Chapter 21 Flashcards
- 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 three times daily, and a stool softener. Which information regarding the client’s condition is most closely correlated with these orders?
a. Woman is a gravida 2, para 2.
b. Woman had a vacuum-assisted birth.
c. Woman received epidural anesthesia.
d. Woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. The use of an epidural anesthesia has no correlation with these orders.
- The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (enzyme immunoassay [EIA] 0.8); hematocrit, 30%. How should the nurse best interpret these data?
a. Rubella vaccine should be administered.
b. Blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of childbirth.
d. Kleihauer-Betke test should be performed.
ANS: A
This client’s rubella titer indicates that she is not immune and needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has an Rh-negative status and the infant has an Rh-positive status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. However, the data provided do not indicate a need for performing this test.
- A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?
a. Run warm water on her breasts during a shower.
b. Apply ice to the breasts for comfort.
c. Express small amounts of milk from the breasts to relieve the pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate intervention for treating engorgement in a mother who is bottle feeding. The ice packs should be applied for 15 minutes on and 45 minutes off to avoid rebound engorgement. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should continuously wear a well-fitted support bra or breast binder for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.
- 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. What is the nurse’s most appropriate response?
a. “Didn’t you like your lunch?”
b. “Does your physician know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”
ANS: D
Offering to warm the food shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. Asking the woman to identify her food does not show cultural sensitivity.
- A primiparous woman is to be discharged from the hospital the following day with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?
a. The woman is disinterested in learning about infant care.
b. The woman continues to hold and cuddle her infant after she has fed her.
c. The woman reads a magazine while her infant sleeps.
d. The woman changes her infant’s diaper and then shows the nurse the contents of the diaper.
ANS: A
The client should be excited, happy, and interested or involved in infant care. A woman who is sad, tearful, or disinterested in caring for her infant may be exhibiting signs of depression or postpartum blues and may require further intervention. Holding and cuddling her infant after feeding is an appropriate parent-infant interaction. Taking time for herself while the infant is sleeping is an appropriate maternal action. Showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant’s elimination patterns.
- The trend in the United States is for women to remain hospitalized no longer than 1 or 2 days after giving birth. Which scenario is not a contributor to this model of care?
a. Wellness orientation model of care rather than a sick-care model
b. Desire to reduce health care costs
c. Consumer demand for fewer medical interventions and more family-focused experiences
d. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information
ANS: D
Nursing time and care are in demand as much as ever; the nurse simply has to do things more quickly. A wellness orientation model of care seems to focus on getting clients out the door sooner. In most cases, less hospitalization results in lower costs. People believe that the family gives more nurturing care than the institution.
- 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. What is the correct interpretation of this legislation?
a. 24; 72
b. 24; 96
c. 48; 96
d. 48; 120
ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge. A client may be discharged either 24 hours after a vaginal birth or 72 hours after a cesarean birth if she is stable and her provider is in agreement. A client is unlikely to remain in the hospital for 120 hours after a cesarean birth unless complications have developed.
- 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. What goal is the nurse attempting to achieve by performing this practice?
a. To improve the accuracy of blood loss estimation, which usually is a subjective assessment
b. To determine which pad is best
c. To demonstrate that other nurses usually underestimate blood loss
d. To reveal to the nurse supervisor that one of them needs some time off
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss; anything done to help in the assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. Instead of determining which pad is best, the nurse is more likely noting saturation volumes and soaking appearances to improve the accuracy of estimated blood loss. Nurses usually overestimate blood loss. Soaking perineal pads and writing down the results does not indicate the need for time off of work.
- Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman spontaneously empty her bladder as soon as possible. If all else fails, what tactic might the nurse use?
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 analgesic agents
d. Inserting a sterile catheter
ANS: D
Invasive procedures are usually the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried first. The oil of peppermint releases vapors that may relax the necessary muscles. It, too, is easy, noninvasive, and should be tried early on. If the woman is anticipating pain from voiding, then pain medications may be helpful. Other nonmedical means should be tried first, but medications still come before the insertion of a catheter.
- What information should the nurse understand fully regarding rubella and Rh status?
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 at least 1 month after vaccination.
c. Rh immunoglobulin is safely administered intravenously because it cannot harm a nursing infant.
d. Rh immunoglobulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
ANS: B
Women should understand that they must practice contraception for at least 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immunoglobulin is administered intramuscular (IM); it should never be administered to an infant. Rh immunoglobulin suppresses the immune system and therefore might thwart the rubella vaccination.
- A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. Which response by the client alerts the nurse that psychosocial outcomes have not been met?
a. The woman excessively discusses her labor and birth experience.
b. The woman feels that her baby is more attractive and clever than any others.
c. The woman has not given the baby a name.
d. The woman has a partner or family members who react very positively about the baby.
ANS: C
If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include a refusal to hold or feed the baby, a lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty is unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis might be Impaired parenting, related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well finds her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The client might voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system helps reduce anxiety related to her new role as a mother.
- Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination?
a. 2 weeks of age
b. 7 to 10 days after childbirth
c. 4 to 5 days after hospital discharge
d. 48 to 72 hours after hospital discharge
ANS: D
Breastfeeding infants are routinely seen by the pediatric health care provider clinic within 3 to 5 days after birth or 48 to 72 hours after hospital discharge and again at 2 weeks of age. Formula-feeding infants may be seen for the first time at 2 weeks of age.
- 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. What is the nurse’s highest priority at this time?
a. Beginning an intravenous (IV) infusion of Ringer’s lactate solution
b. Assessing the woman’s vital signs
c. Calling the woman’s primary health care provider
d. Massaging the woman’s fundus
ANS: D
The nurse should first assess the uterus for atony by massaging the woman’s fundus. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.
- In many hospitals, new mothers are routinely presented with gift bags containing samples of infant formula. This practice is inconsistent with what?
a. Baby Friendly Hospital Initiative
b. Promotion of longer periods of breastfeeding
c. Perception of being supportive to both bottle feeding and breastfeeding mothers
d. Association with earlier cessation of breastfeeding
ANS: A
Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with early cessation of breastfeeding. Baby Friendly USA prohibits the distribution of any gift bags or formula to new mothers.
- When should discharge instruction, or the teaching plan that tells the woman what she needs to know to care for herself and her newborn, officially begin?
a. At the time of admission to the nurse’s unit
b. When the infant is presented to the mother at birth
c. During the first visit with the physician in the unit
d. When the take-home information packet is given to the couple
ANS: A
Discharge planning, the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.
