Perry - Chapter 18

Question 1

A woman gave birth to an infant boy 10 hours ago. Where would the nurse expect to locate this woman’s fundus?

a. One centimeter above the umbilicus
b. Two centimeters below the umbilicus
c. Midway between the umbilicus and the symphysis pubis
d. Nonpalpable abdominally

Answer 1

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

Question 2

Which woman is most likely to experience strong afterpains?

a. A woman who experienced oligohydramnios
b. A woman who is a gravida 4, para 4-0-0-4
c. A woman who is bottle-feeding her infant
d. A woman whose infant weighed 5 pounds, 3 ounces

Answer 2

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

Question 3

A woman gave birth to a healthy infant boy 5 days ago. What type of lochia would the nurse expect to find when assessing this woman?

a. Lochia rubra c. Lochia alba
b. Lochia sangra d. Lochia serosa

Answer 3

ANS: D
Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris, generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales, becoming pink or brown. There is no such term as lochia sangra. Lochia alba occurs in most women after day 10 and can continue up to 6 weeks after childbirth.

Question 4

Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman?

a. Estrogen c. Prolactin
b. Progesterone d. Human placental lactogen

Answer 4

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

Question 5

Two days ago a woman gave birth to a full-term infant. Last night she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is:

a. Elevated temperature caused by postpartum infection.
b. Increased basal metabolic rate after giving birth.
c. Loss of increased blood volume associated with pregnancy.
d. Increased venous pressure in the lower extremities.

Answer 5

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

Question 6

A woman gave birth to a 7-pound, 3-ounce infant 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. c. A ruptured bladder.
b. Excessive uterine bleeding. d. Bladder wall atony.

Answer 6

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

Question 7

The nurse caring for the postpartum woman understands that breast engorgement is caused by:

a. Overproduction of colostrum.
b. Accumulation of milk in the lactiferous ducts.
c. Hyperplasia of mammary tissue.
d. Congestion of veins and lymphatics.

Answer 7

ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatics, not by overproduction of colostrum, overproduction of milk, or hyperplasia of mammary tissue.

Question 8

A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman’s vital signs, the nurse would be concerned to see:

a. Temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50.
b. Temperature 37.4° C, heart rate 88, respirations 36, BP 126/68.
c. Temperature 38° C, heart rate 80, respirations 16, BP 110/80.
d. Temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.

Answer 8

ANS: A
An EBL of 1500 mL with tachycardia and hypotension suggests hypovolemia caused by excessive blood loss. An increased respiratory rate of 36 may be secondary to pain from the birth. Temperature may increase to 38° C during the first 24 hours as a result of the dehydrating effects of labor. A BP of 140/90 is slightly elevated, which may be caused by the use of oxytocic medications.

Question 9

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.”

Answer 9

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

Question 10

The interval between the birth of the newborn and the return of the reproductive organs to their normal nonpregnant state is called the:

a. Involutionary period because of what happens to the uterus.
b. Lochia period because of the nature of the vaginal discharge.
c. Mini-tri period because it lasts only 3 to 6 weeks.
d. Puerperium, or fourth trimester of pregnancy.

Answer 10

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

Question 11

The self-destruction of excess hypertrophied tissue in the uterus is called:

a. Autolysis. c. Afterpain.
b. Subinvolution. d. Diastasis.

Answer 11

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

Question 12

With regard to the postpartum uterus, nurses should be aware that:

a. At the end of the third stage of labor it weighs approximately 500 g.
b. After 2 weeks postpartum it should not be palpable abdominally.
c. After 2 weeks postpartum it weighs 100 g.
d. It returns to its original (prepregnancy) size by 6 weeks postpartum.

Answer 12

ANS: B
After 2 weeks postpartum, the uterus should not be palpable abdominally; however, it has not yet returned to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. It takes 6 full weeks for the uterus to return to its original size. After 2 weeks postpartum the uterus weighs about 350 g, not its original size. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.

Question 13

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

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

Answer 13

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

Question 14

Postbirth uterine/vaginal discharge, called lochia:

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

Answer 14

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

Question 15

Which description of postpartum restoration or healing times is accurate?

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

Answer 15

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

Question 16

With regard to postpartum ovarian function, nurses should be aware that:

a. Almost 75% of women who do not breastfeed resume menstruating within a month after birth.
b. Ovulation occurs slightly earlier for breastfeeding women.
c. Because of menstruation/ovulation schedules, contraception considerations can be postponed until after the puerperium.
d. The first menstrual flow after childbirth usually is heavier than normal.

Answer 16

ANS: D
The first flow is heavier, but within three or four cycles, it is back to normal. Ovulation can occur within the first month, but for 70% of nonlactating women, it returns within 12 weeks after birth. Breastfeeding women take longer to resume ovulation. Because many women ovulate before their first postpartum menstrual period, contraceptive options need to be discussed early in the puerperium.

Question 17

As relates 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 accounts for a weight loss of more than 2 kg during the puerperium.
d. With adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

Answer 17

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

Question 18

Knowing that the condition of the new mother’s breasts will be affected by whether she is breastfeeding, nurses should be able to tell their clients all the following statements except:

a. Breast tenderness is likely to persist for about a week after the start of lactation.
b. As lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day.
c. In nonlactating mothers colostrum is present for the first few days after childbirth.
d. If suckling is never begun (or is discontinued), lactation ceases within a few days to a week.

Answer 18

ANS: A
Breast tenderness should persist for 24 to 48 hours after lactation begins. That movable, noncancerous mass is a filled milk sac. Colostrum is present for a few days whether the mother breastfeeds or not. A mother who does not want to breastfeed should also avoid stimulating her nipples.

Question 19

With regard to the postpartum changes and developments in a woman’s cardiovascular system, nurses should be aware that:

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

Answer 19

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

Question 20

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?

a. Varicosities of the legs
b. Carpal tunnel syndrome
c. Periodic numbness and tingling of the fingers
d. Headaches

Answer 20

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

Question 21

Several changes in the integumentary system that appear during pregnancy disappear after birth, although not always completely. What change is almost certain to be completely reversed?

a. Nail brittleness
b. Darker pigmentation of the areolae and linea nigra
c. Striae gravidarum on the breasts, abdomen, and thighs
d. Spider nevi

Answer 21

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

Question 22

Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the client understands the correct process for completing these conditioning exercises when she reports:

a. “I contract my thighs, buttocks, and abdomen.”
b. “I do 10 of these exercises every day.”
c. “I stand while practicing this new exercise routine.”
d. “I pretend that I am trying to stop the flow of urine midstream.”

Answer 22

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

Question 23

Which maternal event is abnormal in the early postpartum period?

a. Diuresis and diaphoresis
b. Flatulence and constipation
c. Extreme hunger and thirst
d. Lochial color changes from rubra to alba

Answer 23

ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. Diuresis and diaphoresis are the methods by which the body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.

Question 24

Which finding 12 hours after birth requires further assessment?

a. The fundus is palpable two fingerbreadths above the umbilicus.
b. The fundus is palpable at the level of the umbilicus.
c. The fundus is palpable one fingerbreadth below the umbilicus.
d. The fundus is palpable two fingerbreadths below the umbilicus.

Answer 24

ANS: A
The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. A fundus that is palpable at or below the level of the umbilicus is a normal finding for a patient who is 12 hours postpartum. Palpation of the fundus 2 fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.

Question 25

If the patient’s white blood cell (WBC) count is 25,000/mm on her second postpartum day, the nurse should:

a. Tell the physician immediately.
b. Have the laboratory draw blood for reanalysis.
c. Recognize that this is an acceptable range at this point postpartum.
d. Begin antibiotic therapy immediately.

Answer 25

ANS: C
During the first 10 to 12 days after childbirth, values between 20,000 and 25,000/mm are common. Because this is a normal finding there is no reason to alert the physician. There is no need for reassessment or antibiotics because it is expected for the WBCs to be elevated.

Question 26

A postpartum patient asks, “Will these stretch marks go away?” The nurse’s best response is:

a. “They will continue to fade and should be gone by your 6-week checkup.”
b. “No, never.”
c. “Yes, eventually.”
d. “They will fade to silvery lines but won`t disappear completely.”

Answer 26

ANS: D

Stretch marks never disappear altogether; however, they gradually fade to silvery lines.

Question 27

Which documentation on a woman’s chart on postpartum day 14 indicates a normal involution process?

a. Moderate bright red lochial flow
b. Breasts firm and tender
c. Fundus below the symphysis and not palpable
d. Episiotomy slightly red and puffy

Answer 27

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

Question 28

Changes in blood volume after childbirth depend on several factors such as blood loss during childbirth and the amount of extravascular water (physiologic edema) mobilized and excreted. A postpartum nurse anticipates blood loss of (Select all that apply):

a. 100 mL
b. 250 mL or less
c. 300 to 500 mL
d. 500 to 1000 mL
e. 1500 mL or greater

Answer 28

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

Question 29

The physiologic changes that occur during the reversal of the processes of pregnancy are distinctive; however, they are normal. To provide care during this recovery period the nurse must synthesize knowledge regarding anticipated maternal changes and deviations from normal. Please match the vital signs finding that the postpartum nurse may encounter with the probable cause:

a. Elevated temperature within the first 24 hours
b. Rapid pulse
c. Elevated temperature at 36 hours postpartum
d. Hypertension
e. Hypoventilation

29. Puerperal sepsis
30. Unusually high epidural or spinal block
31. Dehydrating effects of labor
32. Hypovolemia resulting from hemorrhage
33. Excessive use of oxytocin

Answer 29

29. ANS: C
    During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.
30. ANS: E
    During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.
31. ANS: A
    During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.
32. ANS: B
    During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.
33. ANS: D
    During the first 24 hours postpartum, temperature may increase to 38¦ C as a result of the dehydrating effects of labor. After 24 hours the woman should be afebrile. Other causes of fever include mastitis, endometritis, urinary tract infection, and other systemic infections. Pulse, along with stroke volume and cardiac output, remains elevated for the first hour or so after childbirth. A rapid pulse, or one that is increasing, may indicate hypovolemia as a result of hemorrhage. Hypoventilation may occur after an unusually high subarachnoid block or epidural narcotic after a cesarean birth. An increased reading in blood pressure may result from the excessive use of the vasopressor or oxytocic medication. Because gestational hypertension can persist into or occur first in the postpartum period, routine evaluation of blood pressure is necessary.