Deck 14: Nursing Care of the Family During the Fourth Trimester

Question 1

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. The nurse's first action is to:

A) Begin an intravenous (IV) infusion of Ringer's lactate solution.
B) Assess the woman's vital signs.
C) Call the woman's primary health care provider.
D) Massage the woman's fundus.

Answer 1

Massage the woman's fundus.

Question 2

A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:

A) Discusses her labor and birth experience excessively.
B) Believes that her baby is more attractive and clever than any others.
C) Has not given the baby a name.
D) Has a partner or family members who react very positively about the baby.

Answer 2

Has not given the baby a name.

Question 3

With regard to rubella and Rh issues, nurses should be aware that:

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 1 month after vaccination.
C) Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
D) Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

Answer 3

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

Question 4

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is:

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 physician to prescribe analgesics.
D) Inserting a sterile catheter.

Question 5

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:

A) Running warm water on her breasts during a shower.
B) Applying ice to the breasts for comfort.
C) Expressing small amounts of milk from the breasts to relieve pressure.
D) Wearing a loose-fitting bra to prevent nipple irritation.

Question 6

If a mother and her family have freely chosen early discharge from the hospital, the nurse and the health care provider are not legally responsible if complications occur and her condition had not been stabilized within normal limits.

Question 7

Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.

A) 24, 73
B) 24, 96
C) 48, 96
D) 48, 120

Question 8

Excessive blood loss after childbirth can have several causes; the most common is:

A) Vaginal or vulvar hematomas.
B) Unrepaired lacerations of the vagina or cervix.
C) Failure of the uterine muscle to contract firmly.
D) Retained placental fragments.

Question 9

If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:

A) Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
B) Having her flex, extend, and rotate her feet, ankles, and legs.
C) Having her sit in a chair.
D) Notifying the physician immediately if a positive Homans' sign occurs.

Question 10

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.

Question 11

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:

A) Has recovered from epidural or spinal anesthesia.
B) Has hidden bleeding underneath her.
C) Has regained some flexibility.
D) Is a candidate to go home after 6 hours.

Question 12

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:

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."

Question 13

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:

A) Formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby.").
B) Teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there.")
C) Including other family members in the teaching of self-care and child care. ("We're all in this together.")
D) Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

Question 14

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:

A) The father of the infant.
B) Her mother (the infant's grandmother).
C) Her eldest daughter (the infant's sister).
D) The nurse.

Question 15

Regardless of her obstetric status, no woman should be discharged from the recovery area until she has completely recovered from the effects of anesthesia and has been cleared by a member of the anesthesia care team.

Question 16

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:

A) Improve the accuracy of blood loss estimation, which usually is a subjective assessment.
B) Determine which pad is best.
C) Demonstrate that other nurses usually underestimate blood loss.
D) Reveal to the nurse supervisor that one of them needs some time off.

Question 17

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is:

A) Retained placental fragments.
B) Unrepaired vaginal lacerations.
C) Uterine atony.
D) Puerperal infection.

Question 18

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 would the nurse best interpret these data?

A) Rubella vaccine should be given.
B) A blood transfusion is necessary.
C) Rh immune globulin is necessary within 72 hours of birth.
D) A Kleihauer-Betke test should be performed.

Question 19

Which finding could prevent early discharge of a newborn who is now 12 hours old?

A) Birth weight of 3000 g
B) One meconium stool since birth
C) Voided, clear, pale urine three times since birth
D) Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.