Deck 30: The Postpartum Family at Risk

Question 1

The nurse is assisting a multiparous postpartum woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. Which is the priority nursing action?
1) Assist the client to empty her bladder.
2) Help the client back to bed to check her fundus.
3) Assess her blood pressure and pulse.
4) Begin an IV of lactated Ringer infusion.

Answer 1

2

Question 2

The nurse conducts discharge teaching for a postpartum client who is diagnosed with deep vein thrombosis (DVT). Which statements indicate accurate understanding of the information presented? Select all that apply.
1) "I will cross my legs while I sit and watch TV in the evening."
2) "I will wear supportive stockings if I have to stand for long periods of time."
3) "I will only have to continue taking Coumadin for 1 month once I am home."
4) "If I develop bleeding gums, I should contact my healthcare provider."
5) "I should plan to elevate my legs during times of rest."

Answer 2

2, 4, 5

Question 3

A postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks if there is something she can do to prevent mastitis this time. Which response by the nurse is most appropriate?
1) "Massage your breasts on a daily basis, and if you find a hardened area, massage it toward the nipple to unblock that duct."
2) "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again."
3) "Apply cold packs to any areas that feel thickened or firm in order to relieve the swelling and stasis of the milk in that area."
4) "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."

Answer 3

1

Question 4

The nurse is assessing a postpartum client who is 36 hours post delivery. Which findings cause the nurse to suspect a reproductive tract infection? Select all that apply.
1) Temperature of 38.0°C (100.4°F) or higher
2) Foul-smelling lochia
3) Uterine tenderness
4) Leg edema and erythema
5) Breast engorgement

Question 5

Which assessment data support the nurse's suspicion that a postpartum client has mastitis? Select all that apply.
1) Pain in the nipple during breastfeeding described as "shooting"
2) Late onset of nipple pain
3) Pink, flaking, pruritic skin of the affected nipple
4) Nipple soreness when the infant latches on
5) Breast engorgement prior to each feeding

Question 6

Which method of initial assessment would best indicate whether a postpartum client is experiencing a urinary complication?
1) Urine pH
2) Calculation of urine output
3) Urine specific gravity
4) Calculation of intake

Question 7

The nurse is reviewing the medical record for a postpartum client. Which findings would necessitate the need for the nurse to monitor the client closely for the development of thrombophlebitis? Select all that apply.
1) Vaginal birth
2) 25 years of age
3) History of diabetes mellitus
4) Current smoker
5) Laboratory values indicating anemia

Question 8

The nurse is conducting discharge instruction for a postpartum client. Which client response indicates accurate understanding of when to notify the healthcare provider?
1) "If I am having trouble getting the baby to latch on, I should call my doctor."
2) "If I continue to have pain after taking my prescribed analgesic, I should call my doctor."
3) "If I saturate one pad every 8 hours, I should call my doctor."
4) "If I don't have a bowel movement within 24 hours of going home, I should call my doctor."

Question 9

The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse?
1) Acute pain
2) Redness
3) Chest pressure
4) Edema

Question 10

The nurse is providing care to a postpartum client 24 hours after delivery who has been diagnosed with metritis. Which response by the nurse is accurate when the client asks what made her sick?
1) "Early infections such as this are often caused by group beta strep (GBS)."
2) "Most infections are often caused by a chlamydial infection. Do you practice safe sex?"
3) "You must have already been sick when you came to deliver your baby."
4) "There is no way to knowing why you got sick. Sometimes it just happens."

Question 11

The charge nurse is reviewing the plan of care for maternal clients currently admitted for postpartum care. During the course of the medical record review, which intervention requires immediate consideration for revision?
1) Daily prothrombin time (PT) measurements for coagulation assessment in a client receiving heparin for treatment of thrombophlebitis.
2) Use of the REEDA (redness, edema, ecchymosis, discharge, approximation) scale for assessment every 8 hours in the care of a client diagnosed with puerperal infection.
3) Misoprostol (Cytotec) administration to a client who demonstrates uterine atony and bleeding after receiving oxytocic medications.
4) Inserting a straight catheter to drain the overdistended bladder of a client during the early postpartum period of her care.

Question 12

A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply.
1) methylergonovine maleate (Methergine)
2) butorphanol tartrate (Stadol)
3) misoprostol (Cytotec)
4) betamethasone (Diprolene)
5) fentanyl (Duragesic)

Question 13

The nurse is conducting teaching for a postpartum client who is approaching discharge. Which topics will the nurse include in the educational session regarding the prevention of postpartum hemorrhage? Select all that apply.
1) Using the peri-bottle
2) Applying ice to the breasts
3) Wearing cotton underwear
4) Performing fundal massage
5) Inspecting the episiotomy site

Question 14

The nurse is revising the care plan of a postpartum client who develops mastitis. Which nursing diagnosis is most appropriate for inclusion in this client's updated plan of care?
1) Ineffective Peripheral Tissue Perfusion related to obstructed venous return
2) Risk for Trauma related to lack of information about appropriate breastfeeding practices
3) Deficient Knowledge related to self-care after discharge on anticoagulant therapy
4) Acute Pain related to tissue hypoxia and edema secondary to vascular obstruction

Question 15

The nurse is planning care for a postpartum client. Which data in the client's history increase the risk for postpartum depression? Select all that apply.
1) Type 1 diabetes mellitus (DM)
2) Bipolar disorder
3) Premenstural dysphoric disorder (PMDD)
4) Recent relocation to a new city
5) Family history of hypertension

Question 16

The postpartum client who delivered a newborn 2 days ago develops endometritis. Which entry in the medical record would the nurse expect to find when reviewing the client's history?
1) "Cesarean birth performed secondary to arrest of dilation."
2) "Rupture of membranes occurred 2 hours prior to delivery."
3) "External fetal monitoring used throughout labor."
4) "History of pregnancy-induced hypertension."

Question 17

The postpartum client presents to the maternity clinic with complaints of urinary urgency and dysuria 3 days after hospital discharge. Which statement is most important for the nurse to make?
1) "Void into this sterile cup without touching the inside of the cup."
2) "Be sure to wipe from back to front after you have a bowel movement."
3) "Call the clinic if you develop nausea and vomiting or constipation."
4) "Decrease your fluid intake for a few days, but eat a lot of vegetables."

Question 18

The nurse is assessing a postpartum client's risk for early postpartum hemorrhage. Which findings in the client's health history place this client at an increase risk for early postpartum hemorrhage? Select all that apply.
1) Microsomia
2) Grand multiparity
3) African American heritage
4) Oxytocin induction of labor
5) History of anorexia nervosa

Question 19

The nurse is performing wellness checks for postpartum clients after hospital discharge via the telephone. Which client should be seen immediately?
1) The client who at 4 weeks postpartum describes feeling sad all the time.
2) The client who at 2 weeks postpartum reports hearing voices talking about the baby.
3) The client who at 1 week postpartum states that she has no appetite and feels tired all the time.
4) The client with a history of depression who states she needs a refill on her sertraline (Zoloft) in 1 week.

Question 20

The maternal nurse educator is conducting a presentation for antepartum clients describing the identification and care of women diagnosed with postpartum psychiatric disorders. Which information should the maternal nurse educator include in the teaching content?
1) Postpartum depression occurs in as many as 50% to 70% of mothers and is characterized by mild depression interspersed with happier feelings.
2) Postpartum depression is typically mild and usually self-limiting, lasting up to 6 weeks.
3) Even if she is asymptomatic, a woman with a history of postpartum depression should be referred to a mental health professional for counseling and biweekly visits postpartum.
4) Women with postpartum depression have a history of exposure to an extremely traumatic personal event that involves actual or threatened death or serious injury and evokes intense fear, helplessness, or horror.