Chapter 20: Postpartum Adaptations McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a

positive Homans sign and asks what it means. The nurse's best response is

A. "You have pitting edema in your ankles."

B. "You have deep tendon reflexes rated 2+."

C. "You have calf pain when I flexed your foot."

D. "You have a 'fleshy' odor to your vaginal drainage."

ANS: C. "You have calf pain when I flexed your foot."

Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein

thrombosis. It does not indicate edema, rate deep tendon reflexes, or describe the odor

of lochia.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 404 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic?

A. Gravida 5, para 5

B. Woman who is bottle-feeding her first child

C. Primipara who delivered a 7-lb boy

D. Woman who has started to breastfeed

ANS: A. Gravida 5, para 5

The discomfort of after pains is more acute for multiparas because repeated stretching of

muscle fibers leads to loss of uterine muscle tone. After pains are particularly severe during

breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The

breastfeeding woman may have increased pain due to engorgement, but the multipara

probably will have the most severe afterbirth pains.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 396 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

Which maternal event is abnormal in the early postpartum period?

a. Diuresis and diaphoresis

b. Flatulence and constipation

c. Extreme hunger and thirst

d. Lochial color changes from rubra to alba

ANS: D. Lochial color changes from rubra to alba

For the first 3 days after childbirth, lochia is mostly red and is termed rubra. Lochia serosa

follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body

rids itself of increased plasma volume after birth. Urine output of 3000 mL/day is common

for the first few days after delivery and is facilitated by hormonal changes in the mother.

Bowel tone remains sluggish for days after birth, leading to flatulence and constipation. The

new mother is hungry and thirsty because of energy used in labor and thirsty because of fluid

restrictions during labor.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 396 | Table 20.1 OBJ: Nursing Process: Assessment

Which finding 12 hours after birth requires further assessment?

A. The fundus is palpable two fingerbreadths above the umbilicus.

B. The fundus is palpable at the level of the umbilicus.

C. The fundus is palpable one fingerbreadth below the umbilicus.

D. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: A. The fundus is palpable two fingerbreadths above the umbilicus.

The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A

fundus that is above the umbilicus may indicate uterine atony or urinary retention. The

nurse needs to make further assessments. The other findings are within normal limits for the

time period.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 395 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day,

the nurse should

a. tell the physician immediately.

b. have the laboratory draw blood for reanalysis.

c. recognize that this is an acceptable range at this point.

d. begin antibiotic therapy immediately.

ANS: C. recognize that this is an acceptable range at this point.

Marked leukocytosis occurs with WBC counts increasing to as high as 30,000/mm3

during labor and the immediate postpartum period. The WBC falls to normal within 6

days postpartum. No action is necessary.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 397 OBJ: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

Postpartal overdistention of the bladder and urinary retention can lead to which complication?

a. Postpartum hemorrhage and eclampsia

B. Fever and increased blood pressure

C. Postpartum hemorrhage and urinary tract infection

D. Urinary tract infection and uterine rupture

ANS: C. Postpartum hemorrhage and urinary tract infection

Incomplete emptying and overdistention of the bladder can lead to urinary tract infection.

Overdistention of the bladder displaces the uterus and prevents contraction of the uterine

muscle. There is no correlation between bladder distention and eclampsia, blood pressure,

or fever. The risk of uterine rupture decreases after the birth.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 398 OBJ: Nursing Process: Assessment

A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is

A. "They will fade and be gone by your 6-week checkup."

B. "No, unfortunately they will never fade away."

C. "Yes, eventually they will totally disappear."

D. "They will fade to silvery lines but won't disappear completely."

ANS: D. “They will fade to silvery lines but won't disappear completely."

The stretch marks will fade to silvery lines but will not disappear completely.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 399 OBJ: Integrated Process: Teaching-Learning

MSC: Client Needs: Physiologic Integrity

A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The

nurse knows the pigmentation will decrease after delivery because of

a. increased estrogen.

b. increased progesterone.

c. decreased melanocyte-stimulating hormone.

d. decreased human placental lactogen.

ANS: C. decreased melanocyte-stimulating hormone.

Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes

in skin pigmentation; the amount decreases after delivery. The linea nigra will eventually fade

away for most women. Estrogen and progesterone levels decrease after delivery. Human

placental lactogen production continues to aid in lactation. However, it does not affect

pigmentation.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 399 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

If the fundus is palpated on the right side of the abdomen above the expected level, the

nurse should suspect that the patient has

a. been lying on her right side too long.

b. a distended bladder.

c. stretched ligaments that are unable to support the uterus.

d. a normal involution.

ANS: B. a distended bladder.

The presence of a full bladder will displace the uterus. This finding does not signify a

problem with positioning or ligaments, nor is it an expected finding.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care

provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener.

What information is most closely correlated with these orders?

A. The woman is a gravida 2, para 2.

B. The woman had a vacuum-assisted birth.

C. The woman received epidural anesthesia.

D. The woman has an episiotomy.

ANS: D. The woman has an episiotomy.

These orders are typical interventions for a woman who has had an episiotomy, lacerations,

and hemorrhoids. A multiparous classification is not an indication for these orders. A

vacuum-assisted birth may be used in conjunction with an episiotomy, which indicates these

interventions, but that is not the only situation in which an episiotomy would be used, so

this is not the best answer. Use of epidural anesthesia has no correlation with these orders.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 397 OBJ: Nursing Process: Planning

MSC: Client Needs: Health Promotion and Maintenance

Rho immune globulin will be ordered postpartum if which situation occurs?

a. Mother Rh-, baby Rh+

b. Mother Rh-, baby Rh-

c. Mother Rh+, baby Rh+

d. Mother Rh+, baby Rh-

ANS: A. Mother Rh-, baby Rh+

An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her

bloodstream when the placenta separated. The Rho immune globulin works to destroy the

fetal cells in the maternal circulation before sensitization occurs. The other blood type

combinations would not necessitate the use of Rhogam.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 400 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

If rubella vaccine is indicated for a postpartum patient, instructions to the patient

should include

a. drinking plenty of fluids to prevent fever.

b. no specific instructions.

c. recommending that she stop breastfeeding for 24 hours after injection.

d. explaining the risks of becoming pregnant within 1 month after injection

ANS: D. explaining the risks of becoming pregnant within 1 month after injection

Potential risks to the fetus can occur if pregnancy results within 28 days after rubella vaccine

administration. Drinking fluids will not prevent a fever. Small amounts of the vaccine do cross

the breast milk, but it is believed that there is no need to discontinue breastfeeding.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

Which nursing action is most appropriate to correct a boggy uterus that is displaced above

and to the right of the umbilicus?

A. Notify the provider of an impending hemorrhage.

B. Assess the blood pressure and pulse.

C. Evaluate the lochia.

D. Assist the patient in emptying her bladder.

ANS: D. Assist the patient in emptying her bladder.

Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the

uterus. Nursing actions need to be implemented before notifying the provider. Blood pressure,

pulse, and lochia are important to assess, but first the nurse assesses the bladder so corrective

action can be taken if needed.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 402 OBJ: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

When caring for a newly delivered woman, the nurse is aware that the best measure to

prevent abdominal distention after a cesarean birth is

a. rectal suppositories.

b. early and frequent ambulation.

c. tightening and relaxing abdominal muscles.

d. providing carbonated beverages.

ANS: B. early and frequent ambulation.

Activity can aid the movement of accumulated gas in the gastrointestinal tract so early, and

frequent ambulation is the best option. Rectal suppositories can be helpful after distention

occurs but do not prevent it. Tightening and relaxing the abdominal muscles is not related.

Carbonated beverages may increase distention.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 406 OBJ: Nursing Process: Planning

What documentation on a woman's chart on postpartum day 14 indicates a normal involution

process?

a. Moderate bright red lochial flow

b. Breasts firm and tender

c. Fundus below the symphysis and not palpable

d. Episiotomy slightly red and puffy

ANS: C. Fundus below the symphysis and not palpable

The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. The lochia

should be changed by this day to serosa. Breasts are not part of the involution process. The

episiotomy should not be red or puffy at this stage.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 395 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

To assess fundal contraction 6 hours after cesarean delivery, the nurse should

A. palpate forcefully through the abdominal dressing.

B. gently palpate, applying the same technique used for vaginal deliveries.

C. place hands on both sides of the abdomen and press downward.

D. rely on assessment of lochial flow rather than palpating the fundus.

ANS: B. gently palpate, applying the same technique used for vaginal deliveries

Assessment of the fundus is the same for both vaginal and cesarean deliveries; however,

palpation should be gentle due to increased discomfort caused by the uterine incision.

Forceful palpation should never be used. The top of the fundus, not the sides, should be

palpated and massaged. The fundus should be palpated and massaged to prevent bleeding.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 403 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

The mother-baby nurse is able to recognize reciprocal attachment behavior. What does this

refer to?

a. The positive feedback an infant exhibits toward parents during the

attachment process

B. Behavior during the sensitive period when the infant is in the quiet alert stage

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

ANS: A. The positive feedback an infant exhibits toward parents during the

attachment process

In this definition, reciprocal refers to the feedback from the infant during the

attachment process.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 412 | Nursing Quality Alert Box OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

The postpartum woman who continually repeats the story of her labor, delivery, and recovery

experiences is

A. providing others with her knowledge of events.

B. making the birth experience "real."

C. taking hold of the events leading to her labor and delivery.

D. accepting her response to labor and delivery.

ANS: B. making the birth experience "real."

Reliving the birth experience makes the event real and helps the mother realize that the

pregnancy is over and that the infant is born and is now a separate individual. She is in the

taking-in phase, trying to make the birth experience seem real. This process meets her

needs, not those of others.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 413 OBJ: Nursing Process: Assessment

During which stage of role attainment do the parents become acquainted with their baby

and combine parenting activities with cues from the infant?

a. Anticipatory

b. Formal

c. Informal

d. Personal

ANS: B. Formal

A major task of the formal stage of role attainment is getting acquainted with the infant. The

anticipatory stage begins during the pregnancy when the parents choose a physician and

attend childbirth classes. The informal stage begins once the parents have learned

appropriate responses to their infant's cues. The personal stage is attained when parents feel

a sense of harmony in their role.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 413 OBJ: Nursing Process: Assessment

A nurse observes a mother on her first postpartum day sitting in bed while her newborn lies

awake in the bassinet. What action by the nurse is best?

A. Realize that this situation is perfectly acceptable.

B. Offer to hand the baby to the woman.

C. Hand the baby to the woman.

D. Explain "taking in" to the woman.

ANS: C. Hand the baby to the woman.

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.

This is done best by simply giving the baby to the mother. While acceptable, the nurse can

still facilitate infant bonding. The woman is dependent and passive at this stage and may have

difficulty making a decision so offering her the baby is not the best option. Women learn best

in the taking-hold phase.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 413 OBJ: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours

ago. Her husband is watching his wife and asking questions about newborn care. The

4-year-old brother is punching his mother on the back. What action by the nurse is best?

Report the incident to the social services department.

Advise the parents that the toddler needs to be reprimanded.

Report to oncoming staff that the mother is not a good disciplinarian.

Realize that this is a normal family adjusting to family change.

ANS: D. Realize that this is a normal family adjusting to family change.

The observed behaviors are normal variations of families adjusting to change. The nurse

could provide suggestions on managing the adjustments. There is no need to report this one

incident. The child does not need to be reprimanded, however; when the family is receptive

the nurse could provide anticipatory guidance for this situation and help them problem solve.

The nurse should avoid labeling the parents.

PTS: 1 DIF: Cognitive Level: Application/Applying

What is the best way for the nurse to promote and support the maternal-infant

bonding process?

A. Help the mother identify her positive feelings toward the newborn.

B. Encourage the mother to provide all newborn care.

C. Assist the family with rooming-in.

D. Return the newborn to the nursery during sleep periods.

ANS: C. Assist the family with rooming-in.

Close and frequent interaction between mother and infant, which is facilitated by rooming-in,

is important in the bonding process. This is often referred to as the mother -baby care or

couplet care. Having the mother express her feelings is important, but it is not the best way to

promote bonding. The mother needs time to rest and recuperate; she should not be expected

to do all of the care. The mother needs to observe the infant during all stages so she will be

aware of what to expect when they go home.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

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 hold

c. Taking in

d. Taking on

ANS: A. Letting go

Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of

maternal adjustment. During the taking-hold phase the mother assumes responsibility for her own

care and shifts her attention to the infant. In the taking-in phase the mother is primarily focused on

her own needs. There is no taking-on phase of maternal adjustment.

PTS: 1 REF: p. 419 | Table 20.3 MSC: Client Needs: Psychosocial Integrity

DIF: Cognitive Level: Knowledge/Remembering

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled

for discharge. As the nurse prepares her for discharge, she begins to cry. What action should

the nurse take first?

a. Assess her for pain.

b. Point out how lucky she is to have a healthy baby.

c. Explain that she is experiencing postpartum blues.

d. Allow her time to express her feelings.

ANS: D. Allow her time to express her feelings.

Many women experience transient postpartum blues and need assistance in expressing their

feelings. This condition affects 70% to 80% of new mothers. The nurse should allow time for

the new mother to express herself. The nurse should not assume she is in pain at this point.

Pointing out how lucky she is belittles her feelings. Patient teaching can be done later.

PTS: 1 DIF: Cognitive Level: Application/Applying

A man calls the nurse's station stating that his wife, who delivered 2 days ago, is happy one

minute and crying the next. The man says, "She was never like this before the baby was

born." What response by the nurse is best?

A. Tell him to ignore the mood swings, as they will go away.

B. Reassure him that this behavior is normal.

C. Advise him to get immediate psychological help for her.

D. Instruct him in the signs, symptoms, and duration of postpartum blues.

ANS: B. Reassure him that this behavior is normal.

Before providing further instructions, inform family members of the fact that postpartum blues

are a normal process to allay anxieties and increase receptiveness to learning. Telling him the

mood swings will go away is belittling his concerns. Postpartum blues are a normal process

that is short lived; no medical intervention is needed. Client teaching is important; however, his

anxieties need to be allayed before he will be receptive to teaching.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: pp. 415-416 OBJ: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

To promote bonding and attachment immediately after delivery, what action by the nurse is

most important?

A. Allow the mother quiet time with her infant.

B. Assist the mother in assuming an en face position with her newborn.

C. Teach the mother about the concepts of bonding and attachment.

D. Assist the mother in feeding her baby.

ANS: B. Assist the mother in assuming an en face position with her newborn.

Assisting the mother in assuming an en face position with her newborn will support the

bonding process. Quiet time with the infant is helpful but not as important as en face

positioning. The mother has just delivered and is more focused on the infant; she will not be

receptive to teaching at this time. This is a good time to initiate breastfeeding, but this is not

as specific to bonding and attachment as the en face position.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 420 OBJ: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

In providing support to a new mother who must return to full-time employment 6 weeks after

avaginal delivery, which action by the nurse is best?

A. Allow her to express her positive and negative feelings freely.

B. Reassure her that she'll get used to leaving her baby.

C. Discuss child care arrangements with her.

d. Allow her to solve the problem on her own.

ANS: A. Allow her to express her positive and negative feelings freely.

Allowing the patient to express feelings will provide positive support in her process of

maternal adjustment. Simply reassuring the mother blocks further communication and

belittles her feelings. Discussing child care arrangements should wait until she has expressed

herself. She should be instrumental in solving the problem; however, allowing her time to

express her feelings and talk the problem over will assist her in making this decision.

PTS: 1 DIF: Cognitive Level: Application/Application

REF: p. 415 OBJ: Nursing Process: Implementation

MSC: Client Needs: Psychosocial Integrity

A new father states, "I know nothing about babies," but he seems to be interested in learning.

What action by the nurse is best?

a. Continue to observe his interaction with the newborn.

b. Tell him when he does something wrong.

c. Show no concern, as he will learn on his own.

d. Include him in teaching sessions.

ANS: D. Include him in teaching sessions.

The nurse must be sensitive to the father's needs and include him whenever possible. As

fathers take on care new role, the nurse should praise every attempt even if his early care is

awkward. It is important to note the bonding process of the mother and the father, but that

does not satisfy the expressed needs of the father. He should be encouraged by pointing out

the correct procedures he does. Criticizing him will discourage him. The nurse should be sure

to include him in all teaching sessions.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 422 OBJ: Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband

brings a large container of brown seaweed soup to the hospital. When the nurse enters the

room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's

most appropriate response is to ask the woman

a. "Didn't you like your lunch?"

b. "Does your doctor know that you are planning to eat that?"

c. "What is that anyway?"

d. "I'll warm the soup in the microwave for you."

ANS: D. "I'll warm the soup in the microwave for you."

This statement shows cultural sensitivity to the dietary preferences of the woman and is

the most appropriate response. Cultural dietary preferences must be respected. Women

may request that family members bring favorite or culturally appropriate foods to the

hospital. Asking if the provider knows she is eating this soup is insensitive.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 418 OBJ: Integrated Process: Culture and Spirituality

A postpartum woman is unable to empty her bladder. What intervention would the nurse try

last?

a. Pouring water from a squeeze bottle over the woman's perineum

b. Providing hot tea

c. Asking the physician to prescribe analgesics

d. Inserting a sterile catheter

ANS: D. Inserting a sterile catheter

Invasive procedures usually are the last to be tried, especially with so many other simple

methods available. Pouring water over the perineum may stimulate voiding. It is easy,

noninvasive, and should be tried early on. Hot tea or other fluids ad lib is an easy, noninvasive

strategy that should be tried early on. If the woman is anticipating pain from voiding, pain

medications may be helpful. Other nonmedical means could be tried first, but medications

still come before insertion of a catheter.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 405 OBJ: Nursing Process: Implementation

MSC: Client Needs: Physiologic Integrity

The nurse caring for the postpartum woman understands that breast engorgement is caused by

a. overproduction of colostrum.

b. accumulation of milk in the lactiferous ducts and glands.

c. hyperplasia of mammary tissue.

d. congestion of veins and lymphatics.

ANS: D. congestion of veins and lymphatics.

Breast engorgement is caused by the temporary congestion of veins and lymphatics,

not overproduction of colostrum, accumulation of milk, or hyperplasia.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 404 OBJ: Nursing Process: Assessment

Which hormone remains elevated in the immediate postpartum period of the

breastfeeding woman?

a. Estrogen

b. Progesterone

c. Prolactin

d. Human placental lactogen

ANS: C. Prolactin

Prolactin levels in the blood increase progressively throughout pregnancy. In women who

breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen and

progesterone levels decrease markedly after expulsion of the placenta, reaching their

lowest levels 1 week into the postpartum period. Human placental lactogen levels

dramatically decrease after expulsion of the placenta.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 400 OBJ: Nursing Process: Assessment

The nurse explains to the nursing student that one mechanism for the diaphoresis and

diuresis experienced during the early postpartum period is which of the following?

A. Elevated temperature caused by postpartum infection

B. Increased basal metabolic rate after giving birth

C. Loss of increased blood volume associated with pregnancy

D. Increased venous pressure in the lower extremities

ANS: C. Loss of increased blood volume associated with pregnancy

Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated

during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis

that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis

is another mechanism by which the body rids itself of excess fluid. An elevated temperature

causes chills and may cause dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis

are not caused by an increase in the basal metabolic rate. Postpartal diuresis may be caused by

the removal of increased venous pressure in the lower extremities.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding

REF: p. 397 OBJ: Integrated Process: Teaching-Learning

Which condition seen in the postpartum period is likely to require careful

medical assessment?

a. Varicosities of the legs

b. Carpal tunnel syndrome

c. Periodic numbness and tingling of the fingers

d. Headaches

ANS: D. Headaches

Headaches in the postpartum period can have a number of causes, some of which deserve

medical attention. Varicosities are common. Carpal tunnel syndrome is relieved in childbirth

when the compression on the median nerve is lessened. Periodic numbness of the fingers

usually disappears after birth unless carrying the baby aggravates the condition.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 399 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Physiologic Integrity

A nurse has taught a woman how to do Kegel exercises. What statement by the patient shows

good understanding?

A. "I contract my thighs, buttocks, and abdomen."

B. "I do 10 of these exercises every day."

C. "I stand while practicing this new exercise routine."

D. "I pretend that I am trying to stop the flow of urine midstream."

ANS: D. "I pretend that I am trying to stop the flow of urine midstream."

The woman can pretend that she is attempting to stop the passing of gas, or the flow of urine

midstream. This will replicate the sensation of the muscles drawing upward and inward.

Each contraction should be as intense as possible without contracting the abdomen, buttocks,

or thighs. Guidelines suggest that these exercises should be done 24 to 100 times per day.

Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position

to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands

and knees.

PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

REF: p. 407 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance: Self-Care

A nurse is examining a woman 2 months after delivery. The woman has lost 25 pounds. What

action by the nurse is best?

A. Counsel her on other weight loss measures.

B. Ask her for a dietary recall for 3 days.

C. Instruct her on exercises for faster loss.

D. Explain that her weight loss is affecting her breast milk.

ANS: B. Ask her for a dietary recall for 3 days.

This woman has lost too much weight for being 8 weeks postpartum. Gradual weight loss is

recommended, so the nurse should first assess the woman's eating habits by conducting a

nutrition history. From that information the nurse can help the woman plan a safer weight loss

plan. She does not need to lose weight faster, so counseling her on weight loss measures or

more exercise is not beneficial. Telling her she is harming her baby is not therapeutic and may

make her less likely to listen to the nurse.

PTS: 1 DIF: Cognitive Level: Application/Applying

REF: p. 415 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

A nurse has taught a woman and partner about measures to improve sexuality after childbirth.

Which statement by the partner demonstrates a need for further teaching?

A. "We will use water-soluble lubricant before intercourse."

B. "We can try having sex in the morning when we are rested."

C. "Breastfeeding before sex will increase vaginal lubrication."

D. "My wife will be more comfortable if she is on top."

ANS: C. “Breastfeeding before sex will increase vaginal lubrication."

Breastfeeding just prior to intercourse may allow uninterrupted time while the baby

sleeps afterward, although it will not increase vaginal lubrication. It also decreases the

chance of leaking milk. The other statements show good understanding.

PTS: 1 DIF: Cognitive Level: Evaluation/Evaluating

REF: p. 409 OBJ: Nursing Process: Evaluation

MSC: Client Needs: Psychosocial Integrity

Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most

common complications of the puerperium. What are these conditions? (Select all that apply.) FOUR answers

a. Primipara

b. Rapid or prolonged labor

c. Overdistention of the uterus

d. Uterine fibroids

e. Preeclampsia

ANS:

b. Rapid or prolonged labor

c. Overdistention of the uterus

d. Uterine fibroids

e. Preeclampsia

Rapid or prolonged labor, overdistention of the uterus, uterine fibroids, and preeclampsia

are all risk factors for postpartum hemorrhage. Being a primipara is not a risk factor.

PTS: 1 REF: p. 401 | Safety Alert Box MSC: Client Needs: Physiologic Integrity

Many women given up smoking during pregnancy to protect the health of the fetus.

The majority of women resumed smoking within the first 6 months postpartum. Factors

that increase the likelihood of relapse include (Select all that apply.) THREE answers

a. living with a smoker.

b. returning to work.

c. weight concerns.

d. successful breastfeeding.

e. failure to breastfeed.

ANS: A, C, E

a. living with a smoker.

c. weight concerns.

e. failure to breastfeed.

Living with a smoker, weight concerns, and failure to breastfeed are all associated with a

higher relapse rate after smoking cessation during pregnancy.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 415 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

The nurse assesses a woman's episiotomy or perineal laceration using the acronym REEDA.

What factors does this include? (Select all that apply.) FOUR answers

a. Redness

b. Edema

c. Approximation

d. Depth

e. Discharge

ANS: A, B, C, E

a. Redness

b. Edema

c. Approximation

e. Discharge

The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and

approximation. Depth is not a consideration with this acronym.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: p. 402 OBJ: Nursing Process: Assessment

MSC: Client Needs: Physiologic Integrity

A woman's chart indicates she has a second-degree laceration. When assessing this patient, the

nurse plans to observe which of the following structures? (Select all that apply.) THREE answers

a. Vaginal mucosa

b. Perineal skin

c. Peritoneal muscle

d. Anus

e. Rectum

ANS:

a. Vaginal mucosa

b. Perineal skin

c. Peritoneal muscle

A second- degree perineal laceration includes vaginal mucosa, perineal skin, and peritoneal

muscle. A third-degree laceration involves the anus, while a fourth-degree laceration includes

the rectum.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering

REF: Box 20.1 OBJ: Nursing Process: Assessment

MSC: Client Needs: Health Promotion and Maintenance

The acronym ________ is used as a reminder that the site of an episiotomy or perineal laceration should be assessed for five physical signs.

REEDA
The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation (the edges of the wound should be close). If redness is accompanied by pain or tenderness, this may indicate infection. Edema may illustrate soft tissue damage and delay wound healing. There should be no discharge. The edges of the wound should be closely approximated as if held together by glue.

The process in which the uterus returns to a non-pregnant state after birth is known as __________.

involution
This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle.

The nurse evaluating the amount of lochia on a newly delivered patient knows that a moderate amount of flow constitutes a 4- to 6-inch stain on the peripad. Is this statement true or false?

True

Since estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels:
Scant—less than a 1-inch stain on the peripad
Light—a 1- to 4-inch stain
Moderate—a 4- to 6-inch stain
Heavy—saturated peripad
Excessive—saturated peripad in 15 minutes
Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth since some of the endometrial lining is removed during surgery.

Clotting factors and fibrinogen levels normally are decreased during pregnancy and remain low in the immediate puerperium. This hypocoagulable state increases the risk of thromboembolism, especially after cesarean birth. Is this statement true or false?

False

Clotting factors and fibrinogen normally are increased during pregnancy and remain elevated in the immediate puerperium. This hypercoagulable state increases the risk of thromboembolism, especially after cesarean birth.