Chapter 29 The Postpartum Family: Early Care Needs and Home Care

1) The nurse had completed a postpartum assessment on a client who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum ecchymosis and edematous, and pain rating 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful three 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

4. Knowledge deficit related to newborn care

Answer: 2

2. Adequate fluid volume is a critical physiological need; therefore, this is the highest-priority nursing diagnosis.

2) During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse?

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 aren't nursing, wear a well-fitted nursing bra at all times, even when you sleep."

Answer: 4

4. The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent discomfort from tension.

3) The postpartum client delivered 4 hours ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1 to 10. She has a history of anaphylactic reaction to Tylenol (acetaminophen). Which nursing action would be best?

1. Offer the client 800 mg ibuprofen orally with food.

2. Provide 2 Percocet (oxycodone with acetaminophen) by mouth.

3. Encourage use of a topical anesthetic spray.

4. Run very warm water into the tub and assist her into the bath.

Answer: 1

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.

4) On the second day postpartum, the client experiences engorgement. To relieve her discomfort, the nurse should encourage the client to:

1. Remove her bra.

2. Apply heat to her breasts.

3. Apply ice packs to her breasts.

4. Limit breastfeeding to twice daily.

Answer: 3

3. Applying ice packs to the breasts relieves discomfort through the numbing effect of ice.

5) The nurse is caring for a client who had a cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time? Select all that apply.

1. Administer analgesics as needed.

2. Encourage the client to ambulate to the bathroom to void.

3. Encourage leg exercises every 2 hours.

4. Encourage the client to cough and deep-breathe every 2 to 4 hours.

5. Encourage the use of breathing, relaxation, and distraction.

Answer: 1, 3, 4, 5

6) The community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother's 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 psychological adjustment."

Answer: 1

Explanation: 1. During slow weaning, over a period of several weeks the mother substitutes more cup feedings or bottle feedings for breastfeeding.

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 patient rooms

2. A kitchen with refrigerator stocked with juice and sandwiches

3. Small, cozy rooms with a patient bed and rocking chair

4. A nursing model based on providing couplet care

Answer: 4

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.

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." What response is best?

1. "We'll take good care of you and your baby. You'll be home before you know it."

2. "You'll be wearing long stockings 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."

Answer: 2

2. Anti-embolism stockings are used until the client is up and walking to prevent thrombus formation.

9) The nurse is caring for a client who delivered by cesarean birth. The client received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention? Select all that apply.

1. Increased intake of cold beverages

2. Leg exercises every 2 hours

3. Abdominal tightening

4. Ambulation

5. Eating a high-protein general diet

Answer: 2, 3, 4

10) The nurse is caring for a 15-year-old client that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

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.

Answer: 3

3. This helps the client learn about her baby and understand him as an individual, and facilitates maternal-infant attachment. This is the highest priority.

11) The nurse is preparing to receive a newly delivered client. The client is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

1. Assign the client a room on the GYN surgical floor instead of the postpartum floor.

2. Prepare to have teaching done in time for discharging the client at 24 hours post-delivery.

3. Make an effort to not bring up the topic of the baby, and discuss the mother's health instead.

4. Ask the client if she wants to feed her baby, and how much contact she wants to have.

Answer: 4

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 caring for a client who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care? 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.

Answer: 2, 3, 4, 5

13) The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological 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."

Answer: 3

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 is recommended as a healthy psychological approach to family bonding."

2. "Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach."

3. "Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to follow specific safety guidelines."

4. "If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress."

Answer: 3

15) Match the position of the fundus with its specific assessment time.

The postpartum woman asks, "When will the nurses stop pushing on my belly?" The nurse informs the woman that this is to ascertain the position of the uterine fundus after birth.

1. Top of fundus is in the midline and at the level of the umbilicus

2. Top of fundus is in the midline about midway between the symphysis pubis and the umbilicus

3. Top of fundus is in the midline and 1 fingerbreadth below the umbilicus

4. Top of fundus remains in the midline and descends about 1 fingerbreadth/day

________ A. Immediately after birth

________ B. 6 to 12 hours after birth

________ C. 1 day after birth

________ D. Second day after birth and thereafter

Answer: 1/B, 2/A, 3/C, 4/D

Explanation: 1: B—6 to 12 hours after birth: Top of fundus is in the midline and at the level of the umbilicus.

2: A—Immediately after birth: Top of fundus is in the midline about midway between the symphysis pubis and the umbilicus.

3: C—1 day after birth: Top of fundus is in the midline and 1 fingerbreadth below the umbilicus.

4: D—Second day after birth and thereafter: Top of fundus remains in the midline and descends about 1 fingerbreadth per day.

16) The postpartum woman states that she has decided not to breastfeed. What mechanical methods of suppression should the nurse recommend be initiated within a few hours of delivery? Select all that apply.

1. Ice packs should be applied over the axillary area

2. Begin wearing a supportive, well-fitting bra

3. Take hot showers several times a day

4. Avoid any stimulation of breasts

5. Sleep on stomach

Answer: 1, 2, 4

Explanation: 1. This is a mechanical method of lactation suppression.

2. This is a mechanical method of lactation suppression.

4. This is a mechanical method of lactation suppression.