Chapter 28 Postpartum Adaptation and Nursing Assessment

1) The nurse has received an end of shift report on the postpartum unit. Which client should she see first?

1. Multipara, second day post-cesarean, moderate lochia serosa

2. Primipara, day of delivery, fundus firm 2 cm above umbilicus

3. Multipara, first postpartum day, 4 cm diastasis recti abdominis

4. Primipara, first postpartum day, hypoactive bowel sounds all quadrants

Answer: 2

2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an over distended bladder or uterine atony and excessive bleeding.

2) The nurse expects an initial weight loss for the average postpartum client to be:

1. 5 to 8 pounds.

2. 10 to 12 pounds.

3. 12 to 15 pounds.

4. 15 to 20 pounds.

Answer: 2

2. 10 to 12 pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.

3) To assess healing of the uterus at the placental site, the nurse assesses:

1. Lab values.

2. Blood pressure.

3. Uterine size.

4. Type, amount, and consistency of lochia.

Answer: 4

4. Type, amount, and consistency of lochia determine the stage of healing of the placenta site, which occurs by a process of exfoliation.

4) A Jewish client delivers a healthy baby boy on Thursday afternoon, and she is set to be discharged on Saturday morning. Why might this present a problem for the client?

1. Jewish custom is to have the infant circumcised 2 days after birth.

2. The woman will expect to be in the hospital at least 7 days after delivery.

3. Saturday is considered the Sabbath and she will not be able to leave the hospital that day.

4. The husband cannot touch his wife while she is experiencing vaginal discharge, so he will not be able to assist his wife to and from the vehicle.

Answer: 3

3. The Sabbath is sacred for Jews, and Jewish custom prohibits travel, writing, and the use of electricity on the Sabbath. Therefore, the woman will not travel home or sign any discharge forms until after the Sabbath.

5) On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be due to:

1. The taking-hold phase.

2. Postpartum hemorrhage.

3. The taking-in phase.

4. Epidural anesthesia

Answer: 3

3. The taking-in phase, which occurs during the first day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest.

6) The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client? Select all that apply.

1. Be sure she gets a kosher diet.

2. Expect that most visitors will be women.

3. Uncover only the necessary skin when assessing.

4. The patient will avoid cold air and water after birth.

5. She will prefer a male physician.

Answer: 1

Explanation: 1. A kosher diet is appropriate for Jewish women, not Muslims. Although many of the dietary laws are similar, kosher is not appropriate for a Muslim client.

7) The nurse is observing a new graduate's assessment of a postpartum client. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse?

1. Ask the client to void, and don clean gloves.

2. Discussing the effectiveness of client comfort measures while performing the perineal assessment.

3. Instructing the client's visitors to leave the room prior to beginning the assessment.

4. Requesting that the client lie flat in bed with her head on a pillow prior to the fundal assessment.

Answer: 3

3. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment.

8) Put the following components specific to postpartum examination of a client in the proper sequential order.

1. L-lochia

2. E-emotional

3. H-Homans'/hemorrhoids

4. B-breast

5. E-episiotomy/laceration/edema

6. U-uterus

7. B-bowel

Answer: 4, 6, 8, 7, 1, 5, 3, 2

9) The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. The best response is:

1. "We see this from time to time. It's not a big deal."

2. "The gush is an indication that your fundus isn't contracting."

3. "Don't worry. I'll make sure everything is fine."

4. "Blood has pooled in the vagina while you were in bed."

Answer: 4

4. Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semi-sitting in bed, which leads to a gush when fundal massage is undertaken.

10) The postpartum nurse is caring for a first-time mother who is unable to breastfeed her baby. While assessing the client's breasts the day after birth, which teaching point should the nurse include?

1. The let-down reflex

2. Lactation suppression

3. The purpose of fundal massage

4. The cause of afterpains

Answer: 2

2. It is important to teach non-breastfeeding clients about lactation suppression after delivery but before discharge.

11) Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. The nurse would:

1. Answer questions quickly and try to divert her attention to other subjects.

2. Review documentation of the birth experience and discuss it with her.

3. Contact the physician to warn him the client might want to file a lawsuit due to her preoccupation with her birth experience.

4. Submit a referral to social services because you are concerned about obsessive behavior.

Answer: 2

2. Review documentation of the birth experience and discuss it with her so the client can integrate the experience. Three hours after birth, the mother needs to talk about her perceptions of her labor and delivery.

12) During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this client?

1. Ask the mother if she has previous experience caring for babies, and then teach her how to interact appropriately with her infant.

2. Contact social services with concerns of neglect.

3. Provide the care the infant needs while continuing to evaluate the mother's actions.

4. Take the infant to the nursery so it can receive more consistent care.

Answer: 1

Explanation: 1. Many primipara mothers will be hesitant to care for the infant because they feel inadequate. Taking time to talk to the mother and teach her how to care for her baby is the proper nursing intervention.

13) During the first several months after birth, the mother and infant begin to know each other. This relationship progresses through several phases. Which of the following actions are to be expected in the phase of mutual regulation?

1. The infant grasps his or her mother's finger while nursing.

2. The infant begins to seek out the mother over other individuals.

3. The mother spends more time making eye-to-eye contact with the infant.

4. The mother vocalizes feelings of frustration with her infant.

Answer: 4

4. The mother is most likely to vocalize her negative maternal feelings during the phase of mutual regulation, when both the mother and infant are determining the amount of control each partner will have in the relationship.

14) The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?

1. Describe the likely reaction of siblings to the new baby.

2. Discuss adaptation to grandparenthood by her parents.

3. Determine if father-infant attachment is taking place.

4. Assist the mother in identifying behavior cues of the baby.

Answer: 4

4. Helping the mother to identify her baby's behavior cues facilitates the acquaintance phase of maternal-infant attachment.

15) The nurse is performing an assessment of early attachment. During the assessment, the nurse needs to answer the question "Does the mother seem pleased with her baby's appearance and sex?" Which action of the mother might help answer this question?

1. The mother enfolds the infant in her arms.

2. The mother feeds the infant every 2 to 3 hours as instructed.

3. The mother points out family traits she sees in the newborn.

4. The mother asks questions about how to properly bathe her infant.

Answer: 3

3. This action will help determine if the mother is pleased with her baby's appearance. She may point out both positive and negative traits.

16) The nurse is teaching the postpartum mother about involution. The mother asks the nurse what factors could impede the involution of the uterus. Factors include (select all that apply):

1. Inadequate diet

2. Overdistended uterus

3. Prolonged labor

4. Introitus edema

5. Full bladder

Answer: 2, 3, 5

2. This is a factor that could impede involution.

3. This is a factor that could impede involution.

5. This is a factor that could impede involution.

17) The woman has just delivered a child, she experiences intense tremors resembling shivering. The nurse explains the reasons for these tremors as (select all that apply):

1. The woman has been chilled.

2. The woman is experiencing a sudden release of pressure on the pelvic nerves.

3. The woman is experiencing a response to the fetus-to-mother transfusion that occurred during placental separation.

4. The woman has an infection.

5. The woman is having a reaction to maternal epinephrine production.

Answer: 2, 3, 5

2. This is a reason for the tremors.

3. This is a reason for the tremors.

5. This is a reason for the tremors.