Chapter 35- davidson

Question 1

The nurse determines the fundus of a postpartum patient to be boggy. Initially, the nurse should:

1. Document the findings.
2. Catheterize the patient.
3. Massage gently and reassess.
4. Call the physician immediately.

Answer 1

Correct Answer: 3

Rationale 3: Massaging gently and reassessing would be the initial intervention to prevent postpartum hemorrhage.

Question 2

The nurse is caring for a postpartum patient who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

1. Offer a warm water bottle for her abdomen.
2. Call the physician to report this finding.
3. Inform her that this is not normal, and she will need an oxytocic agent.
4. Administer a mild analgesic to help with breastfeeding.
5. Administer a mild analgesic at bedtime to ensure rest.

Answer 2

Correct Answer: 1,4,5

Rationale 1: The nurse should offer comfort measures that address the discomfort of afterpains. A warm water bottle against the abdomen can reduce pain.

Rationale 4: A mild analgesic taken 1 hour before breastfeeding helps reduce discomfort, and is not harmful to the infant.

Rationale 5: The nurse should offer comfort measures that address the discomfort of afterpains. A mild analgesic will decrease pain.

Question 3

The nurse would expect a physician to prescribe which medication to a postpartum patient with heavy bleeding and a boggy uterus?

1. Methylergonovine maleate (Methergine)
2. Rh immune globulin (RhoGAM)
3. Terbutaline (Brethine)
4. Docusate (Colace)

Answer 3

Correct Answer: 1

Rationale 1: Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage.

Question 4

A postpartum patient has inflamed hemorrhoids. Which nursing intervention would be appropriate?

1. Encourage sitz baths.
2. Position the patient in the supine position.
3. Avoid stool softeners.
4. Decrease fluid intake.

Answer 4

Correct Answer: 1

Rationale 1: Encouraging sitz baths is the correct approach because moist heat decreases inflammation and provides for comfort.

Question 5

The nurse assesses the postpartum patient who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?

1. Encourage the new mother to be patient, saying, “It will happen soon.”
2. Instruct the patient to eat a low-fiber diet.
3. Decrease fluid intake.
4. Obtain an order for a stool softener.

Answer 5

Correct Answer: 4

Rationale 4: Obtaining an order for a stool softener is the correct intervention by the third day. The patient might fear having a bowel movement due to perineal soreness, and stool softeners would increase bulk and moisture in the fecal material, allowing for more comfortable evacuation.

Question 6

The nurse has received the end-of-shift report on the postpartum unit. Which patient should the nurse see first?

1. Multip, 2nd day post-cesarean, moderate lochia serosa
2. Primip, day of delivery, fundus firm 2 cm above umbilicus
3. Multip, 1st postpartum day, 4 cm diastasis recti abdominis
4. Primip, 1st postpartum day, hypoactive bowel sounds all quadrants

Answer 6

Correct Answer: 2

Rationale 2: This patient is the top priority. The fundus should not be positioned above the umbilicus after delivery. This high location could indicate an overdistended bladder or uterine atony and excessive bleeding.

Question 7

The nurse expects an initial weight loss for the average postpartum patient to be:

1. 5–8 pounds.
2. 10–12 pounds.
3. 12–15 pounds.
4. 15–20 pounds.

Answer 7

Correct Answer: 2

Rationale 2: Ten to twelve pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.

Question 8

To assess the healing of the uterus at the placental site, the nurse assesses:

1. Lab values.
2. Blood pressure.
3. Uterine size.
4. Type, amount, and consistency of lochia.

Answer 8

Correct Answer: 4

Rationale 4: The type, amount, and consistency of the lochia determine the stage of healing of the placental site, which occurs by a process of exfoliation.

Question 9

The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the patient makes which statement?

1. “I should expect a lighter flow next week.”
2. “The flow will increase if I am too active.”
3. “My bleeding will remain red for about a month.”
4. “I will be able to use a pantiliner in a day or two.”

Answer 9

Correct Answer: 3

Rationale 3: By the second postpartum day, the lochia should no longer be bright red.

Question 10

Every time the nurse enters the room of a postpartum patient who gave birth 3 hours ago, the patient asks something else about her birth experience. The nurse should:

1. Answer questions quickly and try to divert her attention to other subjects.
2. Review the documentation of the birth experience and discuss it with her.
3. Contact the physician to warn him the patient might want to file a lawsuit, based on her preoccupation with the birth experience.
4. Submit a referral to Social Services because of possible obsessive behavior.

Answer 10

Correct Answer: 2

Rationale 2: Reviewing the documentation of the birth experience and discussing it with the mother allows her to integrate the experience. Three hours after birth, the mother needs to talk about her perceptions of her labor and delivery.

Question 11

Which statement by a new mother 1 week postpartum indicates maternal role attainment?

1. “I don’t think I’ll ever know what I’m doing.”
2. “This baby feels like a real stranger to me.”
3. “It works better for me to undress the baby and to nurse in the chair rather than the bed.”
4. “My sister took to mothering in no time. Why can’t I?”

Answer 11

Correct Answer: 3

Rationale 3: This statement indicates a stage of maternal role attainment in which the new mother feels comfortable enough to make her own decisions about parenting.

Question 12

On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to:

1. The taking-hold phase.
2. Postpartum hemorrhage.
3. The taking-in phase.
4. Epidural anesthesia.

Answer 12

Correct Answer: 3

Rationale 3: The taking-in phase, which occurs during the 1st day or two following birth, is characterized by a passive and dependent affect. The mother also might be in need of food and rest.

Question 13

The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?

1. “The en face position promotes bonding and attachment.”
2. “Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed.”
3. “In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous.”
4. “The needs of the mother and of her infant are balanced during the phase of mutual regulation.”

Answer 13

Correct Answer: 2

Rationale 2: Ideally, initial skin-to-skin contact is immediate. The benefits of this practice are supported by a preponderance of evidence.

Question 14

The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this patient?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

1. Be sure she gets a kosher diet.
2. Expect that most visitors will be women.
3. Uncover only the necessary skin when assessing.
4. The father will take an active role in infant care.
5. She will prefer a male physician.

Answer 14

Correct Answer: 2,3,4

Rationale 2: In Muslim cultures, childrearing and infant care are handled largely by the mother and female relatives, and the father might be only minimally involved.
Rationale 3: Modesty is very important to Muslims. The patient should be draped with the bed covers during the postpartum assessment.
Rationale 4: In Muslim cultures, childrearing and infant care are handled largely by the mother and female relatives, and the father might be only minimally involved.

Question 15

The community nurse is working with a patient from southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to:

1. Help the new mother by allowing her to focus on resting and caring for the baby.
2. Teach her son-in-law the right way to be a father, since this is his first child.
3. Make sure that her daughter does not become abusive towards the infant.
4. Pass on the cultural values and beliefs to the newborn grandchild.

Answer 15

Correct Answer: 1

Rationale 1: It is common among childbearing Asian families in the United States to have the wife’s mother live with the new family for several months. The grandmother shares her wisdom and experience and allows the mother time to rest and focus on the baby.

Question 16

Which strategies would the nurse utilize to promote culturally competent care for the postpartum patient?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Examine one’s own cultural beliefs, biases, stereotypes, and prejudices.
2. Respect the values and beliefs of others.
3. Limit the alternative food choices offered patients to minimize conflicts.
4. Incorporate the family’s cultural practices into the care.
5. Evaluate whether the family’s cultural practices might have negative consequences.

Answer 16

Correct Answer: 1,2,4,5

Rationale 1: Nurses should examine their beliefs and acknowledge their own biases so they are aware of how these beliefs and biases influence nursing care.

Rationale 2: To individualize care for each patient, nurses need to respect the mother’s choices, cultural variations, and preferences when possible, as long as there are no negative consequences for the patient’s health.

Rationale 4: Nurses should recognize that it is ultimately the patient’s right to make her own healthcare choices and decisions as long as they are not detrimental to the patient’s health.

Rationale 5: Nurse should evaluate whether the family’s practices might have negative consequences and inform the patient of these consequences.

Question 17

The nurse assesses for Homans’ sign by:

1. Extending the foot and inquiring about calf pain.
2. Extending the leg and inquiring about foot pain.
3. Flexing the knee and inquiring about thigh pain.
4. Dorsiflexing the foot and inquiring about calf pain.

Answer 17

Correct Answer: 4

Rationale 4: Dorsiflexing the foot and inquiring about calf pain is the correct way to assess for Homans’ sign

Question 18

A nurse is assigning care of postpartum patients to a licensed vocational nurse (LVN). Which postpartum patient is at the greatest risk for postpartum bleeding from uterine atony, and should not be delegated to an LVN’s care?

1. A breastfeeding postpartum patient
2. A postpartum patient who began early ambulation
3. A patient who delivered vaginally after a prolonged labor
4. A primiparous patient

Answer 18

Correct Answer: 3

Rationale 3: The patient at greatest risk for postpartum hemorrhage because of uterine atony is the patient who had a prolonged labor.

Question 19

The postpartum nurse is caring for a patient who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of:

1. Increased blood pressure.
2. Hypoglycemia.
3. Postpartum hemorrhage.
4. Postpartum infection.

Answer 19

Correct Answer: 3

Rationale 3: The nurse will assess for postpartum hemorrhage. This patient is at risk for hemorrhage due to overdistention of the uterus with twins and possible slower uterine involution.

Question 20

The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?

1. Asking the patient to void and donning clean gloves
2. Listening to bowel sounds, then asking when her last BM occurred
3. Telling visitors the assessment will be quick, then checking the fundus
4. Completing the assessment and explaining the results to the patient

Answer 20

Correct Answer: 3

Rationale 3: The patient should be asked whether she wants visitors to remain in the room or leave the room prior to beginning the assessment.

Question 21

The patient delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringer’s solution running at 100 ml/hr. Her fundus is firm, 1 FB U, to the right of midline. The best nursing action is to:

1. Massage the fundus vigorously.
2. Assess the patient’s pain level.
3. Increase the rate of the IV.
4. Assist the patient to the bathroom.

Answer 21

Correct Answer: 4

Rationale 4: Emptying the bladder is the top priority.

Question 22

During a postpartum examination of a patient who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. The assessment finding that would necessitate follow-up would be the:

1. Firm fundus.
2. Fundus at the umbilical level.
3. Moderate lochia rubra.
4. Steady trickle of blood.

Answer 22

Correct Answer: 4

Rationale 4: The steady trickle of blood could indicate a laceration in the birth canal, and should be reported to the M.D. for follow-up.

Question 23

Which of the following behaviors noted in the postpartum client would require the nurse to assess further?

1. Responds hesitantly to infant cries.
2. Expresses satisfaction about the sex of the baby.
3. Numerous friends visit the client and give advice.
4. Talks to and cuddles with the infant frequently.

Answer 23

Correct Answer: 1

Rationale 1: Responding hesitantly to infant cries might need further assessment to determine what the mother is feeling. She might not know what to do, and needs assistance to guide her.

Question 24

The nurse is performing a postpartum assessment on a newly delivered patient. When checking the fundus, there is a gush of blood. The patient asks why that is happening. The best response is:

1. “We see this from time to time. It’s not a big deal.”
2. “The gush is an indication that your fundus isn’t contracting.”
3. “Don’t worry. I’ll make sure everything is fine.”
4. “Blood pooled in the vagina while you were in bed.”

Answer 24

Correct Answer: 4

Rationale 4: Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or semi-sitting in bed, which leads to a gush when fundal massage is undertaken.

Question 25

A postpartum client asks the nurse to weigh her. The nurse expects an initial weight loss of:

1. 10—12 pounds.
2. 5—8 pounds.
3. 15—20 pounds.
4. 12—15 pounds.

Answer 25

Correct Answer: 1

Rationale 1: Ten to twelve pounds is the usual initial weight loss. This weight is lost with the birth of the infant and the expulsion of the placenta and the amniotic fluid.

Question 26

The community nurse is meeting a new mother for the first time. The patient delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the patient would indicate to the nurse that the patient is experiencing postpartum blues?

1. “I am so happy and blessed to have my new baby.”
2. “One minute I’m laughing and the next I’m crying.”
3. “My husband is helping out by changing the baby at night.”
4. “Breastfeeding is going quite well now that the engorgement is gone.”

Answer 26

Correct Answer: 2

Rationale 2: Postpartum blues are a transient period of about 2 weeks marked by mild depressive symptoms that are self-limiting. Manifestations include mood swings, anger, weepiness, lack of appetite, feeling let down, and difficulty sleeping.

Question 27

The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include:
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Prolonged labor.
2. Difficult birth.
3. Full bladder.
4. Breastfeeding.
5. Infection.

Answer 27

Correct Answer: 1,2,3,5

Rationale 1: Prolonged time of contractions during labor relaxes the uterine muscles and can retard uterine involution.

Rationale 2: During a difficult birth, the uterus is manipulated excessively, which can retard uterine involution.

Rationale 3: As the uterus is pushed up and, usually, to the right, pressure on it interferes with effective uterine contraction and involution.

Rationale 5: Inflammation interferes with the uterine muscles’ ability to contract effectively.

Question 28

When preparing for and performing an assessment of the postpartum patient, the nurse would:
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Ask the patient to void before assessing the uterus.
2. Inform the patient of the need for regular assessments.
3. Defer patient teaching to another time.
4. Perform the procedures as gently as possible.
5. Take precautions to prevent exposure to body fluids.

Answer 28

Correct Answer: 1,2,4,5

Rationale 1: Palpating the fundus when the woman has a full bladder might give false information about the progress of involution.

Rationale 2: Informing the patient of the purpose of regular assessments will allay any concerns the patient might have about her health status.

Rationale 4: The woman should be relaxed before starting, and procedures should be performed as gently as possible, to avoid unnecessary discomfort.

Rationale 5: Gloves should be worn when assessing the breasts, perineum, and lochia.

Question 29

Which physical assessment findings would the nurse consider normal for the postpartum patient following a vaginal delivery?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Elevated blood pressure
2. Fundus firm and midline
3. Moderate amount of lochia serosa
4. Edema and bruising of perineum
5. Inflamed hemorrhoids

Answer 29

Correct Answer: 2,4

Rationale 2: A firm fundus that is midline indicates the normal progression of uterine involution.

Rationale 4: After a vaginal delivery, there are slight edema and bruising in an intact perineum.

Question 30

The postpartum patient is about to go home. The nurse includes which subject in the teaching plan?

1. Puerperal tachycardia
2. Striae and chloasma
3. Diastasis of the recti muscles
4. HELLP syndrome

Answer 30

Correct Answer: 3

Rationale 3: Diastasis recti abdominis can be improved with abdominal tightening exercises, best taught when the mother is receptive to instruction during the postpartum assessment.

Question 31

A nurse is preparing to discharge a postpartum client. The nurse notes on her chart that she is nonimmune to rubella. The nurse:

1. Administers a rubella vaccine prior to discharge.
2. Instructs the client to obtain a rubella vaccine after 1 month has elapsed.
3. Charts this information in the discharge summary notes.
4. Takes no action because none is needed.

Answer 31

Correct Answer: 1

Rationale 1: If the postpartum client is nonimmune to rubella, a rubella vaccine is administered prior to discharge.

Question 32

The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?

1. Describe the likely reaction of siblings to the new baby.
2. Discuss adaptation to grandparenthood by her parents.
3. Determine whether father–infant attachment is taking place.
4. Assist the mother in identifying the baby’s behavior cues.

Answer 32

Correct Answer: 4

Rationale 4: Helping the mother to identify her baby’s behavior cues facilitates the acquaintance phase of maternal–infant attachment.

Question 33

At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing:
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Anticipatory guidance about the realities of being a parent.
2. Parenting literature and reference manuals.
3. Phone numbers and locations of local parenting groups.
4. Referral for specialized interventions related to postpartum blues.
5. Phone numbers and names of postpartum doulas.

Answer 33

Correct Answer: 1,2,3,5

Rationale 1: Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles.

Rationale 2: Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles
.
Rationale 3: New-mother support groups are helpful for women who lack a social support system.

Rationale 5: Postpartum doulas are professionals trained to help the new mother after the birth of the baby.

Question 34

A nurse is caring for several postpartum patients. Which patient is demonstrating a problem attaching to her newborn?

1. The patient who is discussing how the baby looks like her father
2. The patient who is singing softly to her baby
3. The patient who continues to touch her baby with only her fingertips
4. The patient who picks her baby up when the baby cries

Answer 34

Correct Answer: 3

Rationale 3: During the attachment process, the patient should proceed from fingertip touch to palmar contact to enfolding the infant close to her own body. If the patient continues to touch with only her fingertips, she might not be developing adequate early attachment.

Question 35

The nurse is caring for a patient who recently emigrated from a southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. The most likely explanation for this behavior is that the patient:

1. Is not attaching to her infant appropriately.
2. Is not going to be a good mother, and the baby is at risk.
3. Has no mother present to role-model behaviors.
4. Is exhibiting normal behavior for her culture.

Answer 35

Correct Answer: 4

Rationale 4: In many cultures, especially those in developing countries with traditionally high infant mortality rates, the mother is expected to rest while the female relatives and sometimes the spouse provide child care for the first several weeks to months.

Question 36

The community nurse is working with a client whose only child is eight months old. Which statement does the nurse expect the mother to make?

1. “I have a lot more time to myself than I thought I would have.”
2. “My confidence level in my parenting is higher than I anticipated.”
3. “I am constantly tired. I feel like I could sleep for a week.”
4. “My baby likes everyone, and never fusses when she’s held by a stranger.”

Answer 36

Correct Answer: 3

Rationale 3: Fatigue is a common issue with new mothers due to the demands of nighttime care.

Question 37

The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. “We should avoid holding the baby too much.”
2. “Looking directly into the baby’s eyes might frighten him.”
3. “Talking to the baby is good because he’ll recognize our voices.”
4. “Holding the baby so we have direct face-to-face contact is good.”
5. “We should expect the baby to smile when we talk to him.”

Answer 37

Correct Answer: 3,4

Rationale 3: Attachment behaviors include talking to the baby (especially in a high-pitched voice).

Rationale 4: Attachment behaviors include holding the baby in the en face position.

Question 38

Which factors would the nurse observe that would indicate a new mother’s early attachment to the newborn?
Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Face-to-face contact and eye contact
2. Failure to choose a name for the baby
3. Decreased interest in the infant’s cues
4. Pointing out familial traits of the newborn
5. Displaying satisfaction with the infant’s sex

Answer 38

Correct Answer: 1,4,5

Rationale 1: This indicates that the mother is attracted to the infant and is attending to the infant’s behavior.

Rationale 4: The ability to point out family traits shows that she is pleased with the baby’s appearance and recognizes the infant as belonging to the family unit.

Rationale 5: Showing pleasure with the infant’s appearance and sex indicates bonding is occurring.