Chapter 20

Question 1

1. A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman’s fundus?
   a. 1 centimeter above the umbilicus
   b. 2 centimeters below the umbilicus
   c. Midway between the umbilicus and the symphysis pubis
   d. Nonpalpable abdominally

Answer 1

ANS: A
The fundus descends approximately 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus is normally halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.

Question 2

2. What are the most common causes for subinvolution of the uterus?
   a. Postpartum hemorrhage and infection
   b. Multiple gestation and postpartum hemorrhage
   c. Uterine tetany and overproduction of oxytocin
   d. Retained placental fragments and infection

Answer 2

ANS: D
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are retained placental fragments and infection. Subinvolution may be caused by an infection and result in hemorrhage. Multiple gestations may cause uterine atony, resulting in postpartum hemorrhaging. Uterine tetany and overproduction of oxytocin do not cause subinvolution.

Question 3

3. Which client is most likely to experience strong and uncomfortable afterpains?
   a. A woman who experienced oligohydramnios
   b. A woman who is a gravida 4, para 4-0-0-4
   c. A woman who is bottle-feeding her infant
   d. A woman whose infant weighed 5 pounds, 3 ounces

Answer 3

ANS: B
Afterpains are more common in multiparous women. In a woman who experienced polyhydramnios, afterpains are more noticeable because the uterus was greatly distended. Breastfeeding may cause the afterpains to intensify. In a woman who delivered a large infant, afterpains are more noticeable because the uterus was greatly distended.

Question 4

4. A woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when evaluating this client?
   a. Lochia rubra
   b. Lochia sangra
   c. Lochia alba
   d. Lochia serosa

Answer 4

ANS: D
Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. Lochia sangra is not a real term. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.

Question 5

5. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman?
   a. Estrogen
   b. Progesterone
   c. Prolactin
   d. Human placental lactogen

Answer 5

ANS: C
Prolactin levels in the blood progressively increase throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. Estrogen levels decrease significantly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. Progesterone levels decrease significantly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. Human placental lactogen levels dramatically decrease after expulsion of the placenta.

Question 6

6. Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. Which physiologic alteration is the cause for the diaphoresis and diuresis that this client is experiencing?
   a. Elevated temperature caused by postpartum infection
   b. Increased basal metabolic rate after giving birth
   c. Loss of increased blood volume associated with pregnancy
   d. Increased venous pressure in the lower extremities

Answer 6

ANS: C
Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. An elevated temperature causes chills and possibly dehydration, not diaphoresis and diuresis. Diaphoresis and diuresis are sometimes referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities.

Question 7

7. Which term best describes the interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state?
   a. Involutionary period because of what happens to the uterus
   b. Lochia period because of the nature of the vaginal discharge
   c. Mini-tri period because it lasts only 3 to 6 weeks
   d. Puerperium, or fourth trimester of pregnancy

Answer 7

ANS: D
The puerperium, also called the fourth trimester or the postpartum period of pregnancy, is the final period of pregnancy and lasts approximately 3 to 6 weeks. Involution marks the end of the puerperium. Lochia refers to the various vaginal discharges during the puerperium.

Question 8

8. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the woman’s vital signs, which finding would be of greatest concern to the nurse?
   a. Temperature 37.9° C, heart rate 120 beats per minute (bpm), respirations 20 breaths per minute, and blood pressure 90/50 mm Hg
   b. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg
   c. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg
   d. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg

Answer 8

ANS: A
An EBL of 1500 ml with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. Temperature 37.4° C, heart rate 88 bpm, respirations 36 breaths per minute, and blood pressure 126/68 mm Hg are normal vital signs except for an increased respiratory rate, which may be secondary to pain from the birth. Temperature 38° C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressure 110/80 mm Hg are normal vital signs except for the temperature, which may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor. Temperature 36.8° C, heart rate 60 bpm, respirations 18 breaths per minute, and blood pressure 140/90 mm Hg are normal vital signs, although the blood pressure is slightly elevated, which may be attributable to the use of oxytocic medications.

Question 9

9. A client is concerned that her breasts are engorged and uncomfortable. What is the nurse’s explanation for this physiologic change?
   a. Overproduction of colostrum
   b. Accumulation of milk in the lactiferous ducts and glands
   c. Hyperplasia of mammary tissue
   d. Congestion of veins and lymphatic vessels

Answer 9

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatic vessels. An overproduction of colostrum, an accumulation of milk in the lactiferous ducts and glands, and hyperplasia of mammary tissue do not cause breast engorgement.

Question 10

10. After delivery, excess hypertrophied tissue in the uterus undergoes a period of self-destruction. What is the correct term for this process?
    a. Autolysis
    b. Subinvolution
    c. Afterpains
    d. Diastasis

Answer 10

ANS: A
Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the uterus to return to a nonpregnant state. Afterpains are caused by uterine cramps 2 to 3 days after birth. Diastasis refers to the separation of muscles.

Question 11

11. Which statement regarding the postpartum uterus is correct?
    a. At the end of the third stage of labor, the postpartum uterus weighs approximately 500 g.
    b. After 2 weeks postpartum, it should be abdominally nonpalpable.
    c. After 2 weeks postpartum, it weighs 100 g.
    d. Postpartum uterus returns to its original (prepregnancy) size by 6 weeks postpartum.

Answer 11

ANS: B
The uterus does not return to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. After 2 weeks postpartum, the uterus weighs approximately 350 g. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.

Question 12

12. A client asks the nurse when her ovaries will begin working again. Which explanation by the nurse is most accurate?
    a. Almost 75% of women who do not breastfeed resume menstruating within 1 month after birth.
    b. Ovulation occurs slightly earlier for breastfeeding women.
    c. Because of menstruation and ovulation schedules, contraception considerations can be postponed until after the puerperium.
    d. The first menstrual flow after childbirth usually is heavier than normal.

Answer 12

ANS: D
The first flow is heavier, but within three or four cycles, the flow is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns in approximately 3 months. Women who are breastfeeding take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium.

Question 13

13. The nurse should be cognizant of which postpartum physiologic alteration?
    a. Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal values within a few hours of childbirth.
    b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth.
    c. Lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections.
    d. Hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

Answer 13

ANS: B
Respirations should decrease to within the woman’s normal prepregnancy range by 6 to 8 weeks after childbirth. Stroke volume increases and cardiac output remains high for a couple of days. However, the heart rate and blood pressure quickly return to normal. Leukocytosis increases 10 to 12 days after childbirth, which can obscure the diagnosis of acute infections, producing false-negative test results. The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth.

Question 14

14. Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?
    a. Varicosities of the legs
    b. Carpal tunnel syndrome
    c. Periodic numbness and tingling of the fingers
    d. Headaches

Answer 14

ANS: D
Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after childbirth unless carrying the baby aggravates the condition.

Question 15

15. Several delivery changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?
    a. Nail brittleness
    b. Darker pigmentation of the areolae and linea nigra
    c. Striae gravidarum on the breasts, abdomen, and thighs
    d. Spider nevi

Answer 15

ANS: A
The nails return to their prepregnancy consistency and strength. Some women have permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum (stretch marks) usually do not completely disappear. For some women, spider nevi persist indefinitely.

Question 16

16. Pelvic floor exercises, also known as Kegel exercises, will help to strengthen the perineal muscles and encourage healing after childbirth. The nurse requests the client to repeat back instructions for this exercise. Which response by the client indicates successful learning?
    a. “I contract my thighs, buttocks, and abdomen.”
    b. “I perform 10 of these exercises every day.”
    c. “I stand while practicing this new exercise routine.”
    d. “I pretend that I am trying to stop the flow of urine in midstream.”

Answer 16

ANS: D
The woman can pretend that she is attempting to stop the passing of gas or the flow of urine midstream, which will replicate the sensation of the muscles drawing upward and inward. Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be performed 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine with the knees bent. A secondary position is on the hands and knees.

Question 17

17. Which statement by a newly delivered woman indicates that she knows what to expect regarding her menstrual activity after childbirth?
    a. “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.”
    b. “My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles.”
    c. “I will not have a menstrual cycle for 6 months after childbirth.”
    d. “My first menstrual cycle will be heavier than normal and then will be light for several months after.”

Answer 17

ANS: B
“My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles” is an accurate statement and indicates her understanding of her expected menstrual activity. She can expect her first menstrual cycle to be heavier than normal, which occurs by 3 months after childbirth, and the volume of her subsequent cycles will return to prepregnant levels within three to four cycles.

Question 18

18. The nurse is providing instruction to the newly delivered client regarding postbirth uterine and vaginal discharge, called lochia. Which statement is the most appropriate?
    a. Lochia is similar to a light menstrual period for the first 6 to 12 hours.
    b. It is usually greater after cesarean births.
    c. Lochia will usually decrease with ambulation and breastfeeding.
    d. It should smell like normal menstrual flow unless an infection is present.

Answer 18

ANS: D
An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births and usually increases with ambulation and breastfeeding.

Question 19

19. Which description of postpartum restoration or healing times is accurate?
    a. The cervix shortens, becomes firm, and returns to form within a month postpartum.
    b. Vaginal rugae reappear by 3 weeks postpartum.
    c. Most episiotomies heal within a week.
    d. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

Answer 19

ANS: B
Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

Question 20

20. Which statement, related to the reconditioning of the urinary system after childbirth, should the nurse understand?
    a. Kidney function returns to normal a few days after birth.
    b. Diastasis recti abdominis is a common condition that alters the voiding reflex.
    c. Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium.
    d. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth.

Answer 20

ANS: C
Excess fluid loss through other means besides perspiration and increased urinary output occurs as well. Kidney function usually returns to normal in approximately 1 month. Diastasis recti abdominis is the separation of muscles in the abdominal wall and has no effect on the voiding reflex. Bladder tone is usually restored 5 to 7 days after childbirth.

Question 21

21. What should the nurse’s next action be if the client’s white blood cell (WBC) count is 25,000/mm3 on her second postpartum day?
    a. Immediately inform the physician.
    b. Have the laboratory draw blood for reanalysis.
    c. Recognize that this count is an acceptable range at this point postpartum.
    d. Immediately begin antibiotic therapy.

Answer 21

ANS: C
During the first 10 to 12 days after childbirth, WBC values between 20,000 and 25,000/mm3 are common. Because a WBC count of 25,000/mm3 on her second postpartum day is normal, alerting the physician is not warranted nor is reassessment or antibiotics needed; the WBC count is not elevated.

Question 22

22. Which documentation on a woman’s chart on postpartum day 14 indicates a normal involution process?
    a. Moderate bright red lochial flow
    b. Breasts firm and tender
    c. Fundus below the symphysis and nonpalpable
    d. Episiotomy slightly red and puffy

Answer 22

ANS: C
The fundus descends 1 cm per day; consequently, it is no longer palpable by postpartum day 14. The lochia should be changed by this day to serosa. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage.

Question 23

1. The breast-feeding mother should be taught to expect which changes to the condition of the breasts? (Select all that apply.)
   a. Breast tenderness is likely to persist for approximately 1 week after the start of lactation.
   b. As lactation is established, a mass may form that can be distinguished from cancer by its positional shift from day to day.
   c. In nonlactating mothers, colostrum is present for the first few days after childbirth.
   d. If suckling is never begun or is discontinued, then lactation ceases within a few days to a week.
   e. Little change occurs to the breasts in the first 48 hours.

Answer 23

ANS: B, C, D
Breasts become fuller and heavier as colostrum transitions to milk; this fullness should last 72 to 96 hours. The movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether or not the mother breastfeeds. A mother who does not want to breastfeed should also avoid stimulating her nipples. Little change to the breasts occurs in the first 24 hours of childbirth.

Question 24

2. Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. What amount of blood loss does the postpartum nurse anticipate? (Select all that apply.)
   a. 100 ml
   b. 250 ml or less
   c. 300 to 500 ml
   d. 500 to 1000 ml
   e. 1500 ml or greater

Answer 24

ANS: C, D
The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 ml (10% of blood volume). The typical blood loss for women who gave birth by cesarean is 500 to 1000 ml (15% to 30% of blood volume). During the first few days after childbirth, the plasma volume further decreases as a result of diuresis. Pregnancy-induced hypervolemia (i.e., an increase in blood volume of at least 35%) allows most women to tolerate considerable blood loss during childbirth.

Question 25

The breasts of a woman who is bottle feeding her baby are engorged. The nurse should instruct her to:

a. Wear a snug, supportive bra.
b. Allow warm water to soothe the breasts during a shower.
c. Express milk from breasts occasionally to relieve discomfort.
d. Place absorbent pads with plastic liners into her bra to absorb leakage.

Answer 25

Ans: A
A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Ice packs, fresh cabbage leaves, and mild analgesics may also relieve discomfort. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners would keep the nipples and areola moist, leading to excoriation and cracking.

Question 26

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious likely consequence of bladder distention is:

a. Urinary tract infection.
b. Excessive uterine bleeding.
c. A ruptured bladder.
d. Bladder wall atony.

Answer 26

Ans: B
Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.

Question 27

What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

a. “My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter.”
b. “My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles.”
c. “I will not have a menstrual cycle for 6 months after childbirth.”
d. “My first menstrual cycle will be heavier than normal and then will be light for several months after.”

Answer 27

Ans: B
This is an accurate statement and indicates her understanding of her expected menstrual activity. The woman can expect her first menstrual cycle, which occurs by 3 months after childbirth, to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.

Question 28

With regard to afterbirth pains, nurses should be aware that these pains are:

a. Caused by mild, continual contractions for the duration of the postpartum period.
b. More common in first-time mothers.
c. More noticeable in births in which the uterus was overdistended.
d. Alleviated somewhat when the mother breastfeeds.

Answer 28

Ans: C
A large baby or multiple babies overdistend the uterus. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. Breastfeeding intensifies afterbirth pain because it stimulates contractions.

Question 29

Postbirth uterine/vaginal discharge, called lochia:

a. Is similar to a light menstrual period for the first 6 to 12 hours.
b. Is usually greater after cesarean births.
c. Will usually decrease with ambulation and breastfeeding.
d. Should smell like normal menstrual flow unless an infection is present.

Answer 29

Ans: D
An offensive odor usually indicates an infection. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia is usually seen after cesarean births. It usually increases with ambulation and breastfeeding.

Question 30

Which description of postpartum restoration or healing times is accurate?

a. The cervix shortens, becomes firm, and returns to form within a month postpartum.
b. Rugae reappear within 3 to 4 weeks.
c. Most episiotomies heal within a week.
d. Hemorrhoids usually decrease in size within 2 weeks of childbirth.

Answer 30

Ans: B
Rugae are never again as prominent as in a nulliparous woman. Localized dryness may occur until ovarian function resumes. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

Question 31

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

a. Kidney function returns to normal a few days after birth.
b. Diastasis recti abdominis is a common condition that alters the voiding reflex.
c. Fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium.
d. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth.

Answer 31

Ans: C
Excess fluid loss through other means occurs as well. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Bladder tone usually is restored 5 to 7 days after childbirth.

Question 32

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman 1 day postpartum. An expected finding is:

a. Little if any change.
b. Leakage of milk at let-down.
c. Swollen, warm and tender on palpation.
d. A few blisters and a bruise on each areola.

Answer 32

Ans: A
Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.

Question 33

Which of the following findings would raise concern for the nurse who is monitoring a postpartum patient who had a spontaneous vaginal delivery (SVD) of a 10-lb baby boy?

a. Lochia rubra with minimal clots expressed on fundal massage
b. Fundus midline and firm with nonpalpable bladder
c. Fundus midline and firm with spurts of bright red blood upon fundal massage
d. Patient report of mild to moderate cramping and request for pain medication

Answer 33

Ans: C
Even though the fundus is firm and midline, the fact that spurts of blood are evident on fundal massage may indicate that a tear is present. Further investigation is required as this is considered nonlochial bleeding. Lochia rubra with minimal clots expressed on fundal massage would be considered a normal finding, given that the patient had an SVD of a large infant. Fundus midline and firm with nonpalpable bladder would be considered a normal finding. A report of mild to moderate cramping with a request for pain medication would be considered a normal finding in the postpartum period; the cramping is due to uterine contractions as the uterus returns to its normal prepregnancy status.

Question 34

Which of the following changes are consistent with metabolic function during the postpartum period? (Select all that apply.)

a. Moderate hyperglycemia
b. Increased BMR in the immediate postpartum period
c. Secretion of insulinase
d. Mildly increased T3 and T4 levels for the first several weeks postpartum
e. Decrease in estrogen and cortisol levels

Answer 34

Ans: B, C, E
BMR remains elevated for the first 2 weeks after birth and then returns to prepregnancy levels. Insulinase enzyme reverses the diabetogenic effects of pregnancy, leading to decreased glucose levels in the postpartum period. Decreases in hormones such as estrogen and cortisol are seen during the postpartum period.
Blood sugar levels typically decrease in the postpartum period as a result of the reversal of diabetogenic effects of pregnancy. Thyroid hormones gradually decrease to prepregnant levels in the 4 weeks following delivery.