Chapter 22 notes

1. Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition?

A. retained placental fragments

B. hypertension

C. thrombophlebitis

D. uterine subinvolution

Answer: C

Rationale: The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.

2. The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum:

A. depression.

B. psychosis.

C. bipolar disorder.

D. blues

Answer: D

Rationale: Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness, increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for herself and her newborn. Postpartum depression is a major depressive episode associated with birth. Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder refers to a mood disorder typically involving episodes of depression and mania.

3. A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom?

A. an inverted nipple on the affected breast

B. no breast milk in the affected breast

C. an ecchymotic area on the affected breast

D. hardening of an area in the affected breast

Answer: D

Rationale: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is often distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk Potential

4. After teaching a class on postpartum depression, the instructor determines that the teaching was successful when the class states that postpartum depression occurs in about what percentage of postpartum women?

A. 5%

B. 10%

C. 15%

D. 25%

Answer: C

Rationale: Postpartum depression occurs in approximately 20% of all postpartum women and in 60% of adolescent mothers. (Most texts will note about 10% to 15%.) Thus, the best answer is 15%.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: RememberClient Needs: Psychosocial Integrity

5. A nurse is developing a presentation for a postpartum class on thromboembolic conditions. Which factor would the nurse emphasize as most important in predisposing women to these conditions?

A. venous stasis

B. altered hormonal levels

C. increased blood volume

D. vessel damage

Answer: A

Rationale: The pregnant woman is at risk for a thromboembolic condition because of venous stasis, which is most significant. Vessel damage is a contributing factor but less important. Hormonal changes and increased blood volume are physiologic changes but not the primary cause.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: UnderstandClient Needs: Physiological Integrity: Reduction of Risk Potential

6. When assessing a postpartum woman, which finding would lead the nurse to suspect postpartum hemorrhage?

A. blood loss of about 350 mL

B. hemoglobin drop of 1%

C. change in hematocrit of 12%

D. blood loss of about 400 mL

Answer: C

Rationale: A change in hematocrit of 10% is indicative of postpartum hemorrhage. Blood loss greater than 500 mL after a vaginal birth or 1,000 mL after a cesarean birth is also considered hemorrhage. Smaller losses or minor lab value changes would not be diagnostic.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 812

7. A postpartum woman is experiencing uterine atony. Which intervention would be the priority?

A. performing fundal massage

B. encouraging ambulation

C. applying warm compresses

D. administering antibiotics

Answer: A

Rationale: Uterine atony (failure of the uterus to contract) is the leading cause of postpartum hemorrhage. The priority nursing intervention is to perform fundal massage to stimulate uterine contraction. Ambulation, compresses, or antibiotics do not address immediate bleeding.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 814

8. A woman is diagnosed with postpartum hemorrhage due to a genital tract laceration. Which finding would support this diagnosis?

A. a contracted uterus with continued bleeding

B. soft and boggy uterus

C. decreased lochia

D. enlarged uterus with clots

Answer: A

Rationale: If the uterus is firm and contracted but bleeding persists, this suggests trauma such as lacerations. A boggy uterus indicates atony. Decreased lochia suggests normal involution. An enlarged uterus with clots also suggests atony, not laceration.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: AnalyzeClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 815

9. A postpartum woman is diagnosed with deep vein thrombosis (DVT). Which sign would the nurse expect to find?

A. decreased temperature in the affected leg

B. palpable dorsalis pedis pulse

C. positive Homan’s sign

D. localized redness and warmth

Answer: D

Rationale: DVT is characterized by unilateral leg pain, calf tenderness, swelling, redness, and warmth. A decreased temperature is not typical. Pulses may still be present. Homan’s sign is not reliable and is no longer recommended as diagnostic.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 820

10. Which instruction would the nurse include when teaching a postpartum woman with mastitis about breastfeeding?

A. discontinue breastfeeding until antibiotic therapy is completed

B. continue breastfeeding, even on the affected side

C. limit breastfeeding to every 8 hours until the infection resolves

D. switch to bottle-feeding permanently to prevent recurrence

Answer: B

Rationale: The woman should be encouraged to continue breastfeeding, even on the affected side, to promote drainage of the breast and prevent milk stasis. Mastitis is treated with antibiotics and supportive measures. Discontinuing breastfeeding is not recommended.

Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Physiological AdaptationReference: p. 823

11. A client is experiencing postpartum hemorrhage, and the nurse is attempting to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus?

A. Place the hands on the sides of the abdomen to grasp the uterus.

B. Use an up-and-down motion to massage the uterus.

C. Wait until the uterus is firm to express clots.

D. Continue massaging the uterus for at least 5 minutes.

Answer: C

Rationale: The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the uterus.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 815

12. A postpartum woman is admitted with suspected deep vein thrombosis (DVT). Which of the following assessment findings would the nurse expect to find?

A. Decreased calf circumference

B. Positive Homan's sign

C. Diminished pedal pulses

D. Coolness of the limb

Answer: B

Rationale: A positive Homan's sign, pain on dorsiflexion of the foot, is suggestive of DVT. The affected leg would demonstrate increased calf circumference, warmth (not coolness), and normal or bounding pulses (not diminished).Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 822

13. A postpartum woman with a pulmonary embolism is receiving intravenous heparin therapy. Which of the following would the nurse include in the client’s plan of care?

A. Avoiding intramuscular injections

B. Monitoring platelet counts every 2 weeks

C. Administering protamine sulfate subcutaneously if bleeding occurs

D. Encouraging green leafy vegetables in dietv

Answer: A

Rationale: While receiving heparin, the nurse would avoid giving intramuscular injections due to the risk of bleeding. Platelet counts are monitored more frequently (not every 2 weeks). Protamine sulfate is given intravenously, not subcutaneously. Green leafy vegetables affect warfarin therapy, not heparin.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Pharmacological and Parenteral TherapiesReference: p. 823

14. A postpartum woman is diagnosed with postpartum infection. Which of the following would the nurse most likely expect the primary health care provider to prescribe?

A. Broad-spectrum antibiotics

B. Anticoagulants

C. Antihypertensives

D. Tocolytics

Answer: A

Rationale: Treatment for postpartum infection typically involves administration of broad-spectrum antibiotics. Anticoagulants are used for thromboembolic disorders, antihypertensives for hypertension, and tocolytics for preterm labor, not postpartum infection.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Pharmacological and Parenteral TherapiesReference: p. 825

15. The nurse is teaching a group of new mothers about signs of postpartum infection that should be reported immediately. Which statement by a participant indicates a need for further teaching?

A. "If my temperature goes above 100.4°F, I should call my doctor."

B. "If I have foul-smelling lochia, I need to let my doctor know."

C. "If my breasts feel warm, firm, and tender, I should report it right away."

D. "If I have chills and feel achy all over, I should contact my provider."

Answer: C

Rationale: Warm, firm, and tender breasts are typical findings associated with engorgement and are considered normal in the postpartum period. Fever above 100.4°F after the first 24 hours, foul-smelling lochia, or systemic symptoms such as chills and body aches may indicate infection and should be reported.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: EvaluateClient Needs: Health Promotion and MaintenanceReference: p. 826

16. A postpartum woman is diagnosed with endometritis. Which of the following findings would the nurse expect to assess?

A. Bradycardia and hypotension

B. Abdominal tenderness and foul-smelling lochia

C. Clear vaginal discharge and perineal itching

D. Severe headache and blurred vision

Answer: B

Rationale: Endometritis is characterized by fever, uterine tenderness, and foul-smelling lochia. Bradycardia and hypotension are not typical. Clear discharge and perineal itching suggest infection such as vaginitis. Severe headache and blurred vision are signs of preeclampsia, not endometritis.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Physiological AdaptationReference: p. 827

17. The nurse suspects that a postpartum woman may be developing a wound infection. Which of the following would support the nurse’s suspicion?

A. White, odorless drainage from the incision site

B. Approximation of wound edges

C. Localized pain and swelling at the incision site

D. Afebrile condition

Answer: C

Rationale: Localized pain, swelling, redness, warmth, and purulent drainage are classic signs of wound infection. White, odorless drainage is normal serous drainage. Approximation indicates healing, and fever (not afebrile condition) usually accompanies infection.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: AnalyzeClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 829

18. A postpartum woman with mastitis is receiving instructions about care. Which statement indicates that she understands the teaching?

A. "I need to stop breastfeeding until the infection clears."

B. "I should wear a tight-fitting bra to reduce milk production."

C. "I will apply warm compresses to my breasts before feeding."

D. "I should avoid taking antibiotics while breastfeeding."

Answer: C

Rationale: Warm compresses help with milk flow and reduce discomfort in mastitis. Women are encouraged to continue breastfeeding. Tight bras promote engorgement. Antibiotics are safe and necessary during mastitis treatment.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Health Promotion and MaintenanceReference: p. 831

19. A postpartum woman reports severe pain in her left calf. On assessment, the nurse notes swelling and warmth in the affected leg. Which action should the nurse take first?

A. Elevate the woman’s leg and notify the health care provider.

B. Massage the calf to promote circulation.

C. Apply cold compresses to the affected area.

D. Ambulate the client to increase venous return.

Answer: A

Rationale: The nurse should elevate the affected leg to promote venous return and immediately notify the health care provider since these are signs of a thrombus. Massage may dislodge the clot, ambulation could worsen the condition, and cold compresses are not appropriate; warm compresses are sometimes prescribed.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: ApplyClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 833

20. A postpartum woman is suspected of having a pulmonary embolism. Which of the following symptoms would the nurse expect to observe?

A. Bradycardia, confusion, and hypothermia

B. Sudden chest pain, dyspnea, and tachycardia

C. Abdominal pain, pallor, and hypertension

D. Slow onset of cough, orthopnea, and fever

Answer: B

Rationale: Classic signs of pulmonary embolism include sudden chest pain, shortness of breath (dyspnea), tachycardia, and anxiety. Bradycardia, confusion, hypothermia, abdominal pain, and slow-onset respiratory symptoms are not typical findings.Question format: Multiple ChoiceChapter 22: Nursing Management of the Postpartum Woman at RiskCognitive Level: AnalyzeClient Needs: Physiological Integrity: Reduction of Risk PotentialReference: p. 834

21.Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which finding would the nurse expect to assess? Select all that apply.

A. diaphoresis

B. tachycardia

C. oliguria

D. cool extremities

E. confusion

Answer: A, D

Rationale: Signs and symptoms of mild shock include diaphoresis, increased capillary refill, cool extremities, and maternal anxiety. Tachycardia and oliguria suggest moderate shock. Confusion suggests severe shock.

22.A nurse is providing a refresher class for a group of postpartum nurses. The nurse reviews the risk factors associated with postpartum hemorrhage. The group demonstrates understanding of the information when they identify which risk factors associated with uterine tone? Select all that apply.

A. rapid labor

B. retained blood clots

C. hydramnios

D. operative birth

E. fetal malposition

Answer: A, C

Rationale: Risk factors associated with uterine tone include hydramnios, rapid or prolonged labor, oxytocin use, maternal fever, or prolonged rupture of membranes. Retained blood clots are a risk factor associated with tissue retained in the uterus. Fetal malposition and operative birth are risk factors associated with trauma of the genital tract.

23.A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action:

A. determines that the procedure is effective.

B. helps support the lower uterine segment.

C. aids in expressing accumulated clots.

D. prevents uterine muscle fatigue.

Answer: B

Rationale: The nurse places the nondominant hand on the area above the symphysis pubis to help support the lower uterine segment. The dominant hand on the fundus determines firmness. Gentle downward pressure helps express clots. Over-massaging causes muscle fatigue.

24.A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention?

A. prophylactic heparin administration

B. compression stockings

C. early ambulation

D. warm compresses

Answer: C

Rationale: Although compression stockings and prophylactic heparin may be appropriate, the most cost-effective preventive method is early ambulation. Warm compresses are used to treat superficial venous thrombosis.

25.A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement?

A. "I will use a soft toothbrush to brush my teeth."

B. "I can take ibuprofen if I have any pain."

C. "I need to avoid drinking any alcohol."

D. "I will call my health care provider if my stools are black and tarry."

Answer: B

Rationale: Individuals receiving anticoagulant therapy must avoid aspirin or NSAIDs (such as ibuprofen) due to bleeding risk. A soft toothbrush and avoiding alcohol are correct. Black, tarry stools should be reported.

26.The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply.

A. taking the prescribed antibiotic until it is finished

B. checking temperature once a week

C. washing hands before and after perineal care

D. handling perineal pads by the edges

E. directing peribottle to flow from back to front

Answer: A, C, D

Rationale: Teaching includes finishing antibiotics, daily temperature checks (not weekly), thorough handwashing, and handling perineal pads by the edges. The peri-bottle should flow front to back, not back to front.

27.A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression?

A. "I just feel so overwhelmed and tired."

B. "I'm feeling so guilty and worthless lately."

C. "It's strange, one minute I'm happy, the next I'm sad."

D. "I keep hearing voices telling me to take my baby to the river."

Answer: B

Rationale: Postpartum depression indicators include feelings of worthlessness, guilt, hopelessness, sadness, loss of enjoyment, fatigue, and low energy. Overwhelm and mood swings suggest postpartum blues. Hearing voices indicates postpartum psychosis.

28.As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn?

A. in the first week

B. within the first 2 weeks

C. in approximately 1 month

D. within the first 6 weeks

Answer: D

Rationale: Postpartum depression has a gradual onset and typically becomes evident within 6 weeks. Postpartum blues occur in the first week. Postpartum psychosis appears around 3 months after birth.

29.A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of placental abruption (abruptio placentae). Which finding would help to support the nurse's suspicion?

A. severe uterine pain

B. board-like abdomen

C. appearance of petechiae

D. inversion of the uterus

Answer: C

Rationale: DIC manifests with petechiae, ecchymoses, and impaired clotting. Severe uterine pain and a board-like abdomen suggest abruption itself, not DIC. Uterine inversion is unrelated.

30.On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition?

A. delusional beliefs

B. feelings of anxiety

C. sadness

D. insomnia

Answer: A

Rationale: Postpartum psychosis is characterized by delusions, hallucinations, bizarre behavior, mania, and thoughts of harming self or infant. Anxiety, sadness, and insomnia are more typical of postpartum depression.

31.A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next?

A. Apply warm soaks to the area.

B. Notify the health care provider.

C. Massage the uterine fundus.

D. Encourage the client to void.

Answer: B

Rationale: Findings indicate a perineal hematoma causing postpartum hemorrhage. The nurse should notify the provider immediately. Warm soaks do not control bleeding, and the uterus is already firm, making massage/voiding ineffective.

32.A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as possibly being prescribed as treatment?

A. oxytocin

B. methylergonovine

C. carboprost

D. magnesium sulfate

Answer: D

Rationale: Magnesium sulfate is a tocolytic used to halt preterm labor, not to treat postpartum hemorrhage. Oxytocin, methylergonovine, and carboprost are standard uterotonics for hemorrhage.