding refers to the rapid initial attraction felt by parents for their infant.A postpartum patient calls the clinic and reports to the nurse feelings of fatigue, tearfulness, and anxiety. What is the nruses best response. a. When did these symptoms begin b. sounds like normal postpartum depression c. are you having trouble getting enough sleep d. are you able to get out of bed and provide care for your babyd. are you able to get out of bed and provide care for your baby. rationale: postpartum blues must be distinguished from postpartum depression and postpartum psychosis, which are disabling conditions and require therapeutic management.Which are nursing measures that can promote parent infant bonding and attachment. a. Provide comfort and ample time for rest. b. keep the baby wrapped to avoid cold stress c. position the infant face to face with the mother. d. point out the characteristics of the infant in a positive way. e. limit the amount of modeling so the mother doesnt feel insecure.A: provide comfort and ample time for rest C: position the infant face to face with the mother D: point out the characteristics of the infant in a positive wayWhich strategies should the nurse suggest to a postpartum client to promote stress reduction during the first weeks at home. select all a. limiting coffee, tea, cola, and any caffeinated beverages b. maintaining a rigid schedule c. sleeping when the infant sleeps d. inviting visitors and friends to stop by frequently e. using learned breathing techniques from childbirth classes for relaxationA: limiting coffee, tea, cola, and any caffeinated C: sleeping when the infant sleeps E: using learned breathing techniques from childbirth classes for relaxation.matching: A. passive, dependent. B. begins to see self as mother C: autonomous, seeking information 1. taking-in 2. letting-go 3. taking holdA: passive, dependent: taking in B: Autonomous, seeking information: taking hold C: begins to see self as mother: letting go.