TEST 4: Postpartal Care

Question 1

The Postpartal Client with a Vaginal Birth
1. The nurse from the nursery is bringing a newborn to a mother’s room. The nurse took care of
the mother yesterday and knows the mother and baby well. The nurse should implement which of the
following next to ensure the safest transition of the infant to the mother?
1. Assess whether the mother is able to ambulate to care for the infant.
2. Ask the mother if there is anything else she needs for the care of her baby.
3. Check the crib to determine if there are enough diapers and formula.
4. Complete the hospital identification procedure with mother and infant.

Answer 1

The Postpartal Client with a Vaginal Birth
1. 4. The hospital identification procedures for mothers and infants need to be completed each
time a newborn is returned to a family’s room. It does not matter how well the nurse knows the mother
and infant; this validation is a standard of care in an obstetrical setting. Assessing the mother’s ability
to ambulate, asking the mother if there is anything else she needs to care for the infant, and checking
the crib to determine if there are enough supplies are important steps that are part of the process of
transferring a baby to the mother, but identification verification is a safety measure that must occur
first.
CN: Safety and infection control; CL: Create

Question 2

2. A client is in the first hour of her recovery after a vaginal birth. During an assessment, the
   lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the
   umbilicus; it is firm and midline with no palpable bladder. The client’s vital signs remain at their
   baseline. Based on this information, the nurse would implement which of the following actions?
3. Increase the IV rate.
4. Recheck the admission hematocrit and hemoglobin levels.
5. Report the findings to the health care provider.
6. Document the findings as normal.

Answer 2

2. 3. At any point in the postpartum period, the lochia should be dark in color, rather than bright
      red. The volume should not be great enough to trickle or run from the vagina. The information
      provided states the fundus is firm, midline, and at the umbilicus, which are the expected outcomes at
      this point postpartum. These findings would indicate to the nurse that the bleeding is not coming from
      the uterus or from uterine atony. The bladder is not palpable, which indicates that the bleeding is not
      related to a full bladder, which is further validated by the fundus being at the umbilicus. The most
      likely etiology is cervical or vaginal lacerations or tears. The nurse is unable to do anything to stop
      this type of bleeding and must notify the health care provider. Increasing the IV rate will not decrease
      the amount or type of vaginal bleeding. Rechecking the hematocrit and hemoglobin will only provide
      background information for the nurse and identify the beginning levels for this mother, rather than
      where she is now. It will do nothing to stop the bleeding. The bleeding level and color is not normal
      and documenting such findings as normal is incorrect.
      CN: Management of care; CL: Synthesize

Question 3

3. The nurse is caring for a G 3, T 3, P 0, Ab 0, L 3 woman who is 1 day postpartum following a
   vaginal birth. Which of the following indicates a need for further assessment?
4. Hemoglobin 12.1 g/dL (121 g/L).
5. WBC count of 15,000 (15 × 10 9 /L).
6. Pulse of 60.
7. Temperature of 100.8°F (38.2°C).

Answer 3

3. 4. Within the first 24 hours postpartum, maternal temperature may increase to 100.4°F
      (38.2°C), a normal postpartum finding attributed to dehydration. A temperature above 100.4°F
      (38.2°C) after the first 24 hours indicates a potential for infection. The hemoglobin is in the normal
      range. WBC count is normally elevated as a response to the inflammation, pain, and stress of the
      birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased
      cardiac output (mobilization of excess extracellular fluid into the vascular bed, decreased pressure
      from the uterus on vessels, blood flow back to the heart from the uterus returning to the central
      circulation) and alteration in stroke volume.
      CN: Physiological adaptation; CL: Analyze

Question 4

4. The nurse is providing follow-up care with clients 1 week after the birth of their neonate. The
   nurse would anticipate what outcomes from this new mother? Select all that apply.
5. The client feels tired but is able to care for herself and her new infant.
6. The family has adequate support from one another and others.
7. Lochia is changing from red to pink and is smaller in amount.
8. The client feeds the baby every 6 to 8 hours without difficulty.
9. The client has positive comments about her new infant.

Answer 4

4. 1,2,3,5. Outcome evaluation for a family about 10 days after childbirth would include a motherwho is tired but is able to care for herself and her baby. Having adequate support systems enables the
   mother to care better for herself and family members, as they can provide the backup for situations
   that may arise and a resource for new families. The normal progression for lochia is to change from
   red to pink to off-white while decreasing in amount. This is within the usual time periods for a
   postpartum mother. The baby should be feeding more frequently than every 6 to 8 hours. It is expected
   that a 10-day-old infant feeds every 3 to 4 hours if bottle-feeding and every 11⁄2 to 3 hours if breast-
   feeding. Follow-up questions the nurse would ask to further evaluate this situation include, How many
   wet diapers the infant has daily? How alert the infant is? Did the infant gain any weight at the first
   checkup? It is expected that the mother has positive comments about the infant, but the nurse will
   evaluate to determine if there is at least one positive comment.
   CN: Management of care; CL: Evaluate

Question 5

5. A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in
   place on her perineum. However, her perineum is slightly edematous, and the client is having pain
   rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
6. Begin sitz baths.
7. Administer pain medication per prescription.
8. Replace ice packs to the perineum.
9. Initiate anesthetic sprays to the perineum.

Answer 5

5. 2. Pain medication is the first strategy to initiate at this pain level. When trauma has occurred to
      any area, the usual intervention is ice for the first 24 hours and heat after the first 24 hours. Sitz baths
      are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further
      edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays
      can also be utilized for the perineal area when pain is involved but would not lower the pain to a
      level that the client considers tolerable.
      CN: Physiological adaptation; CL: Synthesize

Question 6

6. A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse
   plans care for this postpartum client, which postpartum goal would have the highest priority?
7. By discharge, the family will bond with the neonate.
8. The client will demonstrate self-care and infant care by the end of the shift.
9. The client will state instructions for discharge during the first postpartum day.4. By the end of the shift, the client will describe a safe home environment.

Answer 6

6. 2. Educating the client about caring for herself and her infant are the two highest priority goals.
      Following childbirth, all mothers, especially the primigravida, require instructions regarding self-
      care and infant care. Learning needs should be assessed in order to meet the specific needs of each
      client. Bonding is significant, but is only one aspect of the needs of this client and the bonding process
      would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the
      discharge occurs after the initial education has taken place for mother and infant and the nurse is
      aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and
      should include maternal as well as newborn safety.
      CN: Management of care; CL: Create

Question 7

7. In response to the nurse’s question about how she is feeling, a postpartum client states that she
   is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The
   nurse determines the client is in which postpartal phase of psychological adaptation?
8. Taking in.
9. Taking on.
10. Taking hold.
11. Letting go.

Answer 7

7. 3. The client is in the taking hold phase with a demonstrated focus on the neonate and learning
      about and fulfilling infant care and needs. The taking in phase is the first period after birth where
      there is emphasis on reviewing and reliving the labor and birth process, concern with self, and
      needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a
      phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks
      postpartum when the mother may be preparing to go back to work. During this time, she can have
      other individuals assume care of the infant and begin the separation process.
      CN: Psychosocial integrity; CL: Analyze

Question 8

8. A client has admitted use of cocaine prior to beginning labor. After the infant is born, the nurse
   should anticipate the need to include which of the following actions in the infant’s plan of care?
9. Urine toxicology screening.
10. Notifying hospital security.
11. Limiting contact with visitors.
12. Contacting local law enforcement.

Answer 8

8. 1. A urine toxicology screening will be collected to document that the infant has been exposed
      to illegal drug use. This documentation will be the basis for legal action for the protection of this
      infant. If the infant tests positive for cocaine, the legal system will be activated to provide and ensure
      protective custody for this child. Hospital security would not become involved unless the mother is
      obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any
      hospitalized clients unless the safety of the infant is jeopardized; thus, limiting contact with visitors
      would not be appropriate. Local law enforcement agencies would be contacted only if the motherinitiates use of drugs on hospital premises and such contact would be made through the hospital
      security system.
      CN: Physiological adaptation; CL: Synthesize

Question 9

9. The nurse is evaluating the client who gave birth vaginally 2 hours ago and is experiencing
   postpartum pain rated 8 on scale of 1 to 10. The client is a G 4, P 4, breast-feeding mother who
   would like medication to decrease the pain in her uterus. Which of the medications listed on the
   prescriptions sheet would be the most appropriate for this client?
10. Aspirin 1,000 mg PO every 4 to 6 hour PRN.
11. Ibuprofen 800 mg PO every 6 to 8 hour PRN.
12. Ducosate 100 mg PO twice a day.
13. Acetaminophen and hydrocodone 10 mg 1 tab PO every 4 to 6 hour PRN.

Answer 9

9. 4. Acetaminophen and hydrocodone would be the drug of choice for this situation because the
      pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use.
      Although ibuprofen would typically be a good choice because it inhibits the prostaglandin synthesis
      associated with a multiparous client breast-feeding, the pain level is too high for this drug to have an
      acceptable effect. Docusate is used as a stool softener postpartum but does not provide pain relief.
      CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 10

10. At which of the following locations would the nurse expect to palpate the fundus of a
    primiparous client immediately after birth of a neonate?
11. Halfway between the umbilicus and the symphysis pubis.
12. At the level of the umbilicus.
13. Just below the level of the umbilicus.
14. Above the level of the umbilicus.

Answer 10

10. 1. Immediately after delivery of the placenta, the nurse would expect to palpate the fundus
       halfway between the umbilicus and the symphysis pubis. Within 2 hours postpartum, the fundus should
       be palpated at the level of the umbilicus. The fundus remains at this level or may rise slightly above
       the umbilicus for approximately 12 hours. After the first 12 hours, the fundus should decrease one
       fingerbreadth (1 cm) per day in size. By the 9th or 10th day, the fundus usually is no longer palpable.
       CN: Health promotion and maintenance; CL: Apply

Question 11

11. When instilling erythromycin ointment into the eyes of a neonate 1 hour old, the nurse would
    explain to the parents that the medication is used to prevent which of the following?
12. Chorioretinitis from cytomegalovirus.
13. Blindness secondary to gonorrhea.
14. Cataracts from beta-hemolytic streptococcus.
15. Strabismus resulting from neonatal maturation.

Answer 11

11. 2. The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia
       neonatorum, or neonatal blindness caused by gonorrhea in the mother. Erythromycin is also effective
       in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may
       result in redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin
       ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective
       treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in
       preventing cataracts. Additionally, neonatal infection with beta-hemolytic streptococcus results in
       pneumonia, bacterial meningitis, or death. Cataracts in the neonate may be congenital or may result
       from maternal exposure to rubella. Erythromycin ointment is also not effective for preventing and
       treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 12

12. The physician prescribes an intramuscular injection of vitamin K for a term neonate. The
    nurse explains to the mother that this medication is used to prevent which of the following?
13. Hypoglycemia.
14. Hyperbilirubinemia.
15. Hemorrhage.
16. Polycythemia.

Answer 12

12. 3. Vitamin K acts as a preventive measure against neonatal hemorrhagic disease. At birth, the
       neonate does not have the intestinal flora to produce vitamin K, which is necessary for coagulation.
       Hypoglycemia is prevented and treated by feeding the infant. Hyperbilirubinemia severity can be
       decreased by early feeding and passage of meconium to excrete the bilirubin. Hyperbilirubinemia is
       treated with phototherapy. Polycythemia may occur in neonates who are large for gestational age or
       postterm. Clamping of the umbilical cord before pulsations cease reduces the incidence of
       polycythemia. Generally, polycythemia is not treated unless it is extremely severe.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 13

13. A grand-multiparous client has just given birth to a large-for-gestational-age infant. The nurse
    determines the client’s primary risk is for:1. Knowledge deficit.
14. Acute pain.
15. Ineffective breast-feeding.
16. Fluid volume deficit.

Answer 13

13. 4. The primary risk is for fluid volume deficit related to blood loss. The client is at increased
       risk for uterine atony and therefore increased blood loss due to having given birth to five or more
       children and for having a large infant. The client may be at risk for pain, ineffective breast-feeding,
       and knowledge deficit, but there is not enough information to indicate that these are priority problems
       at this time.
       CN: Reduction of risk potential; CL: Analyze

Question 14

14. The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous
    client 6 hours after a vaginal birth. The nurse should next:
15. Apply an ice pack to the perineal area.
16. Assess the client’s temperature.
17. Have the client take a warm sitz bath.
18. Contact the physician for prescriptions for an antibiotic.

Answer 14

14. 1. The client has a hematoma. During the first 24 hours postpartum, ice packs can be appliedto the perineal area to reduce swelling and discomfort. Ice packs usually are not effective after the
       first 24 hours. Although vital signs, including temperature, are important assessments, taking the
       client’s temperature is unrelated to the hematoma and would provide no additional information about
       swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat
       is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas
       resolve without further treatment within 6 weeks. Additionally, the nurse should measure the
       hematoma to provide a baseline for subsequent measurements and should notify the physician of its
       presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or
       symptoms of infection.
       CN: Health promotion and maintenance; CL: Synthesize

Question 15

15. Two hours after the vaginal birth of a viable male neonate under epidural anesthesia, a client
    with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the
    client’s bladder, finding it distended. The nurse interprets this finding based on the understanding that
    the client’s bladder distention is most likely caused by which of the following?
16. Prolonged first stage of labor.
17. Urinary tract infection.
18. Pressure of the uterus on the bladder.
19. Edema in the lower urinary tract area.

Answer 15

15. 4. Urinary retention soon after childbirth is usually caused by edema and trauma of the lower
       urinary tract; this commonly results in difficulty with initiating voiding. Hyperemia of the bladder
       mucosa also commonly occurs. The combination of hyperemia and edema predisposes to decreased
       sensation to void, overdistention of the bladder, and incomplete bladder emptying. A prolonged first
       stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a
       urinary tract infection, she would exhibit symptoms such as dysuria and a burning sensation. After
       birth, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on
       the bladder occurs during labor.
       CN: Health promotion and maintenance; CL: Analyze

Question 16

16. A primiparous client who is bottle-feeding her neonate at 12 hours after birth asks the nurse,
    “When will my menstrual cycle return?” Which of the following responses by the nurse would be
    most appropriate?
17. “Your menstrual cycle will return in 3 to 4 weeks.”
18. “It will probably be 6 to 10 weeks before it starts again.”
19. “You can expect your menses to start in 12 to 14 weeks.”
20. “Your menses will return in 16 to 18 weeks.”

Answer 16

16. 2. For clients who are bottle-feeding, the menstrual flow should return in 6 to 10 weeks, after
       a rise in the production of follicle-stimulating hormone by the pituitary gland. Nonlactating mothers
       rarely ovulate before 4 to 6 weeks postpartum. Therefore, 3 to 4 weeks is too early for the menstrual
       cycle to resume. For women who are breast-feeding, the menstrual flow may not return for 3 to 4
       months (12 to 16 weeks) or, in some women, for the entire period of lactation, because ovulation is
       suppressed.
       CN: Health promotion and maintenance; CL: Apply

Question 17

17. While the nurse is preparing to assist the primiparous client to the bathroom to void 6 hours
    after a vaginal birth under epidural anesthesia, the client says that she feels dizzy when sitting up on
    the side of the bed. The nurse explains that this is most likely caused by which of the following?
18. Effects of the anesthetic during labor.
19. Hemorrhage during the birth process.
20. Effects of analgesics used during labor.
21. Decreased blood volume in the vascular system.

Answer 17

17. 4. The client’s dizziness is most likely caused by orthostatic hypotension secondary to the
       decreased volume of blood in the vascular system resulting from the physiologic changes occurring in
       the mother after birth. The client is experiencing dizziness because not enough blood volume is
       available to perfuse the brain. The nurse should first allow the client to “dangle” on the side of the
       bed for a few minutes before attempting to ambulate. By 6 hours postpartum, the effects of the
       anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1
       to 2 hours postpartum, and the effects of local anesthesia usually disappear by 1 hour. The client
       scenario provides no information to indicate that the client experienced any postpartum hemorrhage.
       Normal blood loss during birth should not exceed 500 mL.
       CN: Health promotion and maintenance; CL: Apply

Question 18

18. The nurse enlists the aid of an interpreter when caring for a primiparous client from Mexico
    who speaks only Spanish and gave birth to a viable term neonate 8 hours ago. When developing the
    postpartum dietary plan of care for the client, the nurse would encourage the client’s intake of which
    of the following?
19. Tomatoes.
20. Potatoes.
21. Corn products.
22. Meat products.

Answer 18

18. 4. Because the diet of immigrants from Mexico and Central America commonly includes
       beans, corn products, tomatoes, chili peppers, potatoes, milk, cheeses, and eggs, the nurse needs to
       encourage an intake of meats, dark green leafy vegetables, and other high-protein products that are
       rich in iron. Doing so helps to compensate for the significant blood loss and subsequent iron loss that
       occurs during the postpartum period. Additionally, fresh fruits, meats, and green leafy vegetables may
       be scarce, possibly resulting in deficiencies of vitamin A, vitamin D, and iron. Tomatoes are high invitamin C, potatoes are good sources of carbohydrates and vitamin C, and corn products are high in
       thiamine, but these are not rich sources of iron.
       CN: Health promotion and maintenance; CL: Create

Question 19

19. Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal
    inspection, the nurse observes a small, constant trickle of blood. Which of the following conditionsshould the nurse assess further?
20. Retained placental tissue.
21. Uterine inversion.
22. Bladder distention.
23. Perineal lacerations.

Answer 19

19. 4. A small, constant trickle of blood and a firm fundus are usually indicative of a vaginal tear
       or cervical laceration. If the client had retained placental tissue, the fundus would fail to contract
       fully (uterine atony), exhibiting as a soft or boggy fundus. Also, vaginal bleeding would be evident.
       Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on
       inspection. Bladder distention may result in uterine atony because the pressure of the bladder
       displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft,
       possibly boggy, and displaced from midline.
       CN: Reduction of risk potential; CL: Analyze

Question 20

20. At a postpartum checkup 11 days after childbirth, the nurse asks the client about the color of
    her lochia. Which of the following colors is expected?
21. Dark red.
22. Pink.
23. Brown.
24. White.

Answer 20

20. 4. On about the eleventh postpartum day, the lochia should be lochia alba, clear or white in
       color. Lochia rubra, which is dark red to red, may persist for the first 2 to 3 days postpartum. From
       day 3 to about day 10, lochia serosa, which is pink or brown, is normal.
       CN: Health promotion and maintenance; CL: Evaluate

Question 21

21. After instructing a primiparous client about episiotomy care, which of the following client
    statements indicates successful teaching?
22. “I’ll use hot, sudsy water to clean the episiotomy area.”
23. “I wipe the area from front to back using a blotting motion.”
24. “Before bedtime, I’ll use a cold water sitz bath.”
25. “I can use ice packs for 3 to 4 days after birth.”

Answer 21

21. 2. The nurse should instruct the client to cleanse the perineal area with warm water and to
       wipe from front to back with a blotting motion. Warm water is soothing to the tender tissue, and
       wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the
       client’s discomfort and may even burn the client in a very tender area. After the first 24 hours, warm
       water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the
       area. Ice packs are helpful for the first 24 hours.
       CN: Health promotion and maintenance; CL: Evaluate

Question 22

22. A primiparous client, 20 hours after childbirth, asks the nurse about starting postpartum
    exercises. Which of the following would be most appropriate to include in the nurse’s instructions?
23. Start in a sitting position, then lie back, and return to a sitting position, repeating this five
    times.
24. Assume a prone position, and then do push-ups by using the arms to lift the upper body.
25. Flex the knees while supine, and then inhale deeply and exhale while contracting the
    abdominal muscles.
26. Flex the knees while supine, and then bring chin to chest while exhaling and reach for the knees
    by lifting the head and shoulders while inhaling.

Answer 22

22. 3. After an uncomplicated birth, postpartum exercises may begin on the first postpartum day
       with exercises to strengthen the abdominal muscles. These are done in the supine position with the
       knees flexed, inhaling deeply while allowing the abdomen to expand and then exhaling while
       contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to
       a sitting position) and push-ups or exercises involving reaching for the knees are ordinarily too
       strenuous for the first postpartum day. Sit-ups may be done later in the postpartum period, after
       approximately 3 to 6 weeks.
       CN: Health promotion and maintenance; CL: Apply

Question 23

23. A multiparous client whose fundus is firm and midline at the umbilicus 8 hours after a vaginal
    birth tells the nurse that when she ambulated to the bathroom after sleeping for 4 hours, her dark red
    lochia seemed heavier. Which of the following would the nurse include when explaining to the client
    about the increased lochia on ambulation?
24. Her bleeding needs to be reported to the physician immediately.
25. The increased lochia occurs from lochia pooling in the vaginal vault.
26. The increase in lochia may be an early sign of postpartum hemorrhage.
27. This increase in lochia usually indicates retained placental fragments.

Answer 23

23. 2. Lochia can be expected to increase when the client first ambulates. Lochia tends to pool in
       the uterus and vagina when the client is recumbent and flows out when the client arises. If the client
       had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the
       client would be put back in bed and the physician would be notified. Early postpartum hemorrhage
       occurs during the first 24 hours, but typically the fundus is soft or “boggy.” The client’s fundus here is
       firm and midline. Late postpartal hemorrhage, occurring after the first 24 hours, is usually caused by
       retained placental fragments or abnormal involution of the placental site.
       CN: Health promotion and maintenance; CL: Synthesize

Question 24

24. Four hours after giving spontaneous vaginal birth under epidural anesthesia to a viable
    neonate, the client states she needs to urinate. The nurse should next:
25. Catheterize the client to obtain an accurate measurement.
26. Palpate the bladder to determine distention.
27. Assess the fundus to see if it is at the midline.
28. Measure the first two voidings and record the amount.

Answer 24

24. 4. After birth, the nurse should plan to measure the client’s first two voidings and record the
       amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL
       suggest that the client is experiencing urinary retention. In addition, if urinary retention is occurring,the bladder may be palpable and the fundus may be displaced from midline. The client does not need
       to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before
       voiding is unnecessary. However, if the client has difficulty voiding or exhibits signs of urinary
       retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and
       should be assessed after the client voids.
       CN: Health promotion and maintenance; CL: Synthesiz

Question 25

25. A primiparous client who gave birth vaginally 8 hours ago desires to take a shower. The
    nurse anticipates remaining near the client to assess for which of the following?1. Fatigue.
26. Fainting.
27. Diuresis.
28. Hygiene needs.

Answer 25

25. 2. Clients sometimes feel faint or dizzy when taking a shower for the first time after birth
       because of the sudden change in blood volume in the body. Primarily for this reason, the nurse
       remains nearby while the client takes her first shower after birth. If the client becomes dizzy or
       expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If
       the client faints while in the shower, the nurse should cover the client to protect her privacy, stay with
       the client, and call for assistance. Fatigue postpartum is common and will precede taking a shower.
       Diuresis is a normal physiologic response during the postpartum period and not associated with
       showering. Hygiene needs also precede the shower.
       CN: Safety and infection control; CL: Analyze

Question 26

26. A primiparous client who gave birth 12 hours ago under epidural anesthesia with a midline
    episiotomy tells the nurse that she is experiencing a great deal of discomfort when she sits in a chair
    with the baby. Which of the following instructions would be most appropriate?
27. “Ask for some pain medication before you sit down.”
28. “Squeeze your buttock muscles together before sitting down.”
29. “Keep a relaxed posture before sitting down with your full weight.”
30. “Ask the physician for some analgesic cream or spray.”

Answer 26

26. 2. The nurse should instruct the client to squeeze or contract the muscles of the buttocks
       together before sitting down in the chair; this contracts the pelvic floor muscles, which reduces the
       tension on the tender perineal area. Then the client should put her full weight slowly down on the
       chair. Pain medication may only be prescribed for every 3 to 4 hours, so the client may not be able to
       receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades
       by the fifth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the
       pelvic floor muscles. Most physicians prescribe an analgesic cream or spray when a client has an
       episiotomy, but they provide only temporary relief.
       CN: Health promotion and maintenance; CL: Synthesize

Question 27

27. Which of the following would the nurse include in the primiparous client’s discharge teaching
    plan about measures to provide visual stimulation for the neonate?
28. Maintain eye contact while talking to the baby.
29. Paint the baby’s room in bright colors accented with teddy bears.
30. Use brightly colored animals and cartoon figures on the wall.
31. Move a brightly colored rattle in front of the baby’s eyes.

Answer 27

27. 1. Neonates like to look at eyes, and eye-to-eye contact is a highly effective way to provide
       visual stimulation. The parent’s eyes are circular, move from side to side, and become larger and
       smaller. Neonates have been observed to fix on them. In general, neonates prefer circular objects of
       darkness against a white background. Sharp black and white images of geometric figures are
       appropriate. Use of bright colors on the walls and moving a colorful rattle do not provide as much
       visual stimulation as eye-to-eye contact with talking. Brightly colored animals and cartoon figures are
       more appropriate at approximately 1 year of age.
       CN: Health promotion and maintenance; CL: Create

Question 28

28. A primiparous client has just given birth to a healthy male infant. The client and her husband
    are Muslim and the husband begins chanting a song in Arabic while holding the neonate. The nurse
    interprets the father’s actions as indicative of which of the following?
29. Thanking Allah for giving him a male heir.
30. Singing to his son from the Koran in praise of Allah.
31. Expressing appreciation that his wife and son are healthy.
32. Performing a ritual similar to baptism in other religions.

Answer 28

28. 2. The father is praying to Allah because of the Muslim belief that the first sounds a child
       hears should be from the Koran in praise of and supplication to Allah. Although male children are
       revered in this culture, this practice is performed by Muslims whether the child is male or female.
       The father’s actions are unrelated to his wife and son’s being healthy. The nurse should allow the
       practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the
       family. The Muslim faith does not have a baptism rite whereby the child becomes a member of the
       faith.
       CN: Health promotion and maintenance; CL: Analyze

Question 29

29. An adolescent primiparous client 24 hours postpartum asks the nurse how often she can hold
    her baby without “spoiling” him. Which of the following responses would be most appropriate?
30. “Hold him when he is fussy or crying.”
31. “Hold him as much as you want to hold him.”
32. “Try to hold him infrequently to avoid overstimulation.”
33. “You can hold him periodically throughout the day.”

Answer 29

29. 2. According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to,
       singing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation isimportant and should be encouraged. Holding neonates often is unlikely to spoil them because they
       are totally dependent on other human beings to meet their needs. Being held makes infants feel loved
       and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not
       just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.
       CN: Health promotion and maintenance; CL: Synthesize

Question 30

30. On the first postpartum day, the primiparous client reports perineal pain of 5 on a scale of 1
    to 10 that was unrelieved by ibuprofen 800 mg given 2 hours ago. The nurse should further assess the
    client for:
31. Puerperal infection.
32. Vaginal lacerations.
33. History of drug abuse.
34. Perineal hematoma.

Answer 30

30. 4. If the client continues to have perineal pain after an analgesic medication has been given,
       the nurse should inspect the client’s perineum for a hematoma, because this is the usual cause of such
       discomfort. Ibuprofen is a nonsteroidal anti-inflammatory medication used to relieve mild pain. Pain
       from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as
       acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the first 24
       hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such
       as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when
       implemented after the first 24 hours. Typically hematomas resolve themselves within 6 weeks. A
       puerperal infection would be indicated if the client’s temperature were 100.4°F (41°C) or higher.
       Also, lochia most likely would be foul smelling. A continuous trickle of lochia rubra would suggest a
       possible vaginal laceration. No evidence is presented to suggest a history of drug abuse.
       CN: Reduction of risk potential; CL: Analyze

Question 31

31. The nurse assigns an unlicensed assistive personnel to care for a client who is 1 day
    postpartum. Which of the following would be appropriate to delegate to this person? Select all that
    apply.
32. Changing the perineal pad and reporting the drainage.
33. Assisting the mother to latch the infant onto the breast3. Checking the location of the fundus prior to ambulating the client.
34. Reinforcing good hygiene while assisting the client with washing the perineum.
35. Discussing postpartum depression with the client who is found crying.
36. Assisting the client with ambulation shortly after birth.

Answer 31

31. 1, 4, 6. Delegating care to unlicensed assistive personnel requires that the nurse knows which
    tasks are within their capability. Changing the perineal pad and reporting drainage, reinforcing
    hygiene with perineal care, and assisting with ambulation are within the individual’s capacity.
    Unlicensed assistive personnel should never be asked to complete any assessments, such as checking
    fundal location or performing skilled procedures on a client. In addition, it would be beyond the
    scope of the job of unlicensed assistive personnel to assist the mother with latching on and discussing
    postpartum depression with the client. State Boards of nursing list the procedures and tasks that
    unlicensed assistive personnel can complete when directed.
    CN: Management of care; CL: Synthesize

Question 32

32. While the nurse is caring for a primiparous client on the first postpartum day, the client asks,
    “How is that woman doing who lost her baby from prematurity? We were in labor together.” Which of
    the following responses by the nurse would be most appropriate?
33. Ignore the client’s question and continue with morning care.
34. Tell the client “I’m not sure how the other woman is doing today.”
35. Tell the client “I need to ask the woman’s permission before discussing her well-being.”
36. Explain to the client that “Nurses are not allowed to discuss other clients on the unit.”

Answer 32

32. 4. Legal regulations and ethical decision making require that the nurse maintain confidentiality
       at all times. The nurse’s best response is to explain to the client that nurses are not allowed to discuss
       other clients on the unit. Ignoring the client’s question is inappropriate because doing so would
       interfere with the development of a trusting nurse-client relationship. Confidentiality must be
       maintained at all times. Telling the client that the nurse isn’t sure may imply that the nurse will find out
       and then tell the client about the other woman. Asking the other woman’s permission to discuss her
       with another client is inappropriate because confidentiality must be maintained at all times.
       CN: Management of care; CL: Apply

Question 33

33. A newly postpartum primiparous client asks the nurse, “Can my baby see?” Which of the
    following statements about neonatal vision should the nurse include in the explanation?
34. Neonates primarily focus on moving objects.
35. They can see objects up to 12 inches (30.5 cm) away.
36. Usually they see clearly by about 2 days after birth.
37. Neonates primarily distinguish light from dark.

Answer 33

33. 2. The neonate has immature oculomotor coordination, an inability to accommodate for
       distance, and poorly developed eyes, visual nerves, and brain. However, the normal neonate can see
       objects clearly within a range of 9 to 12 inches (22.9 to 30.5 cm), whether or not they are moving.
       Visual acuity at birth is 20/100 to 20/150, but it improves rapidly during infancy and toddlerhood.
       Newborns can distinguish colors as well as light from dark.
       CN: Health promotion and maintenance; CL: Apply

Question 34

34. While assessing the fundus of a multiparous client 36 hours after birth of a term neonate, the
    nurse notes a separation of the abdominal muscles. The nurse should tell the client:
35. She will have a surgical repair at 6 weeks postpartum.
36. To remain on bed rest until resolution occurs.
37. The separation will resolve on its own with the right posture and diet.
38. To perform exercises involving head and shoulder raising in a lying position.

Answer 34

34. 4. The client is experiencing diastasis recti, a separation of the longitudinal muscles (recti) of
       the abdomen that is usually palpable on the third postpartum day. An exercise involving raising thehead and shoulders about 8 inches (20.3 cm) with the client lying on her back with knees bent and
       hands crossed over the abdomen is preferred. This exercise helps to pull the abdominal muscles
       together and the client gradually works up to performing this exercise 50 times per day. However,
       until the diastasis has closed, the client should avoid exercises that rotate the trunk, twist the hips, or
       bend the trunk to one side, because further separation may occur. The condition does not need a
       surgical repair, and limited activity and bed rest are not necessary. Correct posture and adequate diet
       assist the body to return to its prepregnancy state more quickly but do not resolve the separation of
       abdominal muscles.
       CN: Reduction of risk potential; CL: Synthesize

Question 35

35. A postpartum client gave birth 6 hours ago without anesthesia and just voided 100 mL. The
    nurse palpates the fundus two fingerbreadths above the umbilicus and off to the right side. What
    should the nurse do first?
36. Administer ibuprofen.
37. Reassess in 1 hour.
38. Catheterize the client.
39. Obtain a prescription for a fluid bolus.

Answer 35

35. 3. A uterine fundus located off to one side and above the level of the umbilicus is commonly
       the result of a full bladder. Although the client had voided, the client may be experiencing urinary
       retention with overflow. If anesthesia has been used for birth, the inability to void may be related to
       the lingering effects of anesthesia; however, that is not the case here. Physicians commonly write a
       one-time order for catheterization, after which, typically, enough edema has subsided to make it
       easier and less painful for the client to void and completely empty her bladder. Administering
       ibuprofen would have no effect on the uterine fundus. Waiting to reassess in 1 hour could be
       detrimental since the client’s distended bladder is interfering with uterine involution, predisposing her
       to possible hemorrhage. Administering a bolus of fluid would be inappropriate because it would only
       add to the client’s full bladder.
       CN: Reduction of risk potential; CL: Synthesize

Question 36

36. While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago,
    the client asks, “What can I do to get rid of these stretch marks?” Which of the following responses
    would be most appropriate?
37. “As long as you don’t get pregnant again, the marks will disappear completely.”
38. “They usually fade to a silvery-white color over a period of time.”
39. “You’ll need to use a specially prescribed cream to help them disappear.”
40. “If you lose the weight you gained during pregnancy, the marks will fade to a pale pink.”

Answer 36

36. 2. Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly
       over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will
       not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes
       pregnant again. Special creams are not warranted because they are not helpful and may be expensive.
       Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.
       CN: Health promotion and maintenance; CL: Synthesize

Question 37

37. A primiparous client who gave vaginal birth to a viable term neonate 48 hours ago has a
    midline episiotomy and repair of a third-degree laceration. When preparing the client for discharge,
    which of the following assessments would be most important?
38. Constipation.
39. Diarrhea.3. Excessive bleeding.
40. Rectal fistulas.

Answer 37

37. 1. The client with a third-degree laceration should be assessed for constipation, because a
       third-degree laceration extends into a portion of the anal sphincter. Constipation, not diarrhea, is more
       likely because this condition is extremely painful, possibly causing the client to be reluctant to have a
       bowel movement. The laceration has been sutured and should not be bleeding at 48 hours postpartum.
       Rectal fistulas may develop at a later time, but not at 48 hours postpartum.
       CN: Reduction of risk potential; CL: Create

Question 38

38. In preparation for discharge, the nurse discusses sexual issues with a primiparous client who
    had a routine vaginal birth with a midline episiotomy. The nurse should instruct the client that she can
    resume sexual intercourse:
39. In 6 weeks when the episiotomy is completely healed.
40. After a postpartum check by the health care provider.
41. Whenever the client is feeling amorous and desirable.
42. When lochia flow and episiotomy pain have stopped.

Answer 38

38. 4. For most clients, sexual intercourse can be resumed when the lochia has stopped flowing
       and episiotomy pain has ceased, usually about 3 weeks postpartum. Sexual intercourse may be painful
       until the episiotomy has healed. The client also needs instructions about the possibility that pregnancy
       may occur before the return of the client’s menstrual flow. The postpartum check by the health care
       provider typically occurs 4 to 6 weeks after birth and most women have already had intercourse by
       this time. Typically, new mothers are exhausted and may not feel amorous or desirable for quite a
       while. In addition, the mother’s physiologic responses may be diminished because of low hormonal
       levels, adjustments to the maternal role, and fatigue due to lack of rest and sleep.
       CN: Health promotion and maintenance; CL: Synthesize

Question 39

39. While caring for a multiparous client 4 hours after vaginal birth of a term neonate, the nurse
    notes that the mother’s temperature is 99.8°F (37.2°C), the pulse is 66 bpm, and the respirations are
    18 breaths/min. Her fundus is firm, midline, and at the level of the umbilicus. The nurse should:
40. Continue to monitor the client’s vital signs.
41. Assess the client’s lochia for large clots.
42. Notify the client’s physician about the findings.
43. Offer the mother an ice pack for her forehead.

Answer 39

39. 1. The nurse needs to continue to monitor the client’s vital signs. During the first 24 hourspostpartum it is normal for the mother to have a slight temperature elevation because of dehydration.
       A temperature of 100.4°F (38°C) that persists after the first 24 hours may indicate an infection.
       Bradycardia during the first week postpartum is normal because of decreased blood volume, diuresis,
       and diaphoresis. The client’s respiratory rate is within normal limits. Large clots are indicative of
       hemorrhage. However, the client’s vital signs are within normal limits and her fundus is firm and
       midline. Therefore, large clots and possible hemorrhage can be ruled out. The physician does not
       need to be notified at this time. An ice pack is not necessary because the client’s temperature is within
       normal limits.
       CN: Health promotion and maintenance; CL: Synthesize

Question 40

40. While assessing the episiotomy site of a primiparous client on the first postpartum day, the
    nurse observes a fairly large hemorrhoid at the client’s rectum. After instructing the client about
    measures to relieve hemorrhoid discomfort, which of the following client statements indicates the
    need for additional teaching?
41. “I should try to gently manually replace the hemorrhoid.”
42. “Analgesic sprays and witch hazel pads can relieve the pain.”
43. “I should lie on my back as much as possible to relieve the pain.”
44. “I should drink lots of water and eat foods that have a lot of roughage.”

Answer 40

40. 3. The client needs more teaching when she states, “I should lie on my back as much as
       possible to relieve the pain.” Instead, the client should lie in the Sims position as much as possible to
       aid venous return to the rectal area and to reduce discomfort. Gentle manual replacement of the
       hemorrhoid is an appropriate measure to help relieve the discomfort and prevent enlargement.
       Analgesic sprays and witch hazel pads are helpful in reducing the discomfort of hemorrhoids.
       Drinking lots of water and eating roughage aid in bowel elimination, minimizing the risk of straining
       and subsequent hemorrhoidal development or enlargement.
       CN: Basic care and comfort; CL: Evaluate

Question 41

41. A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and
    speaks only Spanish. The client’s mother asks the nurse if she can bring her daughter some “special
    foods from home.” The nurse responds based on the understanding about which of the following?
42. Foods from home are generally discouraged on the postpartum unit.
43. The mother can bring the daughter any foods that she desires.
44. This is permissible as long as the foods are nutritious and high in iron.
45. The client’s physician needs to give permission for the foods.

Answer 41

41. 2. On most postpartum units, clients on regular diets are allowed to eat whatever kinds of
       food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain
       the physician’s permission. Although it is preferred, the foods do not necessarily have to be high in
       iron. In some cultures, there is a belief in the “hot-cold” theory of disease; certain foods (hot) are
       preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse
       should allow the mother to bring her daughter “special foods from home.” Doing so demonstrates
       cultural sensitivity and aids in developing a trusting relationship.
       CN: Basic care and comfort; CL: Synthesize

Question 42

42. A primiparous client, 48 hours after a vaginal birth, is to be discharged with a prescription
    for vitamins with iron because she is anemic. To maximize absorption of the iron, the nurse instructs
    the client to take the medication with which of the following?
43. Orange juice.
44. Herbal tea.
45. Milk.
46. Grape juice.

Answer 42

42. 1. Iron is best absorbed in an acid environment or with vitamin C. For maximum iron
       absorption, the client should take the medication with orange juice or a vitamin C supplement. Herbal
       tea has no effect on iron absorption. Milk decreases iron absorption. Grape juice is not acidic and
       therefore would have no effect on iron absorption.
       CN: Pharmacological and parenteral therapies; CL: Synthesize

Question 43

43. The nurse is caring for a multiparous client after vaginal birth of a set of male twins 2 hours
    ago. The nurse should encourage the mother and husband to:
44. Bottle-feed the twins to prevent exhaustion and fatigue.
45. Plan for each parent to spend equal amounts of time with each twin.3. Avoid assistance from other family members until attachment occurs.
46. Relate to each twin individually to enhance the attachment process.

Answer 43

43. 4. It is believed that the process of attachment is structured so that the parents become
       attached to only one infant at a time. Therefore, the nurse should encourage the parents to relate to
       each twin individually, rather than as a unit, to enhance the attachment process. Mothers of twins are
       usually able to breast-feed successfully because the milk supply increases on demand. However,
       possible fatigue and exhaustion require that the mother rest whenever possible. It would be highly
       unlikely and unrealistic that each parent would be able to spend equal amounts of time with both
       twins. Other responsibilities, such as employment, may prevent this. The parents should try to engage
       assistance from family and friends, because caring for twins or other multiple births (eg, triplets) can
       be exhausting for the family.
       CN: Psychosocial integrity; CL: Synthesize

Question 44

44. Twelve hours after a vaginal birth with epidural anesthesia, the nurse palpates the fundus of a
    primiparous client and finds it to be firm, above the umbilicus, and deviated to the right. Which of the
    following would the nurse do next?
45. Document this as a normal finding in the client’s record.
46. Contact the physician for a prescription for oxytocin.
47. Encourage the client to ambulate to the bathroom and void.
48. Gently massage the fundus to expel the clots.

Answer 44

44. 3. At 12 hours postpartum, the fundus normally should be in the midline and at the level of the
       umbilicus. When the fundus is firm yet above the umbilicus, and deviated to the right rather than in themidline, the client’s bladder is most likely distended. The client should be encouraged to ambulate to
       the bathroom and attempt to void, because a full bladder can prevent normal involution. A firm but
       deviated fundus above the level of the umbilicus is not a normal finding and if voiding does not return
       it to midline, it should be reported to the physician. Oxytocin is used to treat uterine atony. This
       client’s fundus is firm, not boggy or soft, which would suggest atony. Gentle massage is not necessary
       because there is no evidence of atony or clots.
       Reduction of risk potential; CL: Synthesize

Question 45

45. A nurse is discussing discharge instructions with a client. Which of the following statements
    indicate that the client understands the resources and information available if needed after discharge?
    Select all that apply.
46. “I know to wait 2 weeks before I start my birth control pills.”
47. “I have the hospital phone number if I have any questions.”
48. “If I have any breathing problems, chest pain, or pounding fast heart rate, I will seek medical
    assistance.”
49. “My mother is coming to help for a month so I will be fine.”
50. “I know if I get fever or chills or change in lochia to call the physician.”
51. “I will continue my prenatal vitamins until my postpartum checkup or longer.”

Answer 45

45. 2, 3, 5, 6. The nurse is responsible for providing discharge instructions that include signs and
    symptoms that need to be reported to the physician as well as resources and follow-up for home care
    if needed. Phone numbers and health practices to promote healing, such as the use of prenatal
    vitamins, are also essential pieces of information. The use of birth control pills needs to be discussed
    with the physician. A progesterone-only pill is used if the client is breast-feeding. Oral
    contraceptives should be initiated according to the physician’s advice. Although the client’s mother
    may be helpful, the client’s statement that she will be fine because her mother is coming indicates that
    she is unaware or ignoring information about valuable information and resources.
    CN: Reduction of risk potential; CL: Evaluate

Question 46

The Postpartal Client Who Breast-Feeds

46. The nurse is reviewing discharge instructions with a postpartum breast-feeding client who is
    going home. She has chosen medroxyprogesterone (Depo-Provera) as birth control. Which statement
    by the client identifies that she needs further instruction concerning birth control?
47. “I will wait for my 6-week checkup to get my first Depo-Provera shot.”
48. “Depo-Provera injections last for 90 days.”
49. “My milk supply should be well established before using Depo-Provera.”
50. “You will give me my first Depo-Provera shot before I leave today.”

Answer 46

The Postpartal Client Who Breast-feeds
46. 4. Depo-Provera is a progestin contraceptive that can reduce the initial production of breast
milk. It is given to a breast-feeding woman when she returns for the 6-week postpartum checkup. By
this time, the milk supply is well established and will remain at that level. Depo-Provera is effective
as a contraceptive for 90 days. Clients who are bottle-feeding may be given Depo-Provera prior to
discharge from the hospital.
CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 47

47. A postpartum primiparous client is having difficulty breast-feeding her infant. The infant
    latches on to the breast, but the mother’s nipples are extremely sore during and after each feeding. The
    client needs further instruction about breast-feeding when she states:
48. “The baby needs to have as much of the nipple and areola in his mouth as possible to prevent
    sore and cracked nipples.”
49. “I can put breast milk on my nipples to heal the sore areas.”
50. “As long as some of my nipple is in the baby’s mouth, the baby will receive enough milk.”
51. “Feeding the baby for a half-hour on each side will not make my breasts sore.”

Answer 47

47. 3. As much of the mother’s nipple and areola need to be in the infant’s mouth in order to
       establish a latch that does not cause nipple cracks or fissures. Having the nipple and the areola deep
       in the infant’s mouth decreases the stress on the end of the nipple, therefore decreasing pain, cracking,
       and fissures. Breast milk has been found to heal nipples when placed on the nipple at the completion
       of a feeding. The length of time the baby feeds on each nipple is not a factor as long as the nipple is
       correctly placed in the infant’s mouth.
       CN: Health promotion and maintenance; CL: Evaluate

Question 48

48. The nurse is caring for a primipara who gave birth yesterday and has chosen to breast-feed
    her neonate. Which assessment finding is considered unusual for the client at this point postpartum?
49. Milk production.
50. Diaphoresis.
51. Constipation.
52. Diuresis.

Answer 48

48. 1. New mothers usually begin to produce milk at about the third day postpartum and colostrum
       is produced until that time. For clients who have breast-fed another infant during pregnancy, having
       milk shortly after birth is not unusual. Diaphoresis and diuresis are considered normal during this
       time as the body excretes the additional fluids that are no longer needed after the pregnancy.
       Constipation may continue for several days as a result of progesterone remaining in the system, the
       consummation of iron, and trauma to the perineum.
       CN: Physiological adaptation; CL: Analyze

Question 49

49. The nurse is caring for several mother-baby couplets. In planning the care for each of the
    couplets, which mother would the nurse expect to have the most severe afterbirth pains?
50. G 4, P 1 client who is breast-feeding her infant.
51. G 3, P 3 client who is breast-feeding her infant.
52. G 2, P 2 cesarean client who is bottle-feeding her infant.
53. G 3, P 3 client who is bottle-feeding her infant.

Answer 49

49. 2. The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus
       during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by
       intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas
       in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulatesuterine contractions. There are no data to suggest any of these clients has had an overdistended uterus
       or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest
       parity of the clients listed, which—in addition to breast-feeding—places her most at risk for
       afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G
       3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because
       she has given birth to several children, but her choice to bottle-feed reduces her risk of pain.
       CN: Physiological adaptation; CL: Evaluate

Question 50

50. A breast-feeding client is seen at home by the visiting nurse 10 days after a vaginal birth. The
    client has a warm, red, painful breast; a temperature of 100°F (37.7°C); and flulike symptoms. What
    should the nurse do?
51. Encourage the client to breast-feed her infant using the unaffected breast.
52. Refer the woman to her primary health care provider.
53. Inform the client that she needs to discontinue breast-feeding.
54. Instruct the woman to apply warm compresses to the affected breast.

Answer 50

hould instruct her to contact her health care provider, who will likely prescribe a prescription for
antibiotics. She should continue to breast-feed the infant from both breasts. Frequent breast-feeding is
encouraged rather than discontinuing the process for anyone having a breast infection. Applying warm
compresses may relieve pain. However, the underlying infection indicated by the elevated
temperature indicates that additional treatment with antibiotics will be needed.
CN: Management of care; CL: Synthesize

Question 51

51. A diabetic postpartum client plans to breast-feed. The nurse determines that the client’s
    understanding of breast-feeding instructions is sufficient when she states:
52. “Insulin will be transferred to the baby through breast milk.”
53. “Breast-feeding is not recommended for diabetic mothers.”
54. “Breast milk from diabetic mothers contains few antibodies.”
55. “Breast-feeding will assist in lowering maternal blood glucose.”

Answer 51

51. 4. Breast-feeding consumes maternal calories and requires energy that increases the maternal
       basal metabolic rate and assists in lowering the maternal blood glucose level. Insulin is not
       transferred to the infant through breast milk. Breast-feeding is recommended for diabetic mothers
       because it does lower blood glucose levels. The number of antibodies in breast milk is not altered by
       maternal diabetes.
       CN: Physiological adaptation; CL: Evaluate

Question 52

52. A 1-day-old breast-fed infant has a bilirubin level that is at an intermediate risk for jaundice.
    Which statement by the infant’s mother indicates an understanding of the teaching regarding jaundice?
53. I should breast-feed my baby as often as possible.
54. I should supplement with formula after every feeding.
55. I should discontinue breast-feeding and change to formula feeding.
56. I should place my baby in direct sunlight several times a day.

Answer 52

52. 1. Jaundice in a breast-feeding infant is common and is not pathological. Mothers should be
       taught to breast-feed as often as possible, at least every 2 to 3 hours and until the infant is satiated.
       Breast-fed babies rarely need to be supplemented with formula. Mothers should be encouraged to
       continue breast-feeding their infants due to the numerous benefits it provides. Infants should never be
       placed in direct sunlight.
       CN: Health promotion and maintenance; CL: Evaluate

Question 53

53. During a home visit, a breast-feeding client asks the nurse what contraception method she and
    her husband should use until she has her 6-week postpartal examination. Which of the following
    would be most appropriate for the nurse to suggest?
54. Condom with spermicide.
55. Oral contraceptives.
56. Rhythm method.
57. Abstinence.

Answer 53

53. 1. If not contraindicated for moral, cultural, or religious reasons, a condom with spermicide is
       commonly recommended for contraception after birth until the client’s 6-week postpartal examination.
       This method has no effect on the neonate who is breast-feeding. Oral contraceptives containing
       estrogen are not advised for women who are breast-feeding because the hormones decrease the
       production of breast milk. Women who are not breast-feeding may use oral contraceptive agents. The
       rhythm method is not effective because the client is unlikely to be able to determine when ovulation
       has occurred until her menstrual cycle returns. Although breast-feeding is not considered an effective
       form of contraception, breast-feeding usually delays the return of both ovulation and menstruation.
       The length of the delay varies with the duration of lactation and the frequency of breast-feeding.
       While abstinence is one form of birth control and safe while breast-feeding, it may not be acceptable
       to this couple who is asking about a method that will allow them to resume sexual relations.
       CN: Health promotion and maintenance; CL: Synthesize

Question 54

54. A primiparous client who is beginning to breast-feed her neonate asks the nurse, “Is it
    important for my baby to get colostrum?” When instructing the client, the nurse would explain that
    colostrum provides the neonate with:
55. More fat than breast milk.
56. Vitamin K, which the neonate lacks.
57. Delayed meconium passage.
58. Passive immunity from maternal antibodies.

Answer 54

54. 4. Colostrum is a thin, watery, yellow fluid composed of protein, sugar, fat, water, minerals,
       vitamins, and maternal antibodies (eg, immunoglobulin A). It is important for the neonate to receive
       colostrum for passive immunity. Colostrum is lower in fat and lactose than mature breast milk.
       Colostrum does not contain vitamin K. The neonate will produce vitamin K once a feeding pattern isestablished. Colostrum may speed, rather than delay, the passage of meconium.
       CN: Health promotion and maintenance; CL: Apply

Question 55

55. Which of the following forms the basis for the teaching plan about avoiding medication use
    unless prescribed for a primiparous client who is breast-feeding?
56. Breast milk quality and richness are decreased.
57. The mother’s motivation to breast-feed is diminished.
58. Medications may be excreted in breast milk to the nursing neonate.
59. Medications interfere with the mother’s let-down reflex.

Answer 55

55. 3. Various medications can be excreted in the breast milk and affect the nursing neonate. The
       client should avoid all nonprescribed medications (such as acetaminophen) unless approved by the
       primary care provider. Medications typically do not affect the quality of the mother’s breast milk.
       Medications usually do not interfere with or diminish the mother’s motivation to breast-feed, nor do
       they interfere with the mother’s let-down reflex.
       CN: Health promotion and maintenance; CL: Apply

Question 56

56. A breast-feeding primiparous client with a midline episiotomy is prescribed ibuprofen
    (Motrin) 200 mg orally. The nurse instructs the client to take the medication:
57. Before going to bed.
58. Midway between feedings.
59. Immediately after a feeding.
60. When providing supplemental formula.

Answer 56

56. 3. Taking ibuprofen 200 mg orally immediately after breast-feeding helps minimize the
       neonate’s exposure to the drug because drugs are most highly concentrated in the body soon after they
       are taken. Most mothers breast-feed on demand or every 2 to 3 hours, so the effects of the ibuprofen
       should be decreased by the next breast-feeding session. Taking the medication before going to bed is
       inappropriate because, although the mother may go to bed at a certain time, the neonate may wish to
       breast-feed soon after the mother goes to bed. If the mother takes the medication midway between
       feedings, then its peak action may occur midway between feedings. Breast milk is sufficient for the
       neonate’s nutritional needs. Most breast-feeding mothers should not be encouraged to provide
       supplemental feedings to the infant because this may result in nipple confusion.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 57

57. A multiparous client, 28 hours after cesarean birth, who is breast-feeding has severe cramps
    or afterpains. The nurse explains that these are caused by which of the following?
58. Flatulence accumulation after a cesarean birth.
59. Healing of the abdominal incision after cesarean birth.
60. Adverse effects of the medications administered after birth.
61. Release of oxytocin during the breast-feeding session.

Answer 57

57. 4. Breast-feeding stimulates oxytocin secretion, which causes the uterine muscles to contract.
       These contractions account for the discomfort associated with afterpains. Flatulence may occur after a
       cesarean birth. However, the mother typically would have abdominal distention and a bloating
       feeling, not a “cramplike” feeling. Stretching of the tissues or healing may cause slight tenderness or
       itching, not cramping feelings of discomfort. Medications such as mild analgesics or stool softeners,
       commonly administered postpartum, typically do not cause cramping.
       CN: Health promotion and maintenance; CL: Apply

Question 58

58. After the nurse counsels a primiparous client who is breast-feeding her neonate about diet
    and nutritional needs during the lactation period, which of the following client statements indicates a
    need for additional teaching?
59. “I need to increase my intake of vitamin D.”2. “I should drink at least five glasses of fluid daily.”
60. “I need to get an extra 500 cal/day.”
61. “I need to make sure I have enough calcium in my diet.”

Answer 58

58. 2. For the breast-feeding client, drinking at least 8 to 10 glasses of fluid a day is
       recommended. Breast-feeding women need an increased intake of vitamin D for calcium absorption.
       A breast-feeding woman requires an extra 500 cal/day above the recommended nonpregnancy intake
       to produce quality breast milk. Breast-feeding women need adequate calcium for blood clotting and
       strong bones and teeth.
       CN: Basic care and comfort; CL: Evaluate

Question 59

59. A breast-feeding primiparous client asks the nurse how breast milk differs from cow’s milk.
    The nurse responds by saying that breast milk is higher in which of the following?
60. Fat.
61. Iron.
62. Sodium.
63. Calcium.

Answer 59

59. 1. Breast milk has a higher fat content than cow’s milk. Thirty to fifty-five percent of the
       calories in breast milk are from fat. Breast milk contains less iron than cow’s milk does. However,
       the iron absorption from breast milk is greater in the neonate than with cow’s milk. Breast milk
       contains less sodium and calcium than cow’s milk.
       CN: Basic care and comfort; CL: Apply

Question 60

60. While assisting a primiparous client with her first breast-feeding session, which of the
    following actions should the nurse instruct the mother to do to stimulate the neonate to open the mouth
    and grasp the nipple?
61. Pull down gently on the neonate’s chin and insert the nipple.
62. Squeeze both of the neonate’s cheeks simultaneously.
63. Place the nipple into the neonate’s mouth on top of the tongue.
64. Brush the neonate’s lips lightly with the nipple.

Answer 60

60. 4. Lightly brushing the neonate’s lips with the nipple causes the neonate to open the mouth and
       begin sucking. The neonate should be taught to open the mouth and grasp the nipple on his or her own.
       The neonate should not be forced to nurse.
       CN: Health promotion and maintenance; CL: Apply

Question 61

61. A 25-year-old primiparous client who gave birth 2 hours ago has decided to breast-feed her
    neonate. Which of the following instructions should the nurse address as the highest priority in the
    teaching plan about preventing nipple soreness?
62. Keeping plastic liners in the brassiere to keep the nipple drier.
63. Placing as much of the areola as possible into the baby’s mouth.
64. Smoothly pulling the nipple out of the mouth after 10 minutes.
65. Removing any remaining milk left on the nipple with a soft washcloth

Answer 61

61. 2. Several methods can be used to prevent nipple soreness. Placing as much of the areola as
       possible into the neonate’s mouth is one method. This action prevents compression of the nipple
       between the neonate’s gums, which can cause nipple soreness. Other methods include changing
       position with each feeding, avoiding breast engorgement, nursing more frequently, and feeding on
       demand. Plastic liners are not helpful because they prevent air circulation, thus promoting nipple
       soreness. Instead, air drying is recommended. Pulling the baby’s mouth out smoothly after only 10
       minutes may prevent the baby from getting the entire feeding and increases nipple soreness. Any
       breast milk remaining on the nipples should not be wiped off, because the milk has healing properties.
       CN: Health promotion and maintenance; CL: Synthesize

Question 62

62. Which of the following client statements indicates effective teaching about burping a breast-
    fed neonate?
63. “Breast-fed babies who are burped frequently will take more on each breast.”
64. “If I supplement the baby with formula, I will rarely have to burp him.”
65. “I’ll breast-feed my baby every 3 hours so I won’t have to burp him.”
66. “When I switch to the other breast, I’ll burp the baby.”

Answer 62

62. 4. Breast-fed neonates do not swallow as much air as bottle-fed neonates, but they still need
       to be burped. Good times to burp the neonate are when the mother switches from one breast to the
       other and at the end of the breast-feeding session. Neonates do not eat more if they are burped
       frequently. Breast-feeding mothers are advised not to supplement the feedings with formula because
       this may cause nipple confusion and decrease milk production. If supplements are given, the baby still
       needs to be burped. Neonates who are fed every 3 hours still need to be burped.
       CN: Health promotion and maintenance; CL: Evaluate

Question 63

63. After the nurse teaches a primiparous client planning to return to work in 6 weeks about
    storing breast milk, which of the following client statements indicates the need for further teaching?
64. “I can let the milk sit out in a bottle for up to 10 hours.”
65. “I’ll be sure to label the milk with the date, time, and amount.”
66. “I can safely store the milk for 3 days in the refrigerator.”
67. “I can keep the milk in a deep freeze in clean glass bottles for up to 1 year.”

Answer 63

63. 3. Stored breast milk can be safely kept in the refrigerator for up to 7 days or in a deep freeze
       at 0°F (−18°C) for 12 months. Breast milk should be stored in glass containers because
       immunoglobulin tends to stick to plastic bottles. Breast milk can remain without refrigeration or loss
       of nutrients for up to 10 hours. The containers should be labeled with date, time, and amount to
       prevent inadvertent administration of spoiled milk. Frozen breast milk should be thawed in the
       refrigerator for a few hours, placed under warm tap water, and then shaken.
       CN: Health promotion and maintenance; CL: Evaluate

Question 64

64. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she
    is aware of a “let-down sensation” in her breasts and asks what causes it. The nurse explains that the
    let-down sensation is stimulated by which of the following?
65. Adrenalin.
66. Estrogen.
67. Prolactin.
68. Oxytocin.

Answer 64

64. 4. Oxytocin stimulates the let-down reflex when milk is carried to the nipples. A lactating
       mother can experience the let-down reflex suddenly when she hears her baby cry or when she
       anticipates a feeding. Some mothers have reported feeling the let-down reflex just by thinking about
       the baby. Adrenalin may increase if the mother is excited, but this hormone has no direct influence on
       breast-feeding. Estrogen influences development of female secondary sex characteristics and controls
       menstruation. Prolactin stimulates milk production.
       CN: Health promotion and maintenance; CL: Apply

Question 65

65. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she
    has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that
    before nursing her baby, the client should do which of the following?
66. Apply an ice cube to the nipples.
67. Rub her nipples gently with lanolin cream.
68. Express a small amount of breast milk.
69. Offer the neonate a small amount of formula.

Answer 65

65. 3. Expressing a little milk before nursing, massaging the breasts gently, or taking a warm
       shower before feeding also may help to improve milk flow. Although various measures such as ice,
       heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by
       frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast
       engorgement. However, it may temporarily relieve the discomfort associated with breast
       engorgement. Using lanolin on the nipples does not relieve breast engorgement and is unnecessary.
       Use of lanolin may cause sensitivity and irritation. Having frequent breast-feeding sessions, rather
       than offering the neonate a small amount of formula, is the method of choice for preventing and
       relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in
       nipple confusion.
       CN: Health promotion and maintenance; CL: Apply

Question 66

66. A breast-feeding primiparous client who gave birth 8 hours ago asks the nurse, “How will I
    know that my baby is getting enough to eat?” Which of the following guidelines should the nurse
    include in the teaching plan as evidence of adequate intake?
67. Six to eight wet diapers by the fifth day.
68. Three to four transitional stools on the fourth day.
69. Ability to fall asleep easily after feeding on the first day.
70. Regain of lost birth weight by the third day.

Answer 66

66. 1. The nurse should instruct the client that the baby is getting enough to eat when there are sixto eight wet diapers by the fifth day of age. Other signs include good suckling sounds during feeding,
       dripping breast milk at the mouth, and quiet rest or sleep after the feeding. By the fourth day of age,
       the infant should have soft yellow stools, not transitional (greenish) stools. Falling asleep easily after
       feeding on the first day is not a good indicator because most infants are sleepy during the first 24
       hours. Most infants regain their lost birth weight in 7 to 10 days after birth. An infant who has gained
       weight during the first well-baby checkup (usually at 2 weeks) is getting sufficient breast milk at
       feedings.
       CN: Health promotion and maintenance; CL: Apply

Question 67

67. Which of the following should the nurse include in the teaching plan for a primiparous client
    who asks about weaning her neonate?
68. “Wait until you have breast-fed for at least 4 months.”
69. “Eliminate the baby’s favorite feeding times first.”
70. “Plan to omit the daytime feedings last.”
71. “Gradually eliminate one feeding at a time.”

Answer 67

67. 4. The client should wean the infant gradually, eliminating one feeding at a time. The baby can
       be weaned to a bottle (formula) anytime the mother desires; she does not have to breast-feed for 4
       months. Most infants (and mothers) develop a “favorite feeding time,” so this feeding session should
       be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is
       busy.
       CN: Health promotion and maintenance; CL: Create

Question 68

68. Two weeks after a breast-feeding primiparous client is discharged, she calls the birthing
    center and says that she is afraid she is “losing my breast milk. The baby had been nursing every 4
    hours, but now she’s crying to be fed every 2 hours.” The nurse interprets the neonate’s behavior as
    most likely caused by which of the following?
69. Lack of adequate intake to meet maternal nutritional needs.
70. The mother’s fears about the baby’s weight gain.
71. Preventing the neonate from sucking long enough with each feeding.
72. The neonate’s temporary growth spurt, which requires more feedings.

Answer 68

68. 4. Neonates normally increase breast-feeding during periods of rapid growth (growth spurts).
       These can be expected at age 10 to 14 days, 5 to 6 weeks, 2.5 to 3 months, and 4.5 to 6 months. Each
       growth spurt is usually followed by a regular feeding pattern. Lack of adequate intake to meet
       maternal nutritional needs is not associated with the neonate’s desire for more frequent breast-feeding
       sessions. However, an intake of adequate calories is necessary to produce quality breast milk. The
       mother’s fears about weight gain and preventing the neonate from sucking long enough are not
       associated with the desire for more frequent breast-feeding sessions.
       CN: Health promotion and maintenance; CL: Analyze

Question 69

69. During a home visit to a breast-feeding primiparous client at 1 week postpartum, the client
    tells the nurse that her nipples have become sore and cracked from the feedings. Which of the
    following should the nurse instruct the client to do?
70. Wipe off any lanolin creams from the nipple before each feeding.
71. Position the baby with the entire areola in the baby’s mouth.
72. Feed the baby less often for the next several days.
73. Use a mild soap while in the shower to prevent an infection.

Answer 69

69. 2. Even if the nipples are sore and cracked, the mother should position the baby with the
       entire areola in the baby’s mouth so that the nipple is not compressed between the baby’s gums during
       feeding. The best method is to prevent cracked nipples before they occur. This can be done by feeding
       frequently and using proper positioning. Warm, moist tea bags can soothe cracked nipples because of
       tannic acid in the tea. Creams on the nipples should be avoided; wiping off any lanolin creams from
       the nipple before each feeding can cause further soreness. Feeding the baby less often for the next few
       days will cause engorgement (and possible neonatal weight loss), leading to additional problems.
       Soap use while in the shower should be avoided to prevent drying and removal of protective oils.
       CN: Reduction of risk potential; CL: Synthesize

Question 70

70. A new father indicates he feels left out of the new family relationship since he is not able to
    bond the same way as the breast-feeding mother. What is the most appropriate response by the nurse?
71. This is normal and these feelings will go away within a few days.
72. Holding, talking to, and playing with the infant will facilitate bonding between baby and Dad.
73. Bonding occurs later in the first year of life and Dad can become involved when the infant is
    better able to recognize him.
74. Maternal infant bonding takes priority over paternal infant bonding.

Answer 70

70. 2. Time for bonding with their newborns is a frequent concern for fathers of breastfed babies.
       It is common for fathers to express concern about having less intimate contact time. These feelings are
       normal, but they do not go away in a few days. The father of the baby has to dedicate time to spend
       with the infant where he can talk to, hold, cuddle, and/or play with the infant. These strategies
       provide the infant with the contact and stimulation to establish a close bond between them. Bonding
       occurs from the moment of birth and continues in various ways between mother, father, and infant.
       Infants recognize and respond to touch, light, and voice immediately after birth. Bonding between
       both parents is equally important and one does not take priority over the other.
       CN: Psychosocial integrity; CL: Apply

Question 71

71. The triage nurse in the pediatrician’s office returns a call to a mother who is breast-feeding
    her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since
    discharge home. What is the best reply by the nurse?
72. This type of stool indicates the infant may have diarrhea and should be seen in the office today.
73. The stool will transition into a soft brown formed stool within a few days and is appropriate
    for breast-feeding.
74. The stool results from the gassy food eaten by the mother. Instruct the mother to refrain from
    eating these foods while breast-feeding.
75. Soft seedy unformed stools with each feeding are normal for this age infant and will continue
    through breast-feeding.

Answer 71

71. 4. A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as
       it is a change from the meconium the infant had since birth. This stool is not diarrhea even though ithas no form. There is no need for the infant to be seen for this. As long as the infant is breast-feeding,
       the stools will remain of this color and consistency. Brown and formed stool is common for an infant
       who is bottle-fed or after the breast-feeding infant has begun eating food.
       CN: Physiologic adaptation; CL: Apply

Question 72

The Postpartal Client Who Bottle-Feeds

72. The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal birth. The
    mother is bottle-feeding her baby. Which client finding indicates a problem at this time?
73. Firm fundus at the symphysis.
74. White, thick vaginal discharge.
75. Striae that are silver in color.
76. Soft breasts without milk

Answer 72

The Postpartal Client Who Bottle-Feeds
72. 1. By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a
nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem
associated with a uterus that is larger than expected at this time. Normal expectations include a white,
thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without
evidence of milk production (in a bottle-feeding mother).
CN: Physiological adaptation; CL: Analyze

Question 73

73. A client gave birth 2 days ago and has been given instructions on breast care for bottle-
    feeding mothers. Which of the following statements indicates that the nurse should reinforce the
    instructions to the client?
74. “I will wear a sports bra or a well-fitting bra for several days.”
75. “When showering, I’ll direct water onto my shoulders.”
76. “I will use only water to clean my nipples.”
77. “I will use a breast pump to remove any milk that may appear.”

Answer 73

73. 4. The use of a breast pump to remove milk is contraindicated in bottle-feeding mothers.
       Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk
       production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports
       bra that is well fitting provides support and decreases stimulation. (Binders are not suggested.)
       Having the water in a shower land on the shoulders of the mother rather than the breasts also
       decreases stimulation. Only water is necessary to clean nipples when breast or bottle-feeding.
       CN: Basic care and comfort; CL: Evaluate

Question 74

74. A 24-year-old primipara who has given birth to a healthy neonate plans to bottle-feed her
    neonate. What information regarding normal weight gain should the nurse include in the teaching
    plan?
75. A baby normally loses 15% of weight before beginning to gain weight.
76. Adding rice cereal to the bottle is a good way to increase calories if weight gain is slow.
77. Gaining 30 g/day is a normal weight gain pattern.
78. Babies typically double birth weight by 3 months.

Answer 74

74. 3. Gaining 30 g (1 oz) a day is normal for a neonate. Initial weight loss that exceeds 10% of
       birth weight is abnormal. Adding rice cereal to a bottle without a medical indication increases the
       risk of aspiration and may promote obesity. Doubling the birth weight is typical at 5 months.
       CN: Basic care and comfort; CL: Apply

Question 75

75. A primiparous client with a neonate who is 36 hours old asks the nurse, “Why does my baby
    spit up a small amount of formula after feeding?” The nurse explains that the regurgitation is thought
    to result from which of the following?
76. An immature cardiac sphincter.
77. A defect in the gastrointestinal system.
78. Burping the infant too frequently.
79. Moving the infant during the feeding.

Answer 75

75. 1. Initial regurgitation in the neonate during the first 12 to 24 hours may be caused by
       excessive mucus and gastric irritation from foreign substances in the stomach. After the first 24 hours,
       regurgitation is thought to be caused by the neonate’s immature cardiac sphincter. It represents an
       overflow of stomach contents and is probably a result of feeding the neonate too fast or too much. A
       defect in the gastrointestinal system usually results in more severe symptoms. A small amount of
       regurgitation is normal, but vomiting or forceful fluid expulsion is not. Burping the infant often during
       a feeding can decrease the amount of air in the stomach from swallowing. However, burping too often
       can lead the neonate to become tired or fussy. Moving the infant usually does not result in
       regurgitation.
       CN: Health promotion and maintenance; CL: Apply

Question 76

76. A primiparous client who will be bottle-feeding her neonate asks, “What is the best position
    for the baby after feeding?” Which of the following positions should the nurse recommend to aid
    digestion?
77. Supine position.
78. On the left side.
79. Prone without a pillow.
80. Sitting on the caregiver’s lap for 20 minutes.

Answer 76

76. 1. To aid digestion, the neonate should be placed in a supine position. Placing infants on their
       side or prone in a crib after a feeding is no longer recommended due to the increased risk of sudden
       infant death syndrome (SIDS). Although the mother may desire to hold the infant in her lap after
       feeding, this is not necessary for the neonate’s digestion unless the infant has reflux.
       CN: Health promotion and maintenance; CL: Apply

Question 77

77. A primiparous client who is bottle-feeding her neonate asks, “When should I start giving the
    baby solid foods?” The nurse instructs the client to introduce solid foods no sooner than at which
    age?
78. 2 months.
79. 6 months.
80. 8 months.4. 10 months.

Answer 77

77. 2. Pediatricians recommend that infants be given either breast milk or formula until at least 6
       months of age because of the neonate’s difficulty digesting solid foods. Giving solid foods too early
       can lead to food allergies. Because chewing movements do not begin until 7 to 9 months of age, foodsrequiring chewing should be delayed until this time.
       CN: Health promotion and maintenance; CL: Apply

Question 78

78. After instructing a primiparous client who is bottle-feeding about burping, which of the
    following client statements indicates that the client needs further teaching?
79. “I’ll burp him after 15 minutes of feeding him formula.”
80. “After he takes one-half ounce of formula, I’ll burp him.”
81. “I’ll burp him while he is in an upright position.”
82. “I’ll gently pat his back to get him to burp.

Answer 78

78. 1. The client needs further instruction when she says burping should be done after 15 minutes
       of formula feeding. The entire feeding should take only 15 to 20 minutes, and the neonate should be
       burped before that time. During initial feedings, the burping should be done after each half-ounce of
       formula with the neonate in an upright position, patting the neonate gently on the back.
       CN: Health promotion and maintenance; CL: Evaluate

Question 79

79. When teaching a primiparous client about the growth and development of the neonate, which
    of the following should the nurse include as the usual age at which most babies are able to drink from
    a cup independently?
80. 5 to 7 months.
81. 8 to 10 months.
82. 12 to 14 months.
83. 15 to 16 months.

Answer 79

79. 2. Most babies are developmentally ready to drink independently from a cup by the age of 8 to
       10 months. If the child has not mastered drinking from a cup by this time, there may be a problem with
       motor development that requires further investigation.
       CN: Health promotion and maintenance; CL: Apply

Question 80

80. When preparing for discharge a 15-year-old primipara who is bottle-feeding her neonate, the
    nurse instructs the client not to “prop” the bottle while feeding the neonate because this can lead to
    which of the following?
81. Overfeeding and obesity.
82. Aspiration of the formula.
83. Tooth decay in the formative months.
84. Sudden infant death syndrome (SIDS).

Answer 80

80. 2. Bottle “propping” is not recommended because it can lead to aspiration, delayed bonding,
       feelings of mistrust (Erikson), and possible otitis media. The neonate will not be overfed during
       bottle propping but may suck too quickly, possibly resulting in aspiration of the formula. Putting the
       neonate to bed with a bottle can lead to tooth decay later in the formative years, but an infant cannot
       hold the bottle. The cause of SIDS has not been determined. However, it is associated with placing
       the infant in a prone position after eating.
       CN: Reduction of risk potential; CL: Synthesize

Question 81

The Postpartal Client with a Cesarean Birth
81. The nurse is assessing a cesarean section client who gave birth 12 hours ago. Findings
include a distended abdomen with faint bowel sounds × 1 quadrant, fundus firm at umbilicus, lochia
scant, rubra, and pain rated 2 on a scale of 1 to 10. The IV and Foley catheter have been discontinued
and the client received medication 3 hours ago for pain. The client can have pain medication every 3
to 4 hours. The nurse should first:
1. Give the client pain medication.
2. Have the client use the incentive spirometry.
3. Ambulate the client from the bed to the hallway and back.
4. Encourage the client to begin caring for her baby.

Answer 81

The Postpartal Client with a Cesarean Birth
81. 3. The client should have more active bowel sounds by this time postpartum. Ambulation will
encourage passing flatus and begin peristaltic action in the gastrointestinal track. Medicating the
client should be evaluated prior to ambulating but it is probably too soon because the last dose was 3
hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a
component as it decreases peristaltic activity. Incentive spirometry or asking the client to turn, cough,
and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation,
and walking can be used concurrently with these interventions. Participating in infant care is another
way to encourage the mother to move about but the primary goal would be to have her walk on the
unit, a more purposeful activity.
CN: Physiological adaptation; CL: Synthesize

Question 82

82. Carboprost (Hemabate) was injected into the uterus of a client to treat uterine atony during a
    cesarean section. In preparing to care for this client postpartum, the nurse should assess the client for
    which of the following common adverse effects of the medication?
83. Vertigo and confusion.
84. Nausea and diarrhea.
85. Restlessness and increased vaginal bleeding.
86. Headache and hypertension.

Answer 82

82. 2. Hemabate is an oxytocic prostaglandin that causes uterine contraction in women who are
       bleeding heavily. Nausea, vomiting, diarrhea, and fever are common adverse effects of prostaglandin
       administration. Vertigo and confusion are not associated with this drug. Vaginal bleeding may occur
       with inadequate amounts of Hemabate if the client continues to bleed. Restlessness may result if
       inadequate amounts of Hemabate are used and the woman continues to bleed and goes into shock. If
       too large a dose is given, the client may experience headache and hypertension because Hemabate
       does contract smooth muscles.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 83

83. A 30-year-old woman, G 4, P 4, has given cesarean birth to a healthy term female neonate
    due to an abnormal fetal heart rate tracing. At 2 hours postpartum, the nurse assesses the client’s Foley
    catheter and observes that the client’s urine is slightly red tinged. Which of the following should the
    nurse do next?
84. Continue to monitor the client’s input and output.
85. Palpate the client’s fundus gently every 15 minutes.
86. Assess the placement of the Foley catheter.
87. Contact the client’s physician for further prescriptions.

Answer 83

83. 4. Slightly red-tinged urine may indicate that the bladder was accidentally cut during the
       cesarean birth. The nurse should notify the physician as soon as possible about the urine color.
       Continuing to monitor the client’s input and output should be done after the physician is contacted.Palpating the fundus every 15 minutes is not necessary unless the client’s fundus becomes soft or
       “boggy.” Assessment of the Foley catheter is a normal part of the elimination assessment by the nurse,
       but displacement is not the cause of the red-tinged urine.
       CN: Reduction of risk potential; CL: Synthesize

Question 84

84. While changing the neonate’s diaper, the client asks the nurse about some red-tinged drainage
    from the neonate’s vagina. Which of the following responses would be most appropriate?
85. “It’s of no concern because it is such a small amount.”
86. “The cause is usually related to swallowing blood during the birth.”
87. “Sometimes baby girls have this from hormones received from the mother.”
88. “This vaginal spotting is caused by hemorrhagic disease of the newborn.”

Answer 84

84. 3. The most appropriate response would be to explain that the vaginal spotting in female
       neonates is associated with hormones received from the mother. Estrogen is believed to cause slight
       vaginal bleeding or spotting in the female neonate. The condition disappears spontaneously, so there
       is no need for concern. Telling the mother that it is of no concern does not allay the mother’s worry.
       The vaginal spotting is related to hormones received from the mother, not to swallowing blood during
       the birth or hemorrhagic disease of the neonate. Anemia is associated with hemorrhagic disease.
       CN: Health promotion and maintenance; CL: Synthesize

Question 85

85. Four hours after cesarean birth of a neonate weighing 4,000 g (8 lb, 13 oz), the primiparous
    client asks, “If I get pregnant again, will I need to have a cesarean?” When responding to the client,
    the nurse should base the response to the client about vaginal birth after cesarean (VBAC) on which
    of the following?
86. VBAC may be possible if the client has not had a classic uterine incision.
87. A history of rapid labor is a necessary criterion for VBAC.
88. A low transverse incision contraindicates the possibility for VBAC.
89. VBAC is not possible because the neonate was large for gestational age.

Answer 85

85. 1. VBAC can be attempted if the client has not had a classic uterine incision. This type of
       incision carries a danger of uterine rupture. A physician must be available, and a cesarean birth must
       be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse
       incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication
       because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than
       4,000 g by itself is not a contraindication if the mother is not diabetic.
       CN: Health promotion and maintenance; CL: Apply

Question 86

86. A primiparous client who underwent a cesarean birth 30 minutes ago is to receive Rho (D)
    immune globulin (RhoGAM). The nurse should administer the medication within which of thefollowing time frames after birth?
87. 8 hours.
88. 24 hours.
89. 72 hours.
90. 96 hours.

Answer 86

86. 3. For maximum effectiveness, RhoGAM should be administered within 72 hours postpartum.
       Most Rh-negative clients also receive RhoGAM during the prenatal period at 28 weeks’ gestation and
       then again after birth. The drug is given to Rh-negative mothers who have a negative Coombs test and
       give birth to Rh-positive neonates. If there is doubt about the fetus’s blood type after pregnancy is
       terminated, the mother should receive the medication.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 87

87. While the nurse is caring for a primiparous client with cephalopelvic disproportion 4 hours
    after a cesarean birth, the client requests assistance in breast-feeding. To promote maximum maternal
    comfort, which of the following would be most appropriate for the nurse to suggest?
88. Football hold.
89. Scissors hold.
90. Cross-cradle hold.
91. Cradle hold.

Answer 87

87. 1. After a cesarean birth, most mothers have the greatest comfort when the neonate is
       positioned in the football hold with the mother in semi-Fowler’s position, supporting the neonate’s
       head in her hand and resting the neonate’s body on pillows alongside her hip. This position prevents
       pressure on the uterine incision yet allows the neonate easy access to the mother’s breast. The
       scissors hold, where the mother places her hand well back on the breast to prevent touching the
       areola and interfering with the neonate’s mouth placement, is used by the mother to hold the breast and
       support it during breast-feeding. The cross-cradle hold is done when the mother holds the neonate’s
       head in the hand opposite from the breast on which the neonate will feed and the mother’s arm
       supports the neonate’s body across her lap. This position can be uncomfortable because of the
       pressure placed on the client’s incision line. For the cradle hold, the mother cradles the infant
       alongside the arm at the breast on which the neonate will feed. This position also can be
       uncomfortable because of the pressure placed on the incision line.
       CN: Basic care and comfort; CL: Synthesize

Question 88

The Postpartal Client with Complications
88. A multigravid patient gave birth vaginally 2 hours ago. A family member notifies the nurse
that the client is pale and shaky. Which are the priority assessments for the nurse to make?
1. Blood glucose and vital signs.
2. Temperature and level of consciousness.
3. Uterine infection and pain.
4. Fundus and lochia.

Answer 88

The Postpartal Client with Complications
88. 4. A client who is pale and shaking could be experiencing hypovolemic shock likely caused
by blood loss. A primary cause of blood loss after the birth of an infant is uterine atony. Therefore,
the priority assessments should be the fundus of the uterus for firmness and location. In addition, theamount of vaginal bleeding (lochia) should also be assessed. An immediate intervention for uterine
atony is fundal massage that will help the uterus to contract and therefore stop additional bleeding.
Assessing the client’s level of consciousness does not require additional time and can be done by the
nurse while the fundus and lochia are assessed. Obtaining vital signs, blood glucose, and temperature
are important but should be done either after the fundus has been assessed and massaged or should be
obtained by a second responder. Assessing for uterine infection and pain should be done after
treatment for hypovolemic shock has been initiated.
CN: Reduction of risk potential; CL: Analyze

Question 89

89. A postpartum woman has unrelenting pain in her rectum after vaginal birth despite
    administration of pain medications. Which action is most indicated?
90. Administering additional pain medications.
91. Assessing the perineum.
92. Reassuring the patient that pain is normal after vaginal birth.
93. Preparing a warm sitz bath for the client.

Answer 89

89. 2. Pain after childbirth is generally well managed with pain control medications; since they
       did not help this woman, further assessment is necessary. The first nursing action would be to assess
       the source of the pain; the woman may have sustained a laceration or a hematoma as a result of
       childbirth. Assessing the perineum may help the nurse to determine the source of the pain and may
       require follow-up by the primary health care provider. Subsequent nursing interventions may include
       pain medication, sitz bath, or education regarding the healing process.
       CN: Basic care and comfort; CL: Analyze

Question 90

90. A multiparous client at 24 hours postpartum demonstrates a positive Homan sign with
    discomfort. The nurse should:
91. Place a cold pack on the client’s perineal area.
92. Place the client in semi-Fowler’s position.
93. Notify the client’s physician immediately.
94. Ask the client to ambulate around the room.

Answer 90

90. 3. A positive Homan sign, discomfort behind the knee or in the upper calf area on dorsiflexion
       of the foot, may be indicative of thrombophlebitis. Other signs include edema and redness at the site
       and may be more reliable as an indicator of thrombophlebitis. The nurse should notify the physician
       immediately and ask the client to remain in bed to minimize the risk for pulmonary embolus, a serious
       consequence of thrombophlebitis should a clot dislodge. The Homan sign is observed on the client’s
       legs, so placing an ice pack on the perineal area is inappropriate. However, ice to the perineum
       would be useful for episiotomy pain and swelling. The client does not need to be positioned in semi-
       Fowler’s position but should remain on bed rest to prevent dislodgement of a potential clot.
       CN: Reduction of risk potential; CL: Synthesize

Question 91

91. Prophylactic heparin therapy is prescribed to treat thrombophlebitis in a multiparous client
    who gave birth 24 hours ago. After instructing the client about the medication, the nurse determines
    that the client understands the instructions when she states which of the following as the purpose of
    the drug?
92. To thin the blood clots.
93. To increase the lochial flow.
94. To increase the perspiration for diuresis.
95. To prevent further blood clot formation.

Answer 91

91. 4. Heparin therapy is prescribed to prevent further clot formation by inhibiting further
       thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An
       adverse effect of heparin therapy during the puerperium is increased lochia flow, so the nurse must be
       observant for symptoms of hemorrhage, such as heavy lochial flow. Heparin does not increase
       diaphoresis, which is normal for the postpartum client.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 92

92. While caring for a primipara diagnosed with deep vein thrombosis at 48 hours postpartum
    who is receiving treatment with bed rest and intravenous heparin therapy, the nurse should contact the
    client’s physician immediately if the client exhibited which of the following?
93. Pain in her calf.
94. Dyspnea.
95. Hypertension.
96. Bradycardia.

Answer 92

92. 2. A major complication of deep vein thrombosis is pulmonary embolism. Signs and
       symptoms, which may occur suddenly and require immediate treatment, include dyspnea, severe chest
       pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension,
       diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis
       of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary
       embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy.
       Bradycardia for the first 7 days in the postpartum period is normal.
       CN: Reduction of risk potential; CL: Synthesize

Question 93

93. A primiparous client 3 days postpartum is to be discharged on heparin therapy. After teaching
    her about possible adverse effects of heparin therapy, the nurse determines that the client needs
    further instruction when she states that the adverse effects include which of the following?
94. Epistaxis.
95. Bleeding gums.
96. Slow pulse.
97. Petechiae

Answer 93

93. 3. A slow pulse (bradycardia) is normal for the first 7 days postpartum as the body begins to
       adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of heparin
       therapy suggesting prolonged bleeding include hematuria, epistaxis, increased lochial flow, and
       bleeding gums. Typically, tachycardia, not bradycardia, would be associated with hemorrhage.Petechiae indicate bleeding under the skin or in subcutaneous tissue.
       CN: Reduction of risk potential; CL: Evaluate

Question 94

94. After being treated with heparin therapy for thrombophlebitis, a multiparous client who gave
    birth 4 days ago is to be discharged on oral warfarin. After teaching the client about the medication
    and possible effects, which of the following client statements indicates successful teaching?
95. “I can take two aspirin if I get uterine cramps.”
96. “Protamine sulfate should be available if I need it.”
97. “I should use a soft toothbrush to brush my teeth.”
98. “I can drink an occasional glass of wine if I desire.”

Answer 94

94. 3. Successful teaching is demonstrated when the client says, “I should use a soft toothbrush to
       brush my teeth.” Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to
       minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications
       should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the
       antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the
       metabolism of oral anticoagulants and should be avoided.
       CN: Pharmacological and parenteral therapies; CL: Evaluate

Question 95

95. A nurse is explaining basic principles of asepsis and infection control to a client who has a
    respiratory tract infection following birth. The nurse determines the client understands principles of
    infection control to follow when the client says:
96. “I must use barrier isolation.”
97. “I must wear a gown and gloves.”
98. “I must use individual client care equipment.”
99. “I must practice frequent handwashing.”

Answer 95

95. 4. Frequent handwashing is the most important aspect of infection control. The nurse can
       emphasize, monitor, and ensure this strategy for all who come in contact with this client. The use of
       gowns and gloves is appropriate when there is blood and stool. Barrier isolation and individual
       client care equipment are not needed in this situation.
       CN: Reduction of risk potential; CL: Evaluate

Question 96

96. A postpartum multiparous client diagnosed with endometritis is to receive intravenous
    antibiotic therapy with ampicillin. Before administering this drug, the nurse must do which of the
    following?
97. Ask the client if she has any drug allergies.
98. Assess the client’s pulse rate.
99. Place the client in a side-lying position.
100. Check the client’s perineal pad.

Answer 96

96. 1. Before administering ampicillin intravenously, the nurse must ask the client if she has any
       drug allergies, especially to penicillin. Antibiotic therapy can cause adverse effects, such as rash or
       even anaphylaxis. If the client is allergic to penicillin, the physician should be notified and ampicillin
       should not be given. Checking the client’s pulse rate or placing her in a side-lying position are not
       necessary. Assessing the amount of lochia by checking the perineal pad is important for all
       postpartum clients but is not necessary before antibiotic therapy.
       CN: Pharmacological and parenteral therapies; CL: Apply

Question 97

97. Which of the following would be most important for the nurse to encourage in a primiparous
    client diagnosed with endometritis who is receiving intravenous antibiotic therapy?
98. Ambulate to the bathroom frequently.
99. Discontinue breast-feeding temporarily.
100. Maintain bed rest in Fowler’s position.
101. Restrict visitors to prevent contamination.

Answer 97

97. 3. The nurse should encourage the client to maintain Fowler’s position, which promotes
       comfort and facilitates drainage. Endometritis can make the client feel extremely uncomfortable and
       fatigued, so ambulation during intravenous therapy is not as important at this time. The client does not
       need to discontinue breast-feeding, although she may become quite fatigued and need assistance in
       caring for the neonate. Typically, breast-feeding would be discontinued only if the mother lacks the
       necessary energy. The institution’s policy regarding visitors is to be followed. However, visitors do
       not need to be restricted to prevent contamination because the client is not considered to be
       contagious. The nurse should maintain the client’s need for privacy and rest and should respect the
       client’s wishes related to visitors.
       CN: Reduction of risk potential; CL: Synthesize

Question 98

98. Which of the following measures would the nurse expect to include in the teaching plan for a
    multiparous client who gave birth 24 hours ago and is receiving intravenous antibiotic therapy for
    cystitis?
99. Limiting fluid intake to 1 L daily to prevent overload.
100. Emptying the bladder every 2 to 4 hours while awake.
101. Washing the perineum with povidone iodine after voiding.
102. Avoiding the intake of acidic fruit juices until the treatment is discontinued.

Answer 98

98. 2. The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep her
       bladder empty. In addition, she should maintain adequate fluid intake; 3,000 mL/day is recommended.
       Intake of acidic fruit juices (eg, cranberry, apricot) is recommended because of their association with
       reducing the risk for infection. The client should wear cotton underwear and avoid tight-fitting slacks.
       She does not need to wash with povidone iodine after voiding. Plain warm water is sufficient to keep
       the perineal area clean.
       CN: Basic care and comfort; CL: Create

Question 99

99. A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving
    intravenous ampicillin asks the nurse, “Can I still continue to breast-feed my baby?” The nurse should
    tell the client:
100. “You can continue to breast-feed as long as you want to do so.”
101. “Alternate your breast-feeding with formula feeding to help you rest.”
102. “You’ll need to discontinue breast-feeding until the antibiotic therapy is stopped.”
103. “You’ll need to modify your technique by manually pumping your breasts.”

Answer 99

99. 1. The client can continue to breast-feed as often as she desires. Continuation of breast-
       feeding is limited only by the client’s discomfort or malaise. Antibiotics for treatment are chosen
       carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides,nitrofurantoin, and cephalosporins usually are not prescribed for breast-feeding mothers. Manual
       pumping of the breasts is not necessary.
       CN: Health promotion and maintenance; CL: Apply

Question 100

100. Four days after a vaginal birth, a client has excessive lochia rubra with clots. The physicianprescribes carboprost tromethamine, 0.25 mg intramuscularly. Which statement by the client reflects
     the need for more teaching about carboprost?
101. “This medication may cause nausea and vomiting.”
102. “This medication sometimes causes hypotension that leads to dizziness.”
103. “I will also receive medication to help prevent severe diarrhea.”
104. “I may run a fever after being treated with carboprost.”

Answer 100

100. 1. Carboprost tromethamine (Hemabate) may cause hypertension, not hypotension. More
        commonly carboprost tromethamine, a synthetic progastgladin, causes nausea, vomiting, diarrhea, and
        fever. Gastrointestinal symptoms are so common that antiemetic and antidiarreal medications are
        often given as a pretreatment or immediately following carboprost.
        CN: Pharmacological and parenteral therapies; CL: Analyze

Question 101

101. During the first hour postpartum, assessment of a multiparous client who gave cesarean birth
     to a neonate weighing 4,593 g (10 lb, 2 oz) reveals a soft fundus with excessive lochia rubra. The
     nurse should include which of the following in the client’s plan of care?
102. Administration of intravenous oxytocin.
103. Placement of the client in a side-lying position.
104. Rigorous fundal massage every 5 minutes.
105. Preparation for an emergency hysteromyomectomy.

Answer 101

101. 1. The client is exhibiting signs of early postpartal hemorrhage, defined as blood loss greater
        than 500 mL in the first 24 hours postpartum. Rapid intravenous oxytocin infusion of 30 units in 500
        mL of normal saline, oxygen therapy, and gentle fundal massage to contract the uterus are usually
        effective. If bleeding persists, the nurse should inspect the cervix and vagina for lacerations. Other
        pharmacologic interventions may be needed. Severe uncontrolled hemorrhage may require bimanual
        uterine compression, a dilation and curettage to remove any retained placental tissue, or a
        hysterectomy to prevent maternal death from hemorrhage. The client should be placed in the supine
        position to allow evaluation of the fundus. The side-lying position is not helpful in controlling
        postpartum hemorrhage. Vigorous fundal massage every 5 minutes is unnecessary. In addition, it can
        be very painful for the mother. Rather, gentle massage along with oxytocin administration is used to
        stimulate the uterus to contract. A hysteromyomectomy is used to remove fibroid tumors. With
        massive hemorrhage, a hysterectomy (removal of the uterus) may be necessary to control the bleeding.
        CN: Health promotion and maintenance; CL: Create

Question 102

102. A primiparous client who was diagnosed with hydramnios and breech presentation while in
     early labor is diagnosed with early postpartum hemorrhage at 1 hour after a cesarean birth. The client
     asks, “Why am I bleeding so much?” The nurse responds based on the understanding that the most
     likely cause of uterine atony in this client is which of the following?
103. Trauma during labor and birth.
104. Moderate fundal massage after birth.
105. Lengthy and prolonged second stage of labor.
106. Overdistention of the uterus from hydramnios.

Answer 102

102. 4. The most likely cause of this client’s uterine atony is overdistention of the uterus caused by
        the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides
        hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and
        birth can also contribute to uterine atony during the postpartum period. Trauma during labor and birth
        is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario.
        Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a
        lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean birth for breech
        presentation. Therefore, it is unlikely that she had a long labor.
        CN: Physiological adaptation; CL: Apply

Question 103

103. Thirty-six hours after a vaginal birth, a multiparous client is diagnosed with endometritis
     due to β-hemolytic streptococcus. When assessing the client, which of the following would the nurse
     expect to find?
104. Profuse amounts of lochia.
105. Abdominal distention.
106. Nausea and vomiting.
107. Odorless vaginal discharge.

Answer 103

103. 4. Scant and odorless vaginal discharge is associated with endometritis due to b-hemolytic
        streptococcus. The client also will exhibit “sawtooth” temperature spikes between 101°F and 104°F
        (38.3°C to 40°C), tachycardia, and chills. The classic symptom of foul-smelling lochia is not
        associated with this type of endometritis. Profuse and foul-smelling lochia is associated with classic
        endometritis from pathogens such as chlamydia or staphylococcus, not group B hemolytic
        streptococcus. Abdominal distention is associated with parametritis as the pelvic cellulitis advances
        and spreads, causing severe pain and distention. Nausea and vomiting are associated with
        parametritis resulting from an abscess and advancing pelvic cellulitis.
        CN: Reduction of risk potential; CL: Analyze

Question 104

104. A multiparous client visits the urgent care center 5 days after a vaginal birth, experiencing
     persistent lochia rubra in a moderate to heavy amount. The client asks the nurse, “Why am I
     continuing to bleed like this?” The nurse should instruct the client that this type of postpartum
     bleeding is usually caused by which of the following?
105. Uterine atony.
106. Cervical lacerations.
107. Vaginal lacerations.
108. Retained placental fragments.

Answer 104

104. 4. The most likely cause of delayed postpartum hemorrhage is retained placental fragments.
        The client may be scheduled for a dilatation and curettage to remove remaining placental fragments.
        Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, notlate, postpartum hemorrhage.
        CN: Health promotion and maintenance; CL: Apply

Question 105

105. A 26-year-old primiparous client is seen in the urgent care clinic 2 weeks after giving birth
     to a viable female neonate. The client, who is breast-feeding, is diagnosed with infectious mastitis of
     the right breast. The client asks the nurse, “Can I continue breast-feeding?” The nurse should tell the
     client:
106. “You can continue to breast-feed, feeding your baby more frequently.”
107. “You can continue once your symptoms begin to decrease.”
108. “You must discontinue breast-feeding until antibiotic therapy is completed.”4. “You must stop breast-feeding because the breast is contaminated.”

Answer 105

105. 1. The client being treated for infectious mastitis should continue to breast-feed often, or at
        least every 2 to 3 hours. Treatment also includes bed rest, increased fluid intake, local heat
        application, analgesics, and antibiotic therapy. Continually emptying the breasts decreases the risk of
        engorgement or breast abscess. The client should not discontinue breast-feeding unless she chooses to
        do so. The client may continue breast-feeding while receiving antibiotic therapy. Generally, the breast
        milk is not contaminated by the offending organism and is safe for the neonate.
        CN: Physiological adaptation; CL: Synthesize

Question 106

106. A primiparous client who had a vaginal birth 1 hour ago voices anxiety because she has a
     nephew with Down syndrome. After teaching the client about Down syndrome, which of the
     following client statements indicates the need for additional teaching?
107. “Down syndrome is an abnormality that can result from a missing chromosome.”
108. “Down syndrome usually results in some degree of mental retardation.”
109. “There are several methods available to determine whether my baby has Down syndrome.”
110. “Older mothers are more likely to have a baby with chromosomal abnormalities.”

Answer 106

106. 1. Down’s syndrome is a genetic abnormality that is caused by an extra chromosome that
        results in mental retardation. The degree of mental retardation is difficult to predict in a neonate,
        although most children born with Down’s syndrome have some degree of mental retardation. Various
        methods can be used to determine whether a neonate has Down’s syndrome, which is commonly
        manifested by hypotonia, poor Moro reflex, flat facial profile, upslanting palpebral fissures,
        epicanthal folds, and hyperflexible joints. Genetic studies can be indicative of this disorder. Mothers
        older than 35 years of age are at a higher risk for having a child with Down’s syndrome. However,
        chromosomal abnormalities can occur regardless of the mother’s age.
        CN: Reduction of risk potential; CL: Evaluate

Question 107

107. A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing
     center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a
     social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the
     following responses would be most appropriate?
108. “I’ll bring the baby to you for feeding.”
109. “I think we should ask your physician if this is a good idea.”
110. “It’s not a good idea for you to have any contact with the baby.”
111. “I’ll check with the social worker to see if the adopting parents will permit this.”

Answer 107

107. 1. After birth, the client should make the decision about how much she would like to
        participate in the neonate’s care. Seeing and caring for the neonate commonly facilitates the grief
        process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold,
        and care for the neonate. The physician does not need to be contacted about the client’s desire to see
        the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give
        the client permission to feed the baby.
        CN: Health promotion and maintenance; CL: Synthesize

Question 108

107. A 15-year-old unmarried primiparous client is being cared for in the hospital’s birthing
     center after vaginal birth of a viable neonate. The neonate is being placed for adoption through a
     social service agency. Four hours postpartum, the client asks if she can feed her baby. Which of the
     following responses would be most appropriate?
108. “I’ll bring the baby to you for feeding.”
109. “I think we should ask your physician if this is a good idea.”
110. “It’s not a good idea for you to have any contact with the baby.”
111. “I’ll check with the social worker to see if the adopting parents will permit this.”

Answer 108

108. 4. The client needs further instruction when she says that she should begin feeding on the
        right (painful) breast to decrease the pain. Starting the feeding on the unaffected (left) breast can
        stimulate the milk ejection reflex in the right breast and thereby decrease the pain. Frequent nursing or
        pumping is recommended to empty the breast. For some mothers, mastitis is so painful that they
        choose to discontinue breast-feeding, so these mothers need a great deal of support. Applying heat to
        the infected area before starting to feed is appropriate because heat stimulates circulation and
        promotes comfort. Increasing fluid intake is advised to ensure adequate hydration. Antibiotics need to
        be taken until all medication has been used, usually 7 to 10 days to ensure eradication of the infection.
        CN: Reduction of risk potential; CL: Evaluate

Question 109

109. During a home visit to a primiparous client who gave birth vaginally 14 days ago, the client
     says, “I’ve been crying a lot the last few days. I just feel so awful. I am a rotten mother. I just don’t
     have any energy. Plus, my husband just got laid off from his job.” The nurse observes that the client’s
     appearance is disheveled. Which of the following would be the nurse’s best response?
110. “These feelings commonly indicate symptoms of postpartum blues and are normal. They’ll go
     away in a few days.”
111. “I think you’re probably overreacting to the labor and birth process. You’re doing the best you
     can as a mother.”
112. “It’s not unusual for some mothers to feel depressed after the birth of a baby. I think I should
     contact your doctor.”
113. “This may be a symptom of a serious mental illness. I think you should probably go to the
     hospital.”

Answer 109

109. 3. The client is probably experiencing postpartum depression, and the doctor should be
        contacted. Postpartum depression is usually treated with psychotherapy, social support groups, and
        antidepressant medications. Contributing factors include hormonal fluctuations, a history of
        depression, and environmental factors (eg, job loss). An estimated 50% to 70% of women experience
        some degree of postpartum “blues,” but these feelings of sadness disappear within 1 to 2 weeks after
        birth. However, the client is voicing more than just sadness. Telling her that she is overreacting is not
        helpful and may make her feel even less worthy. She is not exhibiting symptoms of a serious mental
        illness (loss of contact with reality) and does not need hospitalization.CN: Health promotion and maintenance; CL: Synthesize

Question 110

110. A 16-year-old girl gave birth to a baby boy a week ago. She has an appointment with her
     obstetrician today who is concerned about the possibility of postpartum depression because the girl
     has been treated for depression in the past and the girl’s mother suffered postpartum depression when
     the girl was born 16 years ago. Which comment by the client would indicate that she understood the
     nurse’s teaching about the postpartum period and her risks for postpartum depression?
111. “Sleep shouldn’t be too much of a problem because the baby will soon start to sleep through
     the night.”
112. “Since I’m breast-feeding, I can eat all the food I want and not feel fat. The baby will use allthe calories.”
113. “If I’m feeling guilty or not capable of caring for the baby and am not sleeping or eating well, I
     need to contact the office.”
114. “I’m going to give the baby the best care possible without asking anyone for help to show all
     those people who think I can’t do it.”

Answer 110

110. 3. Feelings of guilt combined with a lack of self-care (not eating or sleeping enough) can
        predispose a new mother to postpartum depression, especially one who has had previous episodes of
        depression. Sleep is essential to both the mother and baby, but sleeping through the night does not
        usually occur in the first few weeks after birth. While breast-feeding mothers do need good nutrition,
        eating as much as you want after childbirth may inhibit the return to a normal weight and could create
        depression in a new mother, especially a vulnerable one. Attempting to care for an infant with no help
        from others is likely to cause stress that could lead to depression, especially in an adolescent.
        CN: Psychosocial integrity; CL: Evaluate

Question 111

Managing Care Quality and Safety
111. The nurse is catheterizing a client who cannot void after a normal birth 8 hours ago. The
nurse begins the catheterization process and the client asks the nurse if povidone-iodine was used to
clean the meatus for the catheterization. The nurse realizes that the client is allergic to povidone-
iodine and the client is reacting to the cleansing agent. The nurse should take the following steps in
order of priority from first to last.
1. Document incident.
2. Clean povidone-iodine from client’s vaginal area.
3. Notify physician prescribing catheterization.
4. Ask client what her reaction is when exposed to povidone-iodine.
5. File an incident report.

Answer 111

Managing Care Quality and Safety
111. 4, 2, 3, 1, 5. The nurse should immediately ask the client what her reaction is as a result of
the exposure to povidone-iodine. This gives the nurse an idea of whether there needs to be
preparation for an event as severe as cardiac arrest or as simple as skin irritation. The nurse should
then clean the solution from the client, notify the physician of the incident, and ask for a prescription
for medication if needed to counteract the povidone-iodine. The nurse will need to document the
incident on the client’s chart as soon as the client has physically been taken care of. The nurse also
will need to file an incident report.
CN: Management of care; CL: Synthesize

Question 112

112. A nurse is walking down the hall in the main corridor of a hospital when the infant security
     alert system sounds and a code for an infant abduction is announced. The first responsibility of the
     nurse when this situation occurs is to do which of the following?
113. Move to the entrance of the hospital and check each person leaving.
114. Go to the obstetrics unit to determine if they need help with the situation.
115. Call the nursery to ask which baby is missing.
116. Observe individuals in the area for large bags or oversized coats.

Answer 112

112. 4. The process for infant abduction in a hospital system focuses on utilizing all health care
        workers to observe for anyone who may possibly be concealing an infant in a large bag or under an
        oversized coat and is attempting to leave the building. Moving to the entrances and exits and checking
        each individual would be a responsibility of the doorman or security staff within the hospital system.
        Going to the obstetrics unit to determine if they need help would not be advised as the doors to the
        unit will be locked and access will not be available. Calling the nursery to ask about a missing baby
        wastes time, and the nursery staff should not reveal such information.
        CN: Safety and infection control; CL: Synthesize

Question 113

113. The nurse on a mother-baby unit who is working on the night shift is revising the planning
     worksheet for the remaining 2 hours of the shift. The nurse has the following tasks and prescriptions
     to complete prior to the 7 AM change of shift. Using the work plan below, how should the nurse
     organize the following tasks so that everything is completed by 7 AM ?
114. Draw blood for the prescribed laboratory tests (complete blood counts [CBCs]) on three
     postpartum clients with report on charts by shift change.
115. Start IV of D5 1⁄2 NS at keep vein open (KVO) rate on postpartum client just prior to change ofshift.
116. Complete admission assessment of newborn turned over to nurse at 5 AM .
117. Draw newborn bilirubin level at 6 AM .

Answer 113

Drawing the bilirubin levels at 6 AM must occur at a specific time. The admission assessment
should be completed as soon after admission as possible; 5 AM is available to complete this task. The
IV should be started at 6:30 AM and completed as close to change of shift as possible. The nurse
should then draw the blood at 5:30 AM , right after the newborn assessment.
CN: Management of care; CL: Create500 3
5:30 1
6:00 4
6:30 2

Question 114

114. The nurse on the postpartum mother-baby unit is assigned to take care of four couplets, and a
     new couplet will be admitted within the next 30 minutes. All assessments are complete. The nurse can
     delegate care for which couplet to the unlicensed nursing personnel?
115. A G1 P1 with gestational diabetes who is 12 hours postpartum and who still requires insulin.
116. A G4 P4 who is breast-feeding an 8 lb (3,629 g) infant without difficulty.
117. A G3 P3 postpartum client who is receiving magnesium sulfate and whose infant has a
     respiratory rate of 20.
118. A G2 P2 who gave birth vaginally 2 days ago with an infant having low blood glucose levels
     the first 24 hours after birth.

Answer 114

114. 2. The client who is a G4 P4 can be cared for by the CNA II. There are no indications that
        there are any problems with this couplet and the assessments have been completed by the RN. The
        client with gestational diabetes will need specific assessments, medications, and potentially otheractions based on recent birth. Her infant is within the first 24 hours of birth when infants of women
        with gestational diabetes often drop their blood glucose levels and this will require frequent
        assessment and possible interventions. The client who is G3 P3 postpartum and receiving magnesium
        sulfate must be cared for by a registered nurse. The respiratory rate of this client’s infant is borderline
        low and often is related to the administration of magnesium sulfate and should receive a higher level
        of nursing care. The client who is a G2 P2, with an infant with documented low blood sugars, will
        require assessment and potential intervention if the blood sugar levels change; only registered nurses
        can safely manage this care.
        CN: Management of care; CL: Synthesize

Question 115

115. The night nurse has completed the change of shift report. As the day nurse makes rounds on a
     postpartum client receiving magnesium sulfate, it is noted the client developed significantly elevated
     blood pressure during the past shift. Further assessment reveals the magnesium sulfate rate is infusing
     well below the prescribed rate. In addition to adjusting the infusion rate and notifying the MD, which
     of the following is the most important action by the nurse?
116. Complete an incident report.
117. Discuss the matter with the nurse the next time she works.
118. Ask the charge nurse if an incident report is necessary.
119. Evaluate the client’s BP for 4 hours before making a decision.

Answer 115

115. 1. Patient safety is the highest priority and a nursing error has occurred. If the day nurse
        decides to tell the night nurse, the timing of the notification will be up to the nurse initiating the
        incident report. The nurse should confer with the charge nurse concerning the incident but completion
        of the report is required. Waiting for several hours to initiate the report based on changes in patient
        data and assessment is not an ethical or professional decision and should not be considered; again,
        patient safety is the highest priority.
        CN: Reduction of risk; CL: Analyze

Question 116

116. The nurse is serving on the Quality Improvement Committee for the OB unit. Quality
     improvement projects for this unit impacting patient safety and quality of care include which of the
     following? Select all that apply.
117. Use of recycling bins on the unit.
118. Infant identification system.
119. Sibling and family visitation policies.
120. Postpartum discharge instructions.
121. Rooming in guidelines

Answer 116

116. 2,3,4,5. The use of recycling bins on the unit does not impact patient safety or contribute to
     the quality of care. The infant identification system is a patient safety practice. Nursing influences the
     type of system used and how monitoring and identification occur, which improves the quality of
     patient care. The sibling and family visitation policy can be an excellent project. Sibling policies
     regarding visitation can influence patient safety (safety of mother and infant by keeping children with
     colds/flus, infections away from the obstetrics unit). Nursing influences development of the policy
     utilized and implemented on a daily basis. Postpartum instructions represent an area where the skill
     level, quality, and quantity of instruction represent nursing contributions to patient care. The ability
     for a family to remain together during a hospital stay is important to families. The quality of the
     obstetrical experience can be enhanced or determined to be negative by this particular policy, one that
     is often looked at by these committees.
     CN: Management of care; CL: Apply

Question 117

117. A nurse working on the postpartum unit is asked to participate in the unit Patient Safety
     Committee. The nurse wants to know what type of projects would be conducted for the unit. Select all
     that apply.1. Prevention of infant abduction.
118. Safe medication administration.
119. Adequate nourishment on unit.
120. Proper restraints during procedures.
121. Maternal/infant identification system.

Answer 117

117. 1, 2, 4, 5. The safety of clients on an obstetrical unit does include prevention of infant
     abduction. Safe medication administration guidelines apply in obstetrics as well as all units in the
     hospital system. Adequate nourishment on the unit is essential for promotion of breast-feeding and for
     those patients who want to eat shortly after birth but is not a safety concern. Adequate restraints as
     used during circumcisions are a safety concern. An infant always needs proper identification when
     admitted, discharged, and taken to or away from parents, and this is also a great safety issue.
     CN: Reduction of risk; CL: Apply

Question 118

118. A nurse who works on an obstetrical inpatient unit has been assigned to the client safety
     committee. What client safety goals are most applicable to this setting? Select all that apply.
119. Effective and timely “hand-off reports” between labor and birth staff and mother-baby staffs.
120. Ensure that preprocedure verifications are completed by health care providers for any invasive
     procedure.
121. Involve patients in education to prevent cesarean section, episiotomy, and cord infections.
122. Identification of safety risks specific to the unit such as infant abduction.
123. Car seat instruction allowing infants to ride facing backward in the front seat.

Answer 118

118. 1, 2, 3, 4. Specific safety concerns on an obstetrical unit include a very specific “hand-off
     report” after birth and recovery has been completed and the couplet is transitioned to mother-baby
     care. In any invasive procedure including tubal ligations and circumcisions, preprocedure
     verification is a standard procedure. Client education concerning the potential for infection in
     obstetrics is essential for any incision areas. Infant abduction is an ever-present concern for those
     working in a mother-baby unit. Car seat instructions for new parents involve the infant being in the
     back seat of a car facing backward—not in the front seat. Education for the family includes thisimportant area.
     CN: Reduction of risk potential; CL: Evaluate