Question 1

The postpartum nurse is caring for a client 8 hours after an uncomplicated cesarean birth. Which of the following interventions should the nurse include in the client's plan of care to reduce the risk of thrombus formation? Select all that apply.

Accepted Answer

Deep venous thrombosis (DVT) describes the formation of a thrombus (blood clot) that impedes blood flow in a deep vein and may progress to life-threatening pulmonary embolism (PE). Thrombus formation is associated with venous stasis (blood pooling), which may occur during or after surgery due to immobility. In addition, blood hypercoagulability, a physiologic adaptation during pregnancy, also increases the risk of postpartum thrombus formation. The nurse should emphasize interventions that promote blood flow and venous return, especially for clients recovering from cesarean birth. Interventions to prevent postpartum thrombus formation include: Promoting early and frequent ambulation by ensuring adequate pain control (eg, administer analgesic 30 min before activity) (Option A) Instructing the client to perform leg exercises (eg, dorsiflexion, plantar flexion) hourly (Option C) Maintaining prescribed sequential compression devices during sedentary activities (Option D) (Option B) The nurse should have clients ambulate (with assistance) as soon as possible after surgery (ie, usually on the first postoperative day) if they are in stable condition and can support themselves while standing. (Option E) Anticoagulant therapy with heparin, not aspirin, is indicated for postpartum DVT/PE prevention in clients with additional risk factors (eg, history of DVT). Educational objective: Deep venous thrombosis describes the formation of a thrombus that impedes blood flow in a deep vein and may progress to life-threatening pulmonary embolism. Interventions to prevent postpartum thrombus formation include promoting early ambulation by ensuring adequate pain control, instructing the client to perform leg exercises, and maintaining sequential compression devices on the lower extremities.

Question 2

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations.  Which client statement requires further teaching?

Accepted Answer

Initiating an open discussion about sexual activity after childbirth allows the nurse to provide anticipatory guidance and recognize individual client concerns (eg, discomfort, fatigue, fear, body image). The nurse should plan to reinforce the use of contraception because many clients resume sexual activity before their postpartum checkup (4-6 weeks after birth), when contraception methods are usually prescribed. Ovulation may occur as early as 4 weeks after birth and before resumption of menses, especially in clients who formula feed. Clients should be encouraged to use a barrier contraceptive such as condoms to prevent pregnancy until another form of birth control can be prescribed (Option C). (Option A) Sexual activity may be resumed once lacerations/episiotomy are healed, and vaginal bleeding has stopped. For clients with no birth complications, risk of infection or bleeding is low at ≥2 weeks postpartum. (Option B) Sexual arousal takes more time for most postpartum clients due to hormonal changes. Lactating clients may especially experience symptoms of estrogen deficiency (eg, vaginal dryness). Vaginal lubrication is recommended to increase comfort. (Option D) Sexual activity may be inhibited by the couple's sense of responsibility for newborn needs. In addition, sexual arousal may stimulate leakage of breast milk. Feeding the newborn before sexual activity helps alleviate these concerns/distractions. Educational objective: Many postpartum clients resume sexual activity before their postpartum checkups (4-6 weeks after birth). Encouraging the use of barrier contraceptives (eg, condoms) to prevent pregnancy is important because ovulation may occur as early as 4 weeks after birth and before resumption of menses.

Question 3

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?

Accepted Answer

11ecbb05_cc28_3452_b433_87e625fa52e1_MD0009_00 Perinatal mood disorders may occur at any time during pregnancy but are often precipitated in the postpartum period by the sudden drop in estrogen and progesterone levels after birth. Clients with postpartum depression may feel intense and persistent irritability, anxiety, anger, guilt, and sadness. Such feelings may affect the ability to care for the newborn or themselves. A client showing irritability and disinterest in caring for the newborn should be further assessed for postpartum depression and offered a referral for follow-up care. (Option A) Maternal fatigue or decreased energy is common after birth and while caring for a newborn. The nurse can reassure the client that sleeping when the newborn sleeps is a good strategy as normal newborn sleep and feeding habits may require the client's attention frequently day and night. (Options B and D) Postpartum blues ("baby blues") is a common, milder form of depression characterized by emotional lability, sadness, anxiety, and difficulty sleeping. However, the client's ability to function properly is not affected, and symptoms subside within 2 weeks without treatment. If symptoms persist after 2 weeks, further assessment may be necessary. Educational objective: Perinatal mood disorders may occur at any time during pregnancy but are more common in the immediate postpartum period. Clients with postpartum depression may feel intense and persistent anxiety, anger, guilt, and sadness. A client showing irritability and disinterest in caring for the newborn should be assessed for postpartum depression and offered a referral for follow-up care.

Question 4

A nurse is caring for a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement.  What should the nurse teach regarding relief of breast engorgement?

Accepted Answer

Breast engorgement is often painful. The management of engorgement varies based on the client's breastfeeding status; for clients who choose not to breastfeed, treatment focuses on managing symptoms while promoting reduced milk production. Comfort measures include: Applying ice packs to both breasts for 15-20 minutes every 3-4 hours to reduce blood flow and swelling Applying chilled, fresh cabbage leaves to both breasts, replacing with fresh leaves after they wilt. The mechanism of action is unclear but may be related to the cool temperature or to phytoestrogens from the leaves (Option D). Taking an anti-inflammatory analgesic (eg, ibuprofen) as directed to reduce pain Maintaining firm breast support (eg, supportive bra, breast binder) until milk flow is diminished (Option A) Heat application increases blood flow and worsens engorgement. Although running warm water over the breasts may make milk leak and temporarily relieve pressure, more milk is produced later, which is counterproductive in a client who has chosen not to breastfeed. (Options B and C) Breastfeeding is a supply-and-demand process. Massaging the breasts or manually expressing milk stimulates milk production, which exacerbates engorgement if the client is not breastfeeding. Educational objective: Stimulation of milk production (eg, manual milk expression, breast massage) is avoided in clients who intend to exclusively formula feed. Comfort measures for breast engorgement include application of ice packs and chilled, fresh cabbage leaves; analgesics; and firm breast support.

Question 5

The nurse provides a follow-up phone call to a client who gave birth at a birthing center 5 days ago. Which statement by the client should the nurse be most concerned about?

Accepted Answer

11ecbb05_cc28_a983_b433_09eda4ecacd9_MD0009_00 Postpartum hemorrhage (PPH) may be primary (ie, <24 hours since birth) or secondary/delayed (ie, >24 hours but <6 weeks postpartum). Secondary PPH usually results from uterine subinvolution, retained placental fragments/membranes, or uterine infection. The nurse should expect a client >3-4 days postpartum to report a progressive change in lochia from lochia rubra (dark-red vaginal bleeding) to lochia serosa (pink or brown discharge). A gradual decrease in the amount of lochia is reassuring and expected. However, reports of increased vaginal bleeding, soaking a pad in <1-2 hours, reverting from lochia serosa back to lochia rubra, or passing several/large clots (ie, larger than a nickel) are concerning findings that require the nurse's immediate follow-up (Option C). (Option A) Postpartum fatigue is common due to the adjustments needed to provide newborn care or may be related to postpartum anemia. Follow-up is necessary, but it is not the most concerning statement. (Option B) Bright red bleeding with defecation is associated with hemorrhoids, a common finding in pregnancy. Hemorrhoids usually begin to shrink following birth. (Option D) Physiologic fluid retention in pregnancy may cause medial nerve compression (ie, carpal tunnel syndrome), an expected discomfort of pregnancy marked by a tingling or burning sensation of the hands. Educational objective: Secondary or delayed postpartum hemorrhage (PPH) occurs >24 hours but <6 weeks postpartum. Reports of increased vaginal bleeding, soaking a pad in <1-2 hours, reverting from lochia serosa back to lochia rubra, or passing several/large clots are concerning findings associated with secondary PPH.

Question 6

A client who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg, and reports no urge to urinate at 2 hours postpartum. The nurse palpates the client's fundus 2 cm above the umbilicus and to the right. What should the nurse do next?

Accepted Answer

11ecbb05_cc28_f7a4_b433_a9e7cd97a21a_MD0009_00 Postpartum urinary retention is commonly related to decreased bladder sensation (eg, due to regional anesthesia, prolonged labor, or perineal trauma) and postpartum diuresis. Urinary retention can cause bladder distension, which may be noted by a displaced and/or boggy uterus, or by a palpable bladder. If bladder distension cannot be resolved with spontaneous voiding, in-and-out (I&O) catheterization may be indicated, especially if the client: Is unable to ambulate to the restroom or void into a bedpan (Option C) Has not voided within 6-8 hours after delivery or removal of the indwelling urinary catheter after cesarean delivery Has difficulty emptying bladder completely (ie, voiding <100 mL frequently) (Option A) Postpartum clients are at risk for falls due to regional or general anesthesia, orthostatic hypotension, and changes in center of gravity. Risk of injury is increased in clients who ambulate before full sensory/motor function has returned. (Option B) Fluid intake may be encouraged postpartum but does not resolve the client's urinary retention and bladder distension. (Option D) A displaced fundus (ie, elevated above the umbilicus and/or to one side) is evidence of bladder distension. Reassessing in an hour may increase the risk of postpartum hemorrhage, as a full bladder can cause uterine atony. Educational objective: Signs of bladder distension in a postpartum client include a displaced and/or boggy uterus, or a palpable bladder. Performing an in-and-out catheterization can help prevent postpartum hemorrhage related to uterine atony and injuries related to falls if sensory/motor function of the lower extremities is decreased.

Question 7

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant.  Which assessment findings should be reported to the health care provider?

Accepted Answer

A foul odor of lochia suggests endometrial infection. This client has an increased risk of infection due to her prolonged labor, which involved multiple cervical examinations. The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. (Option A) Palpation of the postpartum uterine fundus is commonly uncomfortable for the client. If the client complains of increasing pain, further evaluation is needed. (Option C) Major signs and symptoms of endometrial infection include temperature above 100.4 F (38.0 C); chills; malaise; excessive uterine tenderness; and purulent, foul-smelling lochia. During the first 24 hours postpartum, the temperature is normally elevated; temperature above 100.4 F (38 C) requires further evaluation. (Option D) The WBC count is normally elevated during the first 24 hours postpartum (up to 30,000/mm³ [30.0 x 10⁹/L]). Leukocyte levels that are not decreasing require further evaluation. Educational objective: Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and WBC count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

Question 8

A nurse is caring for a postpartum client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which of the following instructions should the nurse include in client teaching? Select all that apply.

Accepted Answer

11ecbb05_cc25_4e1e_b433_816b7b4da36e_MD0009_00 Lactational mastitis (infection and inflammation of breast tissue) may result from inadequate milk duct drainage or poor breastfeeding technique. Bacteria from the infant's nasopharynx or mother's skin can enter the nipple, especially if it is damaged, and multiply in stagnant milk. Manifestations include fever, muscle aches, and breast pain and inflammation (eg, warmth, redness, edema). Staphylococcus aureus is the most common causative organism and requires antibiotic treatment (eg, dicloxacillin, cephalexin). In addition, the nurse should encourage the client to: Continue breastfeeding frequently (ie, every 2-3 hr) to ensure adequate milk drainage. Ensure proper breastfeeding technique (eg, alternate newborn feeding positions, proper latch). Apply warm compresses and massage the breast to facilitate complete emptying (Option A). Cool compresses can also be used between breastfeeding as needed for comfort. Ensure adequate rest, nutrition, and hydration (Option C). Relieve pain and inflammation with analgesics compatible with breastfeeding (eg, acetaminophen, ibuprofen) (Option D). Wash hands before and after feeding. (Option B) The milk is safe because the newborn is already colonized with maternal microorganisms. Giving pumped or hand-expressed breast milk is acceptable, although direct breastfeeding is preferred because milk ducts are most efficiently drained with this method. (Option E) Underwire or tight bras are not recommended because milk flow is impeded, which worsens engorgement. Soft, supportive bras encourage milk flow. Educational objective: Treatment for lactational mastitis includes antibiotic therapy, continued breastfeeding, breastfeeding support (eg, proper latch technique), warm compresses, massage, adequate nutrition and hydration, and appropriate analgesics (eg, ibuprofen, acetaminophen).

Question 9

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take?

Accepted Answer

11ecbb05_cc26_fbd0_b433_a5a05806c8b1_MD0009_00 Pregnancy is a hypercoagulable state that provides protection from hemorrhage after birth, but also greatly augments risk of thrombus formation. Women who give birth by cesarean section are at particularly increased risk for deep venous thrombosis (DVT). Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism (PE), often characterized by anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen, and notifying the health care provider (HCP) (Option C). (Option A) Any redness, tenderness, or warmth in the lower extremities may indicate DVT, which should be reported to the HCP. However, the nurse's priority is addressing the client's current symptoms indicative of acute PE by assessing oxygenation. (Option B) Although relaxation breathing techniques may be helpful for management of anxiety, this client's symptoms may be stemming from impaired oxygenation secondary to PE. (Option D) Unmanaged pain can cause tachycardia; however, the additional findings of restlessness/anxiety may indicate PE. The nurse should first assess the client's oxygenation status, before administering requested pain medication. Educational objective: Pregnancy is a hypercoagulable state that increases risk for deep venous thrombosis and pulmonary embolism (PE). Signs and symptoms of PE include anxiety/restlessness, pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. Priorities are rapid symptom identification, assessment of oxygenation, and notification of the health care provider.

Question 10

A nurse is caring for a client who had a vaginal birth 2 hours ago. The client has saturated a perineal pad in 20 minutes. During assessment, the nurse notices that the client has a boggy fundus that is deviated to the right and slightly above the umbilicus. Which intervention should the nurse perform first?

Accepted Answer

11ecbb05_cc24_d8ed_b433_4d8c21eaee6c_MD0009_00 Postpartum vaginal bleeding that saturates a perineal padin <1 hour is considered excessive. This client saturated a perineal pad in 20 minutes. Based on the nurse's assessment, the boggy fundus indicates uterine atony. The fundus is also elevated above the umbilicus and deviated to the right, indicating a distended bladder. Bladder distension prevents the uterus from contracting sufficiently to control bleeding at the previous placental site. The client should be assisted to void to correct the bladder distension (Option A). The nurse should then perform fundal massage. (Option B) Oxytocin is a uterotonic that increases contraction of the myometrium, constricting vessels at the previous placental implantation site. An oxytocin infusion should be initiated if initial attempts to control postpartum bleeding (relief of bladder distention and fundal massage) have failed. The usual postpartum oxytocin IV dosage is 125-200 milliunits/min. (Option C) A complete blood count is needed to determine hematocrit and hemoglobin levels following excessive postpartum bleeding. However, this is not the immediate priority. (Option D) Oxygen delivery at 10 L/min via a nonrebreather facemask may be initiated if the client becomes symptomatic following excessive blood loss. However, the first priority is to control the bleeding. Educational objective: Excessive postpartum bleeding is most commonly caused by uterine atony. The nursing priority for uterine atony associated with bladder distension is to assist the client with voiding and then perform fundal massage and other interventions as needed to control excessive bleeding.

Question 11

The nurse is performing an assessment on a 24-hour-old male who was born breech via vaginal birth at 36 weeks gestation. Which assessment finding requires immediate evaluation by the health care provider?

Accepted Answer

An imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage. The anus may be absent or nonpatent, causing stool accumulation in the intestines or, rarely, stool excretion via a fistula between the rectum and genitourinary system (eg, vagina, male urethra). During a newborn assessment, the nurse should carefully examine the anorectum for malformation and determine anal patency by monitoring the location and quantity of stool excretion. If no stool (ie, meconium) is noted within 24 hours of birth, the nurse should notify the health care provider because immediate evaluation of the client is necessary to facilitate diagnosis and correction (eg, surgical intervention) of the suspected defect (Option D). (Option A) In general, foreskin adheres to the glans penis in a male newborn and is not fully retractable until approximately age 3, if the child remains uncircumcised. (Option B) Scrotal edema may result from pressure on the scrotum during labor, especially with breech vaginal birth, but typically resolves spontaneously. (Option C) Undescended testes (eg, palpated in the inguinal canal, found in the abdomen) occur more commonly in male newborns of preterm gestation. Further evaluation is required only if the testes fail to descend over time. Educational objective: Imperforate anus is a congenital malformation of the anorectal opening that prevents normal stool passage. If no stool (ie, meconium) is noted within 24 hours of birth, the nurse should request immediate evaluation of the newborn to facilitate diagnosis and correction of the suspected defect.

Question 12

The pediatric nurse is performing an assessment on a 4-week-old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next?

Accepted Answer

Postpartum depression (PPD) is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping (or sleeping more than usual), anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD (Option D). It is also important to ask about thoughts of self-harm or harm to the newborn. Postpartum depression (PPD) (Option A) Women who do not have strong support systems are at a higher risk for PPD. However, it is most important to assess for the presence of PPD. (Option B) Mothers may have feelings of inadequacy or guilt as they experience challenges in caring for their infant (eg, breastfeeding difficulties, infant colic). The nurse should assess the need for client teaching, which can help to alleviate anxiety and improve outcomes; however, this is not the priority. (Option C) Sleep disturbances are common when caring for a newborn and may worsen depression or anxiety. However, it is most important to directly ask the client about depression. Educational objective: Postpartum depression (PPD) is a perinatal mood disorder characterized by crying, irritability, sleep disturbances, anxiety, or feelings of guilt. Nurses should assess for PPD by asking specific questions about feelings of depression and hopelessness as well as thoughts about self-harm or harm to the newborn.

Question 13

The nurse reviews the chart of a client who gave birth 4 hours ago.  Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage?

Accepted Answer

Postpartum hemorrhage (PPH) is usually defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony, characterized by a soft, "boggy," and poorly contracted uterus, is the most common cause of early PPH (occurring ≤24 hours after birth). Delayed PPH (>24 hours after birth) usually results from retained placental fragments associated with a long third stage of labor (ie, time from birth of baby to expulsion of placenta, lasting >30 minutes). Risk factors for PPH include: History of PPH in prior pregnancyUterine distension due to:Multiple gestationPolyhydramnios (ie, excessive amniotic fluid)Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option A)Uterine fatigue (labor lasting >24 hours)High parityUse of certain medications:Magnesium sulfateProlonged use of oxytocin during laborInhaled anesthesia (ie, general anesthesia) History of PPH in prior pregnancy Uterine distension due to:Multiple gestationPolyhydramnios (ie, excessive amniotic fluid)Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option A) Multiple gestationPolyhydramnios (ie, excessive amniotic fluid)Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option A) Multiple gestation Polyhydramnios (ie, excessive amniotic fluid) Macrosomic infant (≥8 lb 13 oz [4000 g]) (Option A) Uterine fatigue (labor lasting >24 hours) High parity Use of certain medications:Magnesium sulfateProlonged use of oxytocin during laborInhaled anesthesia (ie, general anesthesia) Magnesium sulfateProlonged use of oxytocin during laborInhaled anesthesia (ie, general anesthesia) Magnesium sulfate Prolonged use of oxytocin during labor Inhaled anesthesia (ie, general anesthesia) (Option B) Natural, unmedicated labor and birth reduces the chance of PPH. (Option C) Labor lasting <24 hours does not increase the risk for PPH. (Option D) A third stage of labor lasting <30 minutes does not increase the risk for PPH. Educational objective: Postpartum hemorrhage is defined as maternal blood loss of >500 mL after a vaginal birth or >1000 mL after a cesarean birth. Uterine atony (ie, "boggy" uterus) is the most common cause of early postpartum hemorrhage (occurring ≤24 hours after birth). Risk factors include uterine distension, uterine fatigue, high parity, and certain medications.

Question 14

The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

Accepted Answer

11ecbb05_cc27_e631_b433_a5872fd9d0d8_MD0009_00 Postpartum hemorrhage can occur immediately after birth of the placenta or in the hours and days following birth. Risk factors include grand multiparity (ie, ≥5 births), intrauterine infection, prolonged labor, use of oxytocin during labor, and coagulopathy. A perineal pad that is saturated in ≤1 hour indicates heavy/excessive bleeding, which may lead to hemodynamic compromise if not recognized and corrected with interventions (eg, fundal massage, uterotonics). A client with a high parity who saturated a pad every hour for the past two hours is experiencing excessive bleeding, potentially due to uterine atony. The nurse should immediately assess the client's fundal tone, lochia amount, and vital signs and notify the health care provider (Option D). (Option A) Foul-smelling lochia is a sign of endometritis, a diagnosis that requires further evaluation and antibiotic treatment but is not a priority over hemorrhage. (Option B) Venous stasis and hypercoagulability play a role in the development of postpartum deep venous thrombosis (DVT). For clients with a DVT, anticoagulants such as enoxaparin (Lovenox) help prevent pulmonary embolism (PE). Should symptoms of PE (eg, dyspnea, chest pain) occur, immediate assessment is required. (Option C) Fever and a red, swollen breast are symptoms of mastitis, a diagnosis that requires antibiotics and breastfeeding support but is not life-threatening. Educational objective: The nurse should prioritize assessment of clients with signs of immediately life-threatening postpartum complications (eg, hemorrhage, pulmonary embolism). A perineal pad that is saturated in ≤1 hour indicates excessive bleeding and requires immediate assessment to prevent hemodynamic compromise.

Question 15

The nurse is teaching a postpartum client about breastfeeding.  Which statement by the client indicates a correct understanding of teaching?

Accepted Answer

11ecbb05_cc26_5f8f_b433_b7a30ae67529_MD0009_00 Sore nipples and painful breastfeeding are common reasons clients discontinue breastfeeding. Teaching proper technique helps clients continue breastfeeding, promotes comfort for the mother, and ensures adequate newborn nutrition. Key principles of proper breastfeeding and latch technique include: Breastfeed every 2-3 hours on average (8-12 times/day) Breastfeed "on demand" whenever the newborn exhibits hunger cues (eg, sucking, rooting reflex) Position the newborn "tummy to tummy" with mouth in front of nipple and head in alignment with body Ensure a proper latch (ie, grasps both nipple and part of areola) Feed for at least 15-20 minutes per breast or until the newborn appears satisfied Insert a clean finger beside the newborn's gums to break suction before unlatching (Option C) Alternate which breast is offered first at each feeding (Option A) Five to ten minutes per breast may be insufficient to feed and may lead to inadequate breast emptying and insufficient nutritional intake. (Option B) Awkward manipulation of the head while breastfeeding makes it difficult for the newborn to latch and feed comfortably. The mother should support the newborn's head and keep it in alignment with the body in all breastfeeding positions. (Option D) If the newborn grasps the nipple only, breastfeeding will be painful due to pinching. Educational objective: If the newborn latches incorrectly or needs to be removed from the breast, the client should insert a finger to break suction before unlatching. When the newborn is removed from the breast incorrectly, nipple trauma may occur, leading to sore nipples and painful breastfeeding.

Question 16

The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type.  Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching?

Accepted Answer

11ecbb05_cc2a_5736_b433_cddeeb7061b6_MD0009_00 Rh alloimmunization (ie, isoimmunization) occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs during pregnancy and birth. After exposure, the maternal immune system produces antibodies to the Rh antigen that can cause serious complications for an Rh-positive fetus during future pregnancies (eg, hemolytic anemia). Rh immune globulin (RhoGAM) prevents antibody formation by suppressing the maternal immune response and is effective only if the client has never developed antibodies to the Rh antigen (ie, Rh sensitization). The nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen (eg, indirect Coombs test) and then proceeding with administration of Rh immune globulin (Option C). A positive maternal antibody screen would require further clarification from the health care provider (HCP). (Option A) If the HCP suspects excessive fetomaternal hemorrhage, a Kleihauer-Betke stain is performed to quantify the fetal RBCs in maternal circulation. Depending on the quantity of fetal RBCs, >1 dose of Rh immune globulin may be required. (Option B) Rh immune globulin should be administered within 72 hours of birth to ensure effectiveness. (Option D) If the newborn is Rh negative, Rh immune globulin is not necessary postpartum. Educational objective: Rh alloimmunization occurs when a pregnant client with an Rh-negative blood type is exposed to Rh-positive fetal RBCs. Postpartum, the nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen and then proceeding with administration of Rh immune globulin if the newborn is Rh positive.

Question 17

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?

Accepted Answer

11ecbb05_cc29_6cd5_b433_73e3aa113103_MD0009_00 Persistent headache and blurred vision could indicate postpartum preeclampsia. The majority of clients with preeclampsia develop symptoms before birth; however, a small percentage do not develop the complication until several days after birth. This potentially serious condition can rapidly worsen, leading to seizures and death if left untreated. Additional signs and symptoms may include high blood pressure, proteinuria, and edema (Option B). (Option A) In the immediate postpartum period, lochia should be assessed frequently to monitor for postpartum hemorrhage. Soaking a perineal pad in ≤1 hour would indicate excessive bleeding that requires urgent intervention. (Option C) Red or painful nipples in a breastfeeding client may be the result of incorrect latch and/or improper breastfeeding technique. The nurse should observe the client while breastfeeding, identify any problems with the newborn's latch, and obtain additional assessment from a lactation consultant, if appropriate. (Option D) Strong- or foul-smelling vaginal discharge may represent an infection (eg, endometritis). This assessment finding indicates the need for further evaluation but is not immediately life-threatening. Educational objective: Preeclampsia can develop in the postpartum period several days after birth. Clients in the postpartum period with signs and symptoms of preeclampsia (eg, edema, persistent headache, vision changes, elevated blood pressure) should be evaluated and treated immediately.

Question 18

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply.

Accepted Answer

Intrauterine fetal demise, or stillbirth, is the birth of an infant who is not alive. The nurse can assist with the perinatal bereavement process by using therapeutic communication, encouraging the parents and family to hold the infant, and providing privacy. Parents and family members may wish to help bathe and dress the infant, and should be encouraged to view and hold the body before discharge to the funeral home (Options A and D). The nurse should offer to obtain handprints and footprints, cut a lock of the infant's hair, and photograph the infant (Option E). These keepsakes are often precious mementos for grieving families who must leave the hospital without a child. However, none of these actions should be forced if the parents decline. (Option B) The nurse should encourage family members to name the infant, which helps them identify the child as part of the family. The staff should refer to the infant by name during care. (Option C) The nurse or primary health care provider should call the designated organ procurement organization, according to facility protocol. Discussions surrounding organ donation are best performed by trained personnel. Educational objective: Intrauterine fetal demise (ie, stillbirth) is the birth of an infant who is not alive. The nurse should encourage family members to hold and name the infant. Mementos (eg, hand/foot prints, photographs) should be made for the family to keep. However, none of these actions should be forced if the parents decline.

Exam 6: Maternal & Newborn Health

The postpartum nurse is caring for a client 8 hours after an uncomplicated cesarean birth. Which of the following interventions should the nurse include in the client's plan of care to reduce the risk of thrombus formation? Select all that apply.

Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching?

A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?

A nurse is caring for a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement. What should the nurse teach regarding relief of breast engorgement?

The nurse provides a follow-up phone call to a client who gave birth at a birthing center 5 days ago. Which statement by the client should the nurse be most concerned about?

A client who gave birth vaginally with epidural anesthesia still has limited movement and strength of the right leg, and reports no urge to urinate at 2 hours postpartum. The nurse palpates the client's fundus 2 cm above the umbilicus and to the right. What should the nurse do next?

The nurse is performing a postpartum assessment 12 hours after the prolonged vaginal delivery of a term infant. Which assessment findings should be reported to the health care provider?

A nurse is caring for a postpartum client who is breastfeeding and has been diagnosed with mastitis of the right breast. Which of the following instructions should the nurse include in client teaching? Select all that apply.

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take?

The nurse is performing an assessment on a 24-hour-old male who was born breech via vaginal birth at 36 weeks gestation. Which assessment finding requires immediate evaluation by the health care provider?

The pediatric nurse is performing an assessment on a 4-week-old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next?

The nurse reviews the chart of a client who gave birth 4 hours ago. Which contributing factor indicates that the client has an increased risk of postpartum hemorrhage?

The nurse receives report on several postpartum clients who gave birth at term gestation. Which client should the nurse assess first?

The nurse is teaching a postpartum client about breastfeeding. Which statement by the client indicates a correct understanding of teaching?

The graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching?

A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply.