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Flashcards in Chapter 21 Deck (35):

1. 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.

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.


2. 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.

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.


3. 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.

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.


4. 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.”

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.


5. 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.

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.


6. 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

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.


7. 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

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.


8. 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

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.


9. 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

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.


10. 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.

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.


11. 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.

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.


12. 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

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.


13. 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

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.


14. 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

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.


15. 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

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.


16. Postpartum overdistention of the bladder and urinary retention can lead to which complications?
a. Postpartum hemorrhage and eclampsia
b. Fever and increased blood pressure
c. Postpartum hemorrhage and urinary tract infection
d. Urinary tract infection and uterine rupture

Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. No correlation exists between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.


17. Rho immune globulin will be ordered postpartum if which situation occurs?
a. Mother Rh–, baby Rh+
b. Mother Rh–, baby Rh–
c. Mother Rh+, baby Rh+
d. Mother Rh+, baby Rh–

An Rh– mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh– the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh– blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not in the infant’s.


18. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus?
a. Notify the physician of an impending hemorrhage.
b. Assess the blood pressure and pulse.
c. Evaluate the lochia.
d. Assist the client in emptying her bladder.

Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. Evaluating blood pressure, pulse, and lochia is important if the bleeding continues; however, the focus at this point is to assist the client in emptying her bladder.


19. When caring for a newly delivered woman, what is the best measure to prevent abdominal distention after a cesarean birth?
a. Rectal suppositories
b. Early and frequent ambulation
c. Tightening and relaxing abdominal muscles
d. Carbonated beverages

Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.


1. Many new mothers experience some type of nipple pain during the first weeks of initiating breastfeeding. Should this pain be severe or persistent, it may discourage or inhibit breastfeeding altogether. Which factors might contribute to this pain? (Select all that apply.)
a. Improper feeding position
b. Large-for-gestational age infant
c. Fair skin
d. Progesterone deficiency
e. Flat or retracted nipples

ANS: A, C, E
Nipple lesions may manifest as chapped, cracked, bleeding, sore, erythematous, edematous, or blistered nipples. Factors that contribute to nipple pain include improper positioning or a failure to break suction before removing the baby from the breast. Flat or retracted nipples along with the use of nipple shields, breast shells, or plastic breast pads also contribute to nipple pain. Women with fair skin are more likely to develop sore and cracked nipples. Preventing nipple soreness is preferable to treating soreness after it appears. Vigorous feeding may be a contributing factor, which may be the case with any size infant, not just infants who are large for gestational age. Estrogen or dietary deficiencies can contribute to nipple soreness.


2. Which practices contribute to the prevention of postpartum infection? (Select all that apply.)
a. Not allowing the mother to walk barefoot at the hospital
b. Educating the client to wipe from back to front after voiding
c. Having staff members with conditions such as strep throat, conjunctivitis, and diarrhea stay home
d. Instructing the mother to change her perineal pad from front to back each time she voids or defecates
e. Not permitting visitors with cough or colds to enter the postpartum unit

ANS: A, C, D
Proper perineal care helps prevent infection and aids in the healing process. Educating the woman to wipe from front to back (urethra to anus) after voiding or defecating is a simple first step. Walking barefoot and getting back into bed can contaminate the linens. Clients should wear shoes or slippers. Staff members with infections need to stay home until they are no longer contagious. The client should also wash her hands before and after these functions. Visitors with any signs of illness should not be allowed entry to the postpartum unit.


3. Which physiologic factors are reliable indicators of impending shock from postpartum hemorrhage? (Select all that apply.)
a. Respirations
b. Skin condition
c. Blood pressure
d. Level of consciousness
e. Urinary output

ANS: A, B, D, E
Blood pressure is not a reliable indicator; several more sensitive signs are available. Blood pressure does not drop until 30% to 40% of blood volume is lost. Respirations, pulse, skin condition, urinary output, and level of consciousness are more sensitive means of identifying hypovolemic shock.


4. If a woman is at risk for thrombus and is not ready to ambulate, which nursing intervention would the nurse use? (Select all that apply.)
a. Putting her in antiembolic stockings (thromboembolic deterrent [TED] hose) and/or sequential compression device (SCD) boots
b. Having her flex, extend, and rotate her feet, ankles, and legs
c. Having her sit in a chair
d. Immediately notifying the physician if a positive Homans sign occurs
e. Promoting bed rest

ANS: A, B, D
Sitting immobile in a chair does not help; bed exercise and prophylactic footwear might. TED hose and SCD boots are recommended. The client should be encouraged to ambulate with assistance, not remain in bed. Bed exercises are useful. A positive Homans sign (calf muscle pain or warmth, redness, tenderness) requires the physician’s immediate attention.


5. Postpartum fatigue (PPF) is more than just feeling tired. It is a complex phenomenon affected by physiologic, psychologic, and situational variables. Which factors contribute to this phenomenon? (Select all that apply.)
a. Precipitous labor
b. Hospital routines
c. Bottle feeding
d. Anemia
e. Excitement

ANS: B, D, E
Physical fatigue and exhaustion are often associated with a long labor or cesarean birth, hospital routines, breastfeeding, and infant care. PPF is also attributed to anemia, infection, or thyroid dysfunction. The excitement and exhilaration of delivering a new infant along with well-intentioned visitors may make rest difficult.


6. Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? (Select all that apply.)
a. The mother should check the photo identification (ID) of any person who comes to her room.
b. The baby should be carried in the parent’s arms from the room to the nursery.
c. Because of infant security systems, the baby can be left unattended in the client’s room.
d. Parents should use caution when posting photographs of their infant on the Internet.
e. The mom should request that a second staff member verify the identity of any questionable person.

ANS: A, D, E
Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units, staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule, the baby is never carried in arms between the mother’s room and the nursery, but rather the infant is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photographs of their new baby on the Internet and on other public forums.


Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:
a. Uses soap and warm water to wash the vulva and perineum.
b. Washes from symphysis pubis back to the episiotomy.
c. Changes her perineal pad every 2 to 3 hours.
d. Uses the peribottle to rinse upward into her vagina.

Ans: D
The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash the vulva and perineum is an appropriate measure. Washing from the symphysis pubis back to the episiotomy is an appropriate infection control measure. The client should be instructed to change her perineal pad every 2 to 3 hours.


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. The nurse’s first action is to:
a. Begin an IV infusion of Ringer’s lactate solution.
b. Assess the woman’s vital signs.
c.Call the woman’s primary health care provider.
d. Massage the woman’s fundus.

Ans: D
The nurse should assess the uterus for atony. 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 should be notified after the nurse completes assessment of the woman.


Excessive blood loss after childbirth can have several causes; however, the most common is:
a. Vaginal or vulvar hematomas.
b. Unrepaired lacerations of the vagina or cervix.
c. Failure of the uterine muscle to contract firmly.
d. Retained placental fragments.

Ans: C
Although vaginal or vulvar hematomas, unrepaired lacerations, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention.


Baby-friendly hospitals mandate that infants be put to breast within the first _______ after birth.
a. 1 hour
b. 30 minutes
c. 2 hours
d. 4 hours

Ans: A
Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the BFHI mandates 1 hour. Four hours is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.


Which finding would be a source of concern if noted during the assessment of a woman at 12 hours postpartum?
a. Postural hypotension
b.Temperature of 38° C
c. Bradycardia—pulse rate of 55 beats/min
d. Pain in left calf with dorsiflexion of left foot

Ans: D
These findings indicate presence of Homans sign, are suggestive of thrombophlebitis, and should be investigated. Postural hypotension is an expected finding related to circulatory changes after birth. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. A temperature of 38° C in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake.


The nurse examines a woman 1 hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action is to:
a. Place her on a bedpan to empty her bladder
b. Massage her fundus
c. Call the physician
d. Administer methylergonovine (Methergine), 0.2 mg IM, which has been ordered prn

Ans: B
A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm.
The physician can be called or methylergonovine administered after the fundus massage, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder, so having the woman urinate will not alleviate the problem.


Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse suspects:
a. Bladder distention
b. Uterine atony
c. Constipation
d. Hematoma formation

Ans: D
Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation. Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time.


Nurses are getting ready for bedside reporting at change of shift. A benefit of this type of change of shift report is that:
a. Information is transparent so that the nurses and patients are aware of all pertinent data and delivery of care aspects.
b. Patients can ask questions of the nurses during change of shift report so that they can better direct the delivery of their health care.
c. Nurses are able to visualize their patient’s directly at the time of report leading to better patient satisfaction.
d. There is no need for additional information to be exchanged as the patient is right there to answer questions and voice concerns.

Ans: C
Using a bedside report technique helps the nurse directly visualize the patient in question so as to improve his/her understanding of each patient’s clinical situation. The transparency of information is not a benefit of bedside reporting. A bedside report is a change-of-shift report between nurses involved in the delivery of health care to a patient and/or group of patients; it is not mediated by patient questioning. Also, it is not all inclusive because patient care continues and is evolving over the course of the patient’s hospitalization. Thus, additional information will be needed.


Which test result would provide evidence of fetal blood in maternal circulation?
a. Positive Fern test result
b. Positive Coombs test result
c. Positive Kleihauer-Betke test result
d. Negative Coombs test result

Ans: C
A Kleihauer-Betke test determines the presence of fetal blood in maternal circulation.
A positive fern test result would indicate the presence of amniotic fluid, noting that membranes had ruptured. A positive Coombs test result would indicate that the mother has Rh antibodies, and a negative result would indicate no presence of Rh antibodies.


The nurse is observing a postpartum patient who has been bleeding excessively during the first hour, saturating multiple pads. Which interventions would the nurse anticipate that the physician would order? (Select all that apply.)
a. Document findings in the health care record
b. Decrease flow rate for intravenous fluid administration
c. Administer oxygen via nonrebreather mask @ 10 L/minute
d. Insert a secondary intravenous line access
e. Type & screen for 2 units of blood

Ans: C, D
Administration of oxygen @ 10L/minute via nonrebreather mask would be an anticipated order, as would insertion of a secondary line access for administration of fluids, blood, and/or medications. Although documentation of findings in a health care record is required, this is part of the nursing role and does not require an order by the physician. With regard to the presence of hypovolemic shock, intravenous fluids would be increased and maintained. The flow rate would not typically be decreased unless there was another comorbidity leading to potential fluid overload. Type & Screen would not be an anticipated order because no blood would be held for use; rather a Type & Cross order would be anticipated.