Chapter 22: Nursing Care of the Family During the Postpartum Period

Question 1

1. What is the most likely cause of postpartum hemorrhage in a multiparous patient (G3T2P0A0L2) who gave birth 4 hours ago to a 4300 g newborn after augmentation of labour with oxytocin?
   a. Retained placental fragments
   b. Unrepaired vaginal lacerations
   c. Uterine atony
   d. Puerperal infection

Answer 1

ANS: C
The most likely cause of postpartum bleeding, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this patient. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours after delivery.

Question 2

2. On examining a patient who gave birth 5 hours ago, the nurse finds that the patient has completely saturated a perineal pad within
   15 minutes. What is the nurse’s initial response?
   a. Begin an intravenous (IV) infusion of Ringer’s lactate solution.
   b. Assess the patient’s vital signs.
   c. Call the patient’s primary health care provider.
   d. Massage the patient’s fundus.

Answer 2

ANS: D
The nurse should assess the uterus for atony. When the uterus is atonic, the fundus should be massaged gently and clots expelled. 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 patient.

Question 3

3. A patient gave birth vaginally to a 4400 g infant yesterday. The primary health care provider has written orders for perineal ice packs, use of a sitz bath TID, and a stool softener. What information is most closely correlated with these orders?
   a. The patient is a G2T2P0A0L2.
   b. The patient had a vacuum-assisted birth.
   c. The patient received epidural anaesthesia.
   d. The patient has had an episiotomy.

Answer 3

ANS: D
These orders are typical interventions for a patient 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. Use of epidural anaesthesia has no correlation with these orders.

Question 4

4. The laboratory results for a postpartum patient are as follows: blood type, A; Rh status, positive; rubella titre, 1:8 (EIA 0.6); hematocrit, 30%. How would the nurse best interpret these data?
   a. Rubella vaccine should be given.
   b. A blood transfusion is necessary.
   c. Rh immune globulin is necessary within 72 hours of birth.
   d. A Kleihauer-Betke test should be performed.

Answer 4

ANS: A
For women who are serologically not immune (titre of 1:8 or enzyme immunoassay level less than 0.8), a subcutaneous injection of rubella vaccine is recommended in the immediate postpartum period. This patient’s rubella titre indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the patient needs a blood transfusion. Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test

Question 5

5. A patient gave birth 48 hours ago to a healthy newborn. They have decided to bottle-feed. During the assessment, a nurse notices that both of the patient’s breasts are swollen, warm, and tender on palpation. Which information should the nurse offer the patient?
   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 pressure.
   d. Wear a loose-fitting bra to prevent nipple irritation.

Answer 5

ANS: B
This patient is experiencing engorgement, which can be treated by using ice packs and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra continuously 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.

Question 6

6. A 25-year-old multiparous patient gave birth to an infant 1 day ago. Today their partner brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the partner asks for help with warming the soup so that his wife can eat it. What is the basis of the nurse’s most appropriate response?
   a. Asking the patient if they did not like the lunch that was served to them.
   b. Checking with the patient that they have obtained permission from their health care provider to consume seaweed soup.
   c. Asking the partner what the soup contains.
   d. Offering to warm the soup up in the microwave for the patient.

Answer 6

ANS: D
By offering to warm the soup in the microwave for the patient the nurse is demonstrating cultural appropriateness to the dietary preferences of the patient and is the basis of the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favourite or culturally appropriate foods to the hospital. Asking the partner what the soup contains does not show cultural sensitivity. Dietary choices in the postpartum period do not need approval from a health care provider. Asking her if they did not like their lunch is not appropriate.

Question 7

7. A primiparous patient is to be discharged from the hospital tomorrow with their newborn. Which behaviour indicates a need for further intervention by the nurse before the patient can be discharged?
   a. The patient leaves the infant on the bed while taking a shower.
   b. The patient continues to hold and cuddle their infant after feeding the newborn.
   c. The patient reads a magazine while the infant sleeps.
   d. The patient changes the infant’s diaper and shows the nurse the contents of the
   diaper.

Answer 7

ANS: A
Leaving an infant on a bed unattended is never acceptable, for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent–infant interactions. Changing the diaper and then 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.

Question 8

8. What would prevent early discharge of a postpartum patient?
   a. Afterpains when breastfeeding
   b. Birth at 38 weeks of gestation
   c. Has voided 130 mL since birth
   d. Episiotomy that shows slight redness and edema, is dry and approximated

Answer 8

ANS: C
A volume of at least 150 mL is expected for each voiding. Some women experience difficulty in emptying the bladder, possibly as a result of diminished bladder tone, edema from trauma, use of epidural or spinal anaesthetic, or fear of discomfort, so only voiding 130 mL since delivery indicates that the patient should not be discharged early. Afterpains when breastfeeding is not a reason to delay early discharge. The birth of an infant at term is not a criterion that would prevent early discharge. A normal episiotomy would show slight redness and edema and would be dry and approximated and would not prevent a patient from being discharged early.

Question 9

9. Which finding could prevent early discharge of a newborn at 12 hours of age?
   a. Birth weight of 3000 g
   b. One meconium stool since birth
   c. Voided, clear, pale urine three times since birth
   d. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast

Answer 9

ANS: D
The infant breastfeeding once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast indicates that the infant is having some difficulty with breastfeeding. The infant needs to complete at least two successful feedings (normal sucking and swallowing) before an early discharge can occur. Birth weight of 3000 g; one meconium stool since birth; and voided, clear, pale urine three times since birth are normal infant findings and would not prevent early discharge.

Question 10

10. Which is the primary influence for shorter postpartum hospital stays?
    a. Desire for a family-centred experience
    b. Budget-driven decision
    c. Hospitals
    d. The federal government

Answer 10

ANS: A
Consumers have demanded a more family-centred experience. Hospitals are obligated to follow standards of care. Early discharge was not primarily a budget decision. The early discharge is not influenced by the federal government.

Question 11

11. How long should the nurse teach the patient who is not breastfeeding to wear a well-fitted support bra to suppress lactation in the postpartum period?
    a. 24 hours
    b. 48 hours
    c. 72 hours
    d. 7 days

Answer 11

ANS: C
Women should wear a well-fitted support bra continuously for at least the first 72 hours after giving birth to suppress lactation.

Question 12

12. Which patient should receive Rh immune globulin?
    a. Rh+, sensitized
    b. Rh+, not sensitized
    c. Rh–, sensitized
    d. Rh–, not sensitized

Answer 12

ANS: D
Rh immune globulin is given to a patient in the postpartum period who is Rh–, not sensitized.

Question 13

13. In the recovery room, if a patient is asked either to raise their legs (knees extended) off the bed or to flex their knees, place their feet flat on the bed, and raise their buttocks well off the bed, most likely they are being tested to see whether they
    a. have recovered from epidural or spinal anesthesia.
    b. have hidden bleeding underneath them.
    c. have regained some flexibility.
    d. is a candidate to go home after 6 hours.

Answer 13

ANS: A
If the numb or prickly sensations are gone from their legs after these movements, they have likely recovered from the epidural or spinal anesthesia.

Question 14

14. If a patient is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?
    a. Putting the patient in antiembolic stockings (TED hose) and/or sequential
    compression device (SCD) boots.
    b. Having the patient flex, extend, and rotate their feet, ankles, and legs.
    c. Having the patient sit in a chair.
    d. Notifying the health care provider if there is pain and redness in leg.

Answer 14

ANS: C
Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. Calf muscle pain or warmth, redness, or tenderness requires the health care provider’s immediate attention.

Question 15

15. Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to “mother the mother.” What does this expression refer to?
    a. Formally initializing individualized care by confirming the patient’s and infant’s
    identification (ID) numbers on their respective wrist bands
    b. Teaching the mother to check the identity of any person who comes to remove the
    baby from the room
    c. Including other family members in the teaching of self-care and child care
    d. Nurturing the patient by providing encouragement and support as she takes on the
    many tasks of motherhood

Answer 15

ANS: D
Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the patient in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.

Question 16

16. What is the most common cause of excessive blood loss after childbirth?
    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 fragme

Answer 16

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

Question 17

17. 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 does this activity indicate that the nurse is doing?
    a. Improving the accuracy of blood loss estimation, which usually is a subjective
    assessment
    b. Determining which pad is best
    c. Demonstrating that other nurses usually underestimate blood loss
    d. Indicating to the nurse supervisor that one of them needs some time off

Answer 17

ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It’s possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. If anything, nurses usually overestimate blood loss.

Question 18

18. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the patient empty their bladder spontaneously as soon as possible. Which would be the last intervention that the nurse would implement?
    a. Pouring water from a squeeze bottle over the patient’s perineum
    b. Placing oil of peppermint in a bedpan under the patient
    c. Asking the health care provider to prescribe analgesics
    d. Inserting a sterile catheter

Answer 18

ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, analgesics). Pouring water over the perineum may stimulate voiding. If the patient is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter.

Question 19

19. If a patient is at risk for thrombus and is not ready to ambulate, which intervention should the nurse perform?
    a. Put on antiembolic stockings (TED hose).
    b. Have them avoid leg exercises.
    c. Have them sit in a chair.
    d. Keep their legs flat; do not elevate

Answer 19

ANS: A
Putting on antiembolic stockings (TED hose) is a preventative measure for women who are at risk. Sitting immobile in a chair will not help. Leg exercises are to be encouraged. Elevation of the legs would be encouraged.

Question 20

20. Which does a nurse understand is true with regard to rubella and Rh issues?
    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 1 month after vaccination.
    c. Rh immune globulin is safely administered intravenously because it cannot harm
    a nursing infant.
    d. Rh immune globulin boosts the immune system and thereby enhances the
    effectiveness of vaccinations.

Answer 20

ANS: B
Women should understand that they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore might thwart the rubella vaccination.

Question 21

21. When does planning for discharge 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 health care provider in the unit
    d. When the take-home information packet is given to the couple

Answer 21

ANS: A
Discharge planning, the teaching of maternal and newborn care, begins on the patient’s admission to the unit, continues throughout their stay, and actually never ends as long as they have contact with medical personnel.

Question 22

22. A nurse prevents overdistention of the bladder and urinary retention in a postpartum patient in order to prevent
    a. after birth hemorrhage and eclampsia.
    b. fever and increased blood pressure.
    c. after birth hemorrhage and urinary tract infection.
    d. urinary tract infection and uterine rupture.

Answer 22

ANS: C
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 after birth hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.

Question 23

23. 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 primary health care provider of an impending hemorrhage.
    b. Assess the blood pressure and pulse.
    c. Evaluate the lochia.
    d. Assist the patient in emptying their bladder.

Answer 23

ANS: D
Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the health care provider. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying their bladder.

Question 24

24. When caring for a new postpartum patient, a nurse is aware that the best measure to prevent abdominal distention after a Caesarean birth is
    a. rectal suppositories.
    b. early and frequent ambulation.
    c. tightening and relaxing abdominal muscles.
    d. carbonated beverages.

Answer 24

ANS: B
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.

Question 25

25. The nurse caring for a postpartum patient understands that breast engorgement is caused by
    a. overproduction of colostrum.
    b. accumulation of milk in the lactiferous ducts and glands.
    c. hyperplasia of mammary tissue.
    d. congestion of veins and lymphatics.

Answer 25

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.

Question 26

26. During a phone follow-up conversation with a woman who is 4 days’ after birth, the woman tells the nurse, “I don’t know what’s wrong. I love my son, but I feel so let down. I seem to cry for no reason!” The nurse would recognize that the woman is experiencing
    a. taking-in.
    b. postpartum depression (PPD).
    c. postpartum blues.
    d. attachment difficulty.

Answer 26

ANS: C
During the PP blues women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. The taking-in phase is the period after birth when the mother focuses on her own psychological needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. Crying is not a maladaptive attachment response; it indicates PP blues.

Question 27

27. The postpartum patient who continually repeats the story of their labour, birth, and recovery experience is
    a. providing others with her knowledge of events.
    b. making the birth experience “real.”
    c. taking hold of the events leading to her labour and birth.
    d. accepting their response to labour and birth.

Answer 27

ANS: B
Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. The retelling of the story is to satisfy their needs, not the needs of others. This new mother is in the taking-in phase, trying to make the birth experience seem real and separate the infant from herself.

Question 28

28. A primigravida patient who had an emergency Caesarean birth 3 days ago is scheduled for discharge. As a nurse prepares the patient for discharge, the patient begins to cry. The nurses initial action should be to
    a. assess her for pain.
    b. point out how lucky they are to have a healthy baby.
    c. explain that they are experiencing after birth blues.
    d. allow them time to express their feelings.

Answer 28

ANS: D
Although many women experience transient after birth blues, they need assistance in expressing their feelings. This condition affects 50% to 80% of new mothers. There should be no assumption that the patient is in pain, when in fact she may have no pain whatsoever. This is “blocking” communication and inappropriate in this situation. The patient needs the opportunity to express their feelings first; patient teaching can occur later.

Question 29

29. A man calls the nurse’s station and states that his partner, who gave birth 2 days ago, is happy one minute and crying the next. The man says, “She was never like this before the baby was born.” The nurse’s initial response could be to
    a. tell him to ignore the mood swings, as they will go away.
    b. reassure him that this behaviour is normal.
    c. advise him to get immediate psychological help for her.
    d. instruct him in the signs, symptoms, and duration of after birth blues.

Answer 29

ANS: B
Before providing further instructions, inform family members of the fact that after birth blues are a normal process. Telling her partner to “ignore the mood swings” does not encourage further communication and may belittle the husband’s concerns. After birth blues are usually short-lived; no medical intervention is needed. Patient teaching is important; however, the new father’s anxieties need to be allayed before he will be receptive to teaching.

Question 30

1. Which should the nurse be concerned about with regard to potential psychosocial complications during a 6-week postpartum mother and baby checkup? (Select all that apply.)
   a. The mother discusses their labour and birth experience excessively.
   b. The mother views themselves as ugly and is not able to look at themselves in a
   mirror.
   c. The mother has not given the baby a name.
   d. The mother has a partner who reacts very positively about the baby.
   e. The mother expresses disappointment over the baby’s gender.
   f. The mother believes that their baby is more attractive and clever than any others.

Answer 30

ANS: B, C, E
The mother that views herself as ugly and useless is a potential sign of a psychosocial complication. If the mother is having difficulty naming their new infant, it may be a signal that they are not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. The mother who is not coping well would find their baby unattractive and messy rather than attractive and clever. The mother may also be overly disappointed in the baby’s sex. A new mother who is having difficulty would be unwilling to discuss their labour and birth experience. A mother who is willing to discuss their birth experience is making a healthy personal adjustment. Having a partner or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.