Chapter 26 - Postpartum Period

1. The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client’s temperature is 100.2° F (37.8°C). What is the priority nursing action?

1. Document the findings.

2. Notify the obstetrician.

3. Retake the temperature in 15 minutes.

4. Increase hydration by encouraging oral uids.

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2. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of dizziness. Which nursing action is most appropriate?

1. Raise the head of the client’s bed.

2. Obtain hemoglobin and hematocrit levels.

3. Instruct the client to request help when getting out of bed.

4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client’s symptoms have subsided.

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3. The postpartum nurse is providing instructions to a client after the birth of a healthy newborn. Which time frame would the nurse relay to the client regarding the return of bowel function?

1. 3 days postpartum

2. 7 days postpartum

3. On the day of birth

4. Within 2 weeks postpartum

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4. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?

1. Client pain level

2. Inadequate urinary output

3. Client perception of body changes

4. Potential for imbalanced body fluid volume

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5. The nurse is providing postpartum instructions to a client who will be breast-feeding/chest-feeding the newborn. The nurse determines that the client has understood the instructions if the client makes which statements? Select all that apply.

1. “I need to wear a bra that provides support.”

2. “Drinking alcohol can affect my milk supply.”

3. “I will start my estrogen birth control pills again as soon as I get home.”

4. “I know if my breasts/chest get engorged, I will limit my breast-feeding/chest-feeding and supplement the baby.”

5. “I plan on having bottled water available in the refrigerator so I can get additional fluids easily.”

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6. The nurse is teaching a postpartum client about breast-feeding/chest-feeding. Which instruction would the nurse plan to include in the teaching session?

1. The diet needs to include additional fluids.

2. Prenatal vitamins need to be discontinued.

3. Soap needs to be used to cleanse the breasts/ chest.

4. Birth control measures are unnecessary while breast-feeding/chest-feeding.

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7. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?

1. Elevate the client’s legs.

2. Massage the fundus until it is firm.

3. Ask the client to turn on the left side.

4. Push on the uterus to assist in expressing clots.

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8. The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up?

1. The client with mild afterpains

2. The client with a pulse rate of 60 beats per minute

3. The client with colostrum discharge from both breasts/chest

4. The client with lochia that is red and has a foulsmelling odor

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9. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?

1. Document the findings.

2. Notify the obstetrician (OB).

3. Reassess the client in 2 hours.

4. Encourage increased oral intake of uids.

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10. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. What action would the nurse take initially?

1. Document the finding.

2. Encourage the client to ambulate.

3. Encourage the client to increase fiuid intake.

4. Contact the obstetrician (OB) to report this finding.

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11. The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction?

1. “I will begin abdominal exercises immediately.”

2. “I will notify my obstetrician if I develop a fever.”

3. “I will turn on my side and push up with my arms to get out of bed.”

4. “I will lift nothing heavier than my newborn baby for at least 2 weeks.”

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