Ch. 21- Nursing Care of the family during the postpartum period

1. 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 three times daily, and a stool softener. Which information regarding the client's condition is most closely

correlated with these orders?

a. Woman is a gravida 2, para 2.

b. Woman had a vacuum-assisted birth.

c. Woman received epidural anesthesia.

d. Woman has an episiotomy.

ANS: D

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 would indicate

these interventions. The use of an epidural anesthesia has no correlation with these orders.

2. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 ([EIA] 0.8); hematocrit, 30%. How should the nurse best interpret

these data?

a. Rubella vaccine should be administered.

b. Blood transfusion is necessary.

c. Rh immune globulin is necessary within 72 hours of childbirth.

d. Kleihauer-Betke test should be performed.

ANS: A

This client's rubella titer indicates that she is not immune and needs to receive a vaccine.

These data do not indicate that the client needs a blood transfusion. Rh immune globulin is

indicated only if the client has an Rh-negative status and the infant has an Rh-positive

status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is

suspected, especially if the mother is Rh negative. However, the data provided do not

indicate a need for performing this test.

3. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?

a. Run warm water on her breasts during a shower.

b. Apply ice to the breasts for comfort.

c. Express small amounts of milk from the breasts to relieve the pressure.

d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B

Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate

intervention for treating engorgement in a mother who is bottle feeding. The ice packs

should be applied for 15 minutes on and 45 minutes off to avoid rebound engorgement. A

bottle-feeding mother should continuously wear a well-fitted support bra or breast

binder for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation

suppression. Furthermore, the shifting of the bra against the breasts may stimulate the

nipples and thereby stimulate lactation.

4. 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.

What is the nurse's most appropriate response?

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

b. "Does your health care provider 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

Offering to warm the food 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 the woman to identify her food does not show cultural sensitivity. Both

remaining options demonstrate insensitivity.

5. A primiparous woman is to be discharged from the hospital the following day with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?

a. The woman is weepy and asks to postpone learning about infant care.

b. The woman continues to hold and cuddle her infant after she has fed her.

c. The woman asks for several magazines to read while her infant sleeps.

d. The woman changes her infant's diaper and then shows the nurse the contents of

the diaper.

ANS: A

The client should be excited, happy, and interested or involved in infant care. A woman who

is sad, tearful, or disinterested in caring for her infant may be exhibiting signs of depression

or postpartum blues and may require further intervention. Holding and cuddling her infant

after feeding is an appropriate parent-infant interaction. Taking time for herself while the

infant is sleeping is an appropriate maternal action. Showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying

the nurse of the infant's elimination patterns.

6. The trend in the United States is for women to remain hospitalized no longer than 1 or 2 days after giving birth. Which scenario is not a contributor to this model of care?

a. Wellness orientation model of care rather than a sick-care model

b. Desire to reduce health care costs

c. Consumer demand for fewer medical interventions and more family-focused experiences

d. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information

ANS: D

Nursing time and care are in demand as much as ever; the nurse simply has to do things

more quickly. A wellness orientation model of care seems to focus on getting clients out the

door sooner. In most cases, less hospitalization results in lower costs. People believe that

the family gives more nurturing care than the institution.

7. A hospital has several different perineal pads available for use. A nurse is observed soaking several of them and writing down what is observed. What goal is the nurse attempting to achieve by performing this practice?

a. To improve the accuracy of blood loss estimation, which usually is a subjective

assessment

b. To determine which pad is best

c. To demonstrate that other nurses usually underestimate blood loss

d. To reveal which brand of pad is more absorbent

ANS: A

Saturation of perineal pads is a critical indicator of excessive blood loss; anything done to

help in the assessment is valuable. The nurse is noting the saturation volumes and soaking

appearances. Instead of determining which pad is best, the nurse is more likely noting

saturation volumes and soaking appearances to improve the accuracy of estimated blood

loss. Nurses usually overestimate blood loss

8. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman spontaneously empty her bladder as soon as possible. If all else fails, what

tactic might the nurse use?

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

b. Placing oil of peppermint in a bedpan under the woman

c. Asking the healthcare provider to prescribe analgesic agents

d. Inserting a sterile catheter

ANS: D

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

and easy methods available (e.g., water, peppermint vapors, pain pills). Pouring water over

the perineum may stimulate voiding. It is easy, noninvasive, and should be tried first. The oil

of peppermint releases vapors that may relax the necessary muscles. It, too, is easy,

noninvasive, and should be tried early on. If the woman is anticipating pain from voiding,

then pain medications may be helpful. Other nonmedical means should be tried first, but

medications still come before the insertion of a catheter.

9. What information should the nurse understand fully regarding rubella and Rh status?

a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.

b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination.

c. Rh immunoglobulin is safely administered intravenously because it cannot harm anursing infant.

d. Rh immunoglobulin boosts the immune system and thereby enhances the

effectiveness of vaccinations.

ANS: B

Women should understand that they must practice contraception for at least 1 month after

being vaccinated. Because the live attenuated rubella virus is not communicable in breast

milk, breastfeeding mothers can be vaccinated. Rh immunoglobulin is administered

intramuscular (IM); it should never be administered to an infant. Rh immunoglobulin

suppresses the immune system and therefore might thwart the rubella vaccination.

10. A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. Which response by the client alerts the nurse that psychosocial outcomes have not

been met?

a. The woman excessively discusses her labor and birth experience.

b. The woman feels that her baby is more attractive and cleverer than any others.

c. The woman refers to the baby as "sweetie" since she has not given the baby a name yet.

d. The woman has a partner or family members who react very positively about the baby.

ANS: C

If the mother is having difficulty naming her new infant, it may be a signal that she is not

adapting well to parenthood. Other red flags include a refusal to hold or feed the baby, a lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper

change. A new mother who is having difficulty is unwilling to discuss her labor and birth

experience. An appropriate nursing diagnosis might be Need for health teaching, related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her

birth experience is making a healthy personal adjustment. The mother who is not coping well

finds her baby unattractive and messy. She may also be overly disappointed in the baby's sex. The client might voice concern that the baby reminds her of a family member whom she

does not like. Having a partner and/or other family members react positively is an indication

that this new mother has a good support system in place. This support system helps reduce

anxiety related to her new role as a mother.

11. Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination?

a. 2 weeks of age

b. 7 to 10 days after childbirth

c. 4 to 5 days after hospital discharge

d. 48 to 72 hours after hospital discharge

ANS: D

Breastfeeding infants are routinely seen by the pediatric health care provider clinic within 3

to 5 days after birth or 48 to 72 hours after hospital discharge and again at 2 weeks of age.

Formula-feeding infants may be seen for the first time at 2 weeks of age.

12. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse's highest priority?

a. Beginning an intravenous (IV) infusion of Ringer's lactate solution

b. Assessing the woman's vital signs

c. Calling the woman's primary health care provider

d. Massaging the woman's fundus

ANS: D

The nurse should first assess the uterus for atony by massaging the woman's fundus.

Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood

pressure is not a reliable indicator of impending shock from impending hemorrhage;

assessing vital signs should not be the nurse's first action. The healthcare provider would be

notified after the nurse completes the intervention if the discharge is still excessive.

13. 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

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. If mother and baby are

both Rh+ or Rh- the blood types are alike, so no antibody formation would be anticipated. If

the Rh+ blood of the mother comes in contact with the Rh- blood of the infant, no antibodies

would develop because the antigens are in the mother's blood, not in the infant's.

14. When caring for a newly delivered woman, what is the best measure for the nurse to implement to prevent abdominal distention after a cesarean birth?

a. Rectal suppositories

b. Early and frequent ambulation

c. Tightening and relaxing abdominal muscles

d. Carbonated beverages

ANS: B

Activity will aid the movement of accumulated gas in the gastrointestinal tract that results in

abdominal distention. Rectal suppositories can be helpful after distention occurs; however they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.

1. Which physiologic factors are reliable indicators of impending shock from postpartum hemorrhage? (Select all that apply.)

a. Respirations

b. Skin condition

c. Blood pressure

d. Level of consciousness

e. Urinary output

ANS: A, B, D, E

Blood pressure is not a reliable indicator; several more sensitive signs are available. Blood

pressure does not drop until 30% to 40% of blood volume is lost. Respirations, pulse, skin

condition, urinary output, and level of consciousness are more sensitive means of identifying

hypovolemic shock.

2. If a woman is at risk for thrombus but is not ready to ambulate, which nursing intervention would the nurse include in the plan of care? (Select all that apply.)

a. Putting her in antiembolic stockings

b. Having her flex, extend, and rotate her feet, ankles, and legs

c. Having her sit in a chair for at 30 uninterrupted minutes

d. Immediately notifying the healthcare provider when a positive Homans sign occurs

e. Applying sequential compression devices as prescribed

ANS: A, B, D, E

Sitting immobile in a chair does not help; bed exercise and prophylactic footwear might. TED

hose and SCD boots are recommended. The client should be encouraged to ambulate with

assistance, not remain in bed. Bed exercises are useful. A positive Homans sign (calf muscle pain or warmth, redness, tenderness) requires the healthcare provider's immediate

attention.