Question 1

During the first several months after birth, the mother and infant begin to know each other. This relationship progresses through several phases. Which of the following actions are to be expected in the phase of mutual regulation?

Accepted Answer

In the phase of mutual regulation, the mother and infant are adjusting to each other's cues and rhythms. The mother vocalizing feelings of frustration indicates an attempt to regulate and understand the infant's needs and responses.

Question 2

The nurse expects an initial weight loss for the average postpartum patient to be:

Accepted Answer

The initial weight loss for the average postpartum patient is typically 10-12 pounds. This includes the weight of the baby, placenta, and amniotic fluid.

Question 3

The nurse is performing an assessment of early attachment. During the assessment, the nurse needs to the question "Does the mother seem pleased with her baby's appearance and sex?" Which action of the mother might help this question?

Accepted Answer

When the mother points out family traits in the newborn, it suggests that she is interested and invested in the baby's appearance and genetic heritage. This indicates that the mother might be pleased with her baby's appearance and sex. Enfolding the infant in her arms is a common behavior but does not necessarily indicate the mother's satisfaction with the baby's appearance and sex. Feeding the infant as instructed and asking questions about bathing are routine care tasks and do not reflect the mother's attitude towards the baby's appearance and sex.

Question 4

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

Accepted Answer

The taking-in phase is the first phase of the postpartum period during which the mother is focused on her own needs, such as food and rest, and is less able to retain information or actively participate in learning. This phase typically lasts for the first 1-2 days postpartum. Therefore, the mother's memory lapse about the breastfeeding teaching is most likely due to being in the taking-in phase.

Question 5

The nurse is to begin the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?

Accepted Answer

The most important aspect of postpartum teaching for a new mother is to assist her in identifying behavior cues of the baby, such as hunger cues or signs of discomfort. This will help the mother respond appropriately to her baby's needs and promote bonding and attachment. While discussing the reactions of siblings and adaptation to grandparenthood can be helpful, it is not the most important aspect of teaching for the new mother. Determining father-infant attachment is also important, but this can be addressed in later teaching sessions.

Question 6

The nurse has received an end of shift report on the postpartum unit. Which patient should she see first?

Accepted Answer

The nurse should prioritize seeing the patient who is a primip (first-time mother) on the day of delivery with a fundus firm 2 cm above the umbilicus. This could indicate uterine atony or retained placental fragments, both of which can lead to significant postpartum hemorrhage if not addressed promptly.

Question 7

Every time the nurse enters the room of a postpartum patient who gave birth three hours ago, the patient asks something else about her birth experience. The nurse would:

Accepted Answer

It is common for postpartum patients to have questions and concerns about their birth experience, especially in the first few hours after delivery. The nurse should take the time to review the documentation and discuss any questions or concerns the patient may have. This will help alleviate anxiety and provide the patient with a sense of control over her experience. Answer A may work in some cases, but it is not appropriate to divert the patient's attention if she wants to talk about her birth experience. Answers C and D are not indicated in this situation.

Question 8

The nurse is performing a postpartum assessment on a newly delivered patient. When checking the fundus, there is a gush of blood. The patient asks why that is happening. The best response is:

Accepted Answer

The gush of blood can occur when blood pools in the vagina while the patient is lying down, and moving or manipulating the area (such as during a fundal check) can cause this pooled blood to be expelled. This explanation provides specific, accurate information about the physiological process occurring.

Question 9

During her interactions with a primipara mother, the nurse notices that the mother rarely interacts with the infant unless the infant begins to cry vigorously. She appears relieved when a nurse comes to check on the infant. What is the appropriate nursing intervention for this patient?

Accepted Answer

The nurse should assess the mother's experience and knowledge about infant care and provide education on how to interact with her infant, as this can help improve bonding and caregiving skills.

Question 10

The postpartum nurse is caring for a first-time mother who is unable to breastfeed her baby. While assessing the patient's breasts the day after birth, which teaching point should the nurse include?

Accepted Answer

Lactation suppression is the relevant teaching point for a mother who is unable to breastfeed, as it involves methods to prevent or minimize milk production and discomfort.

Question 11

To assess healing of the uterus at the placental site, the nurse assesses:

Accepted Answer

The type, amount, and consistency of lochia can indicate healing of the uterus at the placental site. Lochia rubra is present immediately after birth and consists of blood and decidual tissue from the placental site. Lochia serosa follows and is a combination of blood, mucus, and leukocytes, indicating decreased bleeding and healing. Finally, lochia alba is a discharge of leukocytes, decidua, and epithelial cells, indicating completion of healing. Uterine size may also be assessed, but it is not specific to healing of the placental site. Lab values and blood pressure are not specific to assessing healing of the uterus at the placental site.

Quiz 29: Postpartum Adaptation and Nursing Assessment