Question 1

The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day.Which of the following nursing interventions would be appropriate?&#10;A)Encourage the client to have patience,saying,&#34;It will happen soon.&#34;&#10;B)Instruct the client to eat a low-fiber diet.&#10;C)Decrease fluid intake.&#10;D)Obtain an order for a stool softener.&#10;

Accepted Answer

It is common for clients to experience constipation after delivery due to effects of anesthesia, decreased muscle tone and decreased mobility, especially if they have had an episiotomy or hemorrhoids, or are taking opioid pain medication. Stool softeners can be helpful in preventing and treating constipation in a postpartum client. Encouraging patience is not an effective intervention as it does not address the cause of constipation. Instructing the client to eat a low-fiber diet and decrease fluid intake would exacerbate constipation.

Question 2

Put the following components specific to postpartum examination of a client in the proper sequential order: Write your answer in the box below.&#10;A)L-lochia&#10;B)E-emotional&#10;C)H-Homans'/hemorrhoids&#10;D)B-breast&#10;E)E-episiotomy/lacerations&#10;F)U-uterus&#10;G)B-bowel&#10;H)B-bladder&#10;

Accepted Answer

The correct sequential order for postpartum examination of a client is:
F - Uterus (to assess for contractions and involution)
A - Lochia (to assess for amount, color, and odor of vaginal discharge)
D - Breast (to assess for any engorgement, tenderness, or nipple issues)
E - Episiotomy/Lacerations (to assess for healing and signs of infection)
H - Bladder (to assess for any urinary retention or incontinence)
G - Bowel (to assess for intestinal activity and any hemorrhoids)
C - Homans'/Hemorrhoids (to assess for DVT or hemorrhoids)
B - Emotional (to assess for any mental health concerns, provide education and support)

Question 3

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:&#10;A)Answer questions quickly and try to divert her attention to other subjects.&#10;B)Review documentation of the birth experience and discuss it with her.&#10;C)Contact the physician to warn him the client might want to file a lawsuit due to her preoccupation with her birth experience.&#10;D)Submit a referral to Social Services out of concern over obsessive behavior.&#10;

Accepted Answer

The nurse should review the documentation of the birth experience and discuss it with the client to help her process and understand what happened. This can also help alleviate any concerns or anxiety the client may have. Answer A would not fully address the client's needs, while answers C and D are not appropriate or necessary actions in this situation.

Question 4

A nurse is caring for several postpartum clients.Which client is demonstrating a problem attaching to her newborn?&#10;A)The client who is discussing how her boy looks like her father&#10;B)The client who is singing softly to her baby&#10;C)The client who continues to touch her baby with only her fingertips&#10;D)The client who picks her baby up when he cries&#10;

Accepted Answer

The client who continues to touch her baby with only her fingertips is demonstrating a potential problem attaching to her newborn. Touching the baby with only fingertips rather than holding and cuddling can signal discomfort, fear, or anxiety about the baby or motherhood in general. The other options do not necessarily indicate a problem with attachment. Talking about physical similarities between the baby and family members, singing to the baby, and picking the baby up when crying are all positive signs of bonding and attachment.

Question 5

A postpartum client asks the nurse to weigh her.The nurse expects an initial weight loss of:&#10;A)10-12 pounds.&#10;B)5-8 pounds.&#10;C)15-20 pounds.&#10;D)12-15 pounds.&#10;

Accepted Answer

The initial weight loss for a postpartum client is typically around 10-12 pounds. This accounts for the weight of the baby, placenta, and amniotic fluid lost during delivery.

Question 6

The nurse is caring for a postpartal client who is experiencing afterpains following the birth of her third child.Which of the following comfort measures should the nurse implement to decrease her pain? Select all that apply.

A)Offer warm blankets for her abdomen.
B)Call the physician to report this finding.
C)Inform her that this is not normal,and she will need an oxytocic agent.
D)Massage the fundus of the uterus gently and observe lochia for clots.
E)Administer a mild analgesic at bedtime to ensure rest.

Accepted Answer

Afterpains are normal, especially in multiparous women (those who have given birth more than once). Warm blankets on the abdomen (A) can help relax the muscles and reduce discomfort. Massaging the fundus of the uterus (D) helps it contract and reduces bleeding, while also checking for any abnormal clots. Administering a mild analgesic (E) can help manage the pain and ensure rest. Reporting to a physician (B) is unnecessary for normal afterpains, and informing the patient that this is not normal (C) is incorrect, as afterpains are a common and expected postpartum occurrence.

Question 7

A nurse is delegating care of postpartum clients to a licensed vocational nurse (LVN).Which postpartum client is at the greatest risk for postpartum bleeding from uterine atony,and should not be delegated to an LVN's care?

A)A breastfeeding postpartum client
B)A postpartum client who began early ambulation
C)The client who delivered vaginally after a prolonged labor
D)A primiparous client

Accepted Answer

The client who delivered vaginally after a prolonged labor is at the greatest risk for postpartum bleeding from uterine atony because prolonged labor can cause overdistension of the uterus and decreased uterine muscle tone, leading to an increased risk of postpartum hemorrhage. This client should not be delegated to an LVN's care, as they may not have the level of expertise needed to identify and intervene in the event of excessive bleeding. Breastfeeding, early ambulation, and primiparous status do not increase the risk of postpartum bleeding from uterine atony.

Question 8

The postpartum nurse is caring for a client who gave birth to full-term twins earlier today.The nurse will know to assess for symptoms of:&#10;A)Increased blood pressure.&#10;B)Hypoglycemia.&#10;C)Postpartum hemorrhage.&#10;D)Postpartum infection.&#10;

Accepted Answer

Postpartum hemorrhage is a significant risk for women who have given birth to multiples, such as twins, due to the increased uterine stretching and the larger placental area. This can lead to a greater likelihood of uterine atony (the inability of the uterus to contract effectively), which is a primary cause of postpartum hemorrhage.

Question 9

The nurse would expect a physician to prescribe which of the following medications if a postpartum client were having heavy bleeding and a boggy uterus?&#10;A)Methylergonovine maleate (Methergine)&#10;B)Rh immune globulin (RhoGAM)&#10;C)Terbutaline (Brethine)&#10;D)Docusate (Colace)&#10;

Accepted Answer

Methylergonovine maleate (Methergine) is a medication used to treat postpartum bleeding caused by a boggy uterus. It works by causing the uterus to contract, which helps to stop the bleeding.

Question 10

A postpartum client has inflamed hemorrhoids.Which of the following nursing interventions would be appropriate?&#10;A)Encourage Sitz baths.&#10;B)Position the client in the supine position.&#10;C)Avoid stool softeners.&#10;D)Decrease fluid intake.&#10;

Accepted Answer

Encouraging Sitz baths can help to reduce inflammation and provide relief for the client's hemorrhoids. Positioning the client in the supine position may increase pressure on the rectal area, worsening the hemorrhoids. Avoiding stool softeners may lead to constipation, which can exacerbate the hemorrhoids. Decreasing fluid intake may also lead to constipation and is not recommended.

Question 11

The postpartum patient is about to go home.The nurse includes which of the following subjects in the teaching plan?&#10;A)Puerperal tachycardia&#10;B)Striae and chloasma&#10;C)Diastasis of the recti muscles&#10;D)HELLP syndrome&#10;

Accepted Answer

The answer of The postpartum patient is about to go...

Question 12

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

A)The taking-hold phase.
B)Postpartum hemorrhage.
C)The taking-in phase.
D)Epidural anesthesia.

Accepted Answer

The answer of On the first postpartum day,the nurse teaches...

Question 13

A nurse is preparing to discharge a postpartum client.The nurse notes on her chart that she is nonimmune to rubella.The nurse:&#10;A)Administers a rubella vaccine prior to discharge.&#10;B)Instructs the client to obtain a rubella vaccine after 1 month has elapsed.&#10;C)Charts this information in the discharge summary notes.&#10;D)Takes no action because none is needed.&#10;

Accepted Answer

The answer of A nurse is preparing to discharge a...

Question 14

The nurse assesses for Homans' sign by:&#10;A)Extending the foot and inquiring about calf pain.&#10;B)Extending the leg and inquiring about foot pain.&#10;C)Flexing the knee and inquiring about thigh pain.&#10;D)Dorsiflexing the foot and inquiring about calf pain.&#10;

Accepted Answer

The answer of The nurse assesses for Homans' sign by:&#10;A)Extending...

Question 15

The nurse determines the fundus of a postpartum client to be boggy.Initially,the nurse should:&#10;A)Document the findings.&#10;B)Catheterize the client.&#10;C)Massage gently and reassess.&#10;D)Call the physician immediately.&#10;

Accepted Answer

The answer of The nurse determines the fundus of a...

Deck 30: Postpartal Adaptation and Nursing Assessment