Flashcards in Exam 4 Resource questions Deck (76)
Postbirth uterine/vaginal discharge, called lochia:
A. Is similar to a Light menstrual period for the first 6-12 hours
B. Is usually greater after cesarean births
C. Will usually decrease with ambulation
D. If a smell is detected then an infection is present
If a smell is detected then an infection is present. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An odor indicates an infection.
A woman gave birth to a 7-lb, 3-ounce 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 consequence likely to occur from bladder distention is:
A. Urinary tract infection
B. Excessive uterine bleeding
C. A ruptured bladder
D. Bladder wall atony
A urinary tract infection may result from overdistention of the bladder, but is not the most serious consequence. 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 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.
Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:
A. Return to prepregnant weight is usually achieved by the end of the after birth period
B. Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3-lb weight loss
C. The expected weight loss immediately after birth averages about 11 to 13 lbs
D. Lactation will inhibit weight loss since caloric intake must increase to support milk production
Prepregnant weight is usually achieved by 2-3 months after birth, not within the 6-week after birth period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 lbs. The expected weight loss immediately following delivery is 11 to 13 lbs, followed by a gradual decrease and a return to prepregnancy weight in 2 to 3 months. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.
After completing a after birth assessment on woman who delivered 36 hours ago, the nurse should report which assessment findings to the health care provider? (SATA)
A. Temperature 100.0* F
B. Pulse 110 beats/min
C. Respiratory rate 12 breaths/min
D. Blood pressure 125/78
E. Temperature 38* C
Answer: B, D
During the first 24 hours after birth, temperature may increase to 38* C (100.4* F). As the observation time is beyond that of the first 24 hours, maternal fever should be reported as this would not be considered a normal finding pulse, remains elevated for the first hour or so after childbirth. It the begins to decrease to a nonpregnant rate. A rapid pulse may indicate hypovolemia. Respiratory rate is normal. Blood pressure is slightly if at all after birth
Which description of after birth restoration of healing times is accurate?
A. The cervix shortens, becomes firm, and returns to form within a month after birth
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
As part of the after birth assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day after birth. Expected findings include: SATA
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
E. Small amount of clear, yellow fluid expressed
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 milk comes in 72-96 hours after birth. Engorgement occurs at day 3 or 4 after birth. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during the first 24 hours.
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 empting of the bladder, bladder tone is usually restored 2 to 3 weeks after childbirth.
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. Excess fluid loss through other means occurs as well. Bladder tone usually is restored 5-7 days after childbirth.
Which 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.
A newly delivered woman following childbirth can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. This is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
With regard to afterbirth pains, nurses should be aware that these pains are:
A. Caused by mild, continual contractions for the duration of the after birth 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.
The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations that persist through the first part of the after birth period. After birth pains are more common in multiparpous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus. Breastfeeding intensifies afterbirth pain because it stimulates contractions.
The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:
A. Wear a snug, supportive bra.
B. Allow warm water to soothe the breasts during a shower
C. Express mill from breasts occasionally to relieve discomfort
D. Place absorbent pads with plastic liners into her bra to absorb leakage
A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
1. Baby-Friendly hospitals mandate that infants be put to breast within what time frame after birth?
A. 1 Hour
B. 30 minutes
C. 2 hours
D. 4 hours
1. Baby-Friendly hospitals mandate that infants be put to breast within what time frame after birth?
A. 1 Hour
B. 30 minutes
C. 2 hours
D. 4 hours
2. A after birth woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? SATA
A. Do not perform Kegel exercises to decrease pelvic floor muscle healing time.
B. B. If breastfeeding, sexual interest may be delayed
C. C. fatigue may affect interest in sexual activity
D. D. Sexual activity can usually be safely resumed 5 to 6 weeks after birth
E. E. Water-soluble lubrication may increase comfort
F. F. The female-on-top position may be more comfortable than other positions.
Answer: C, D, E, F
Kegel exercises are usually recommended and can strengthen the pubococcygeal muscle. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers. The amount of psychologic energy expended by the mother in child care activities may lead to fatigue and decreased interest in sexual activity. Most women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel or jelly is recommended for lubrication. A position in which the mother has control of the depth of insertion of the penis, such as the female-on-top position may be more comfortable than other positions
3. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, two fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:
A. Massage the fundus
B. B. Administer methergine, 0.2 mg PO, that has been ordered prn
C. C. Assist the woman to empty her bladder
D. D. Recognize this as an expected finding during the first 24 hours following birth.
A firm fundus should not be massaged since massage could over stimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.
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 distening
B. Uterine atony
D. 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. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.
Which measure would be least effective in preventing after birth hemorrhage?
A. Administer methergine, 0.2 mg every 6 hours for four doses, as ordered
B. Encourage the woman to void every 2 hours
C. Massage the fundus every hour for the first 24 hours following birth
D. Teach the woman the importance of rest and nutrition to enhance healing
Administration of Methergine can help prevent after birth hemorrhage. Voiding frequently can help the uterus contract, thus preventing after birth hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.
Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours’ after birth? SATA
A. Postural hypotension
B. Temperature of 100.4* F
C. Bradycardia – pulse rate of 55 beats/min
D. Pain in left calf with dorsiflexion of left foot
E. Lochia rubra with foul odor
Answer: D & E
Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4* F in the first 24 hours most like indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected fining in the initial after birth period. These findings indicate a positive Homans’ sign and are suggestive of thrombophlebitis and should be investigated. Lochia with odor may indicate infection.
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 would be to:
A. Place her on a bedpan to empty her bladder
B. Massage her fundus
C. Call the physician
D. Administer Methergine, 0.2 mg IM, which has been ordered prn
There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. 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 would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.
Perineal care is an important infection control measure. When evaluating a after birth 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 the 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
These are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still open cervix.
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
Although vaginal or vulvar hematomas are possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure is the most common cause. Uterine atony can be best thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine atony is the most common cause.
On examining a woman who gave brith 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 intravenous (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
The nurse may begin an intravenous (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 an 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. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.
1. Four hours after a difficult labor and birth, a primiparous woman refused to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
a. Tell the woman she can rest after she feeds her baby
b. Recognize this as a behavior of the taking-hold stage
c. Record the behavior as ineffective maternal-newborn attachment
d. Take the baby back to the nursery, reassuring the woman that rest is a priority at this time
The woman should not be told what to do and needs to care for her own well-being. The taking-hold phase occurs about 1 week after birth. Because the woman needs to rest does not indicate ineffective maternal-newborn attachment. The behavior is described is typical of this phase and not a reflection of ineffective attachment unless it persists. Mothers need to reestablish their own well-being to effectively care for their baby.
2. The maternity nurse promoting parental-infant attachment should incorporate which appropriate cultural beliefs into the plan of care? SATA
a. Asian mothers are encouraged to return to work as soon as possible
b. Jordanian mothers have a 40-day lying-in after birth
c. Japanese mothers rest for the first 2 months after childbirth
d. Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake
e. Encourage Vietnamese mothers to cuddle with their newborn
Answer: B, C
Asian mothers must remain at home with the baby up to 30 days after birth and are not supposed to engage in household chores, including care of the baby. Jordanian mothers have a 40-day lying-in after birth, during which their mothers or sisters care for the baby. Japanese mothers rest for the first 2 months after childbirth. Hispanic practice involves many food restrictions after childbirth, such as avoiding fish, pork, and citrus foods. Vietnamese mothers may give minimal care to their babies and refuse to cuddle or further interact with the baby to ward off “evil” spirits.
3. Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care?
a. PPD symptoms are consistently severe
b. This syndrome affects only new mothers
c. PPD can easily go undetected
d. Only mental health professionals should teach new parents about this condition.
Postpartum depression symptoms range from mild to severe, with women having good days and bad days. Screening should be done for mothers and fathers. PPD may also occur in new fathers. PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. The nurse should include information on PPD and how to differentiate this from the baby blues for all clients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if they occur.
4. The nurse observes several interactions between a after birth woman and her son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?
a. Talks and coos to her son
b. Seldom makes eye contact with her son
c. Cuddles her son close to her
d. Tells visitors how well her son is feeding
Talking and cooing to her son is a normal infant-parent interaction. The woman should be encouraged to hold her infant in the en face position and make eye contact with him. Cuddling is a normal infant-parent interaction. Sharing her son’s success at feeding is a normal infant-parent interaction.
5. Parents can facilitate the adjustment of their other children to a new baby by:
a. Having the children choose or make a gift to give to the new baby on its arrival home
b. Emphasizing activities that keep the new baby and other children together
c. Having the mother carry the new baby into the home so she can show him or her to the other children
d. Reducing stress on other children by limiting their involvement in the care of the new baby
Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them
6. In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior?
a. The parents have difficulty naming the infant
b. The parents hover around the infant, direction attention to and pointing at the infant
c. The parents make no effort to interpret the actions or needs of the infant
d. The parents do not move from fingertip touch to palmar contact and holding.
Reluctance to name the baby is an inhibiting behavior. Hovering over the infant, as well as obviously paying attention to the baby, is a facilitating behavior. Failure to interpret the actions and needs of the infant is an inhibiting behavior. Lack of fingertip, palmar touch, and holding represents an inhibiting behavior.
7. When working with parents who have some form of sensory impairment, nurses should consider which information when writing a plan of care? SATA
a. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals
b. Visually impaired mothers cannot overcome the infant’s need for eye-to-eye contact
c. The best approach for the nurse is to assess the parents’ capabilities rather than focusing on their disabilities
d. Technologic advances, including the internet, can provide deaf parents with a full range of parenting activities and information
e. Childbirth education and other materials are available in Braille
Answers: A. C. D. E
The skepticism, open or hidden, of health care professionals throws up an additional and unneeded hurdle for the parents. Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. After the parents’ capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that paly to their strengths. The internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child’s cry. Sign language is acquired readily by young children. Childbirth education and other materials are available in Braille.
8. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should:
a. Foster an active role in the baby’s care
b. Provide time for the mother to reflect on the events of and her behavior during childbirth
c. Recognize the woman’s limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now
d. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs
Once the mother’s needs are met, she would be more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition.
9. When making a visit to the home of a after birth woman 1 week after birth, the nurse should recognize that the woman would characteristically
a. Express a strong need to review events and her behavior during the process of labor and birth
b. Exhibit a reduced attention span, limiting readiness to learn
c. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn
d. Have reestablished her role as a spouse/partner
This is characteristic of the taking-in stage, which lasts for the first few days after birth. This is characteristic of the taking-in stage , which lasts for the first few days after birth. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth. This reflects the letting-go stage, which indicates that psychosocial recovery is complete.