Unit K-Postpartum Complications

Question 1

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

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

Answer 1

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

Question 2

Which woman is most likely to experience strong afterpains?

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

Answer 2

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

Question 3

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

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

Answer 3

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

Question 4

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

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

Answer 4

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

Question 5

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

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

Answer 5

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

Question 6

A woman gave birth to a 7-lb, 3-ounce infant boy 2 hours ago. The nurse determines that the woman’s bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate after birth period, the most serious consequence likely to occur from bladder distention is:

a. urinary tract infection.
b. excessive uterine bleeding.
c. a ruptured bladder.
d. bladder wall atony.

Answer 6

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

Question 7

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

a. overproduction of colostrum.
b. accumulation of milk in the lactiferous ducts.
c. hyperplasia of mammary tissue.
d. congestion of veins and lymphatics.

Answer 7

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

Question 8

A woman gave birth to a 7-lb, 6-ounce infant girl 1 hour ago. The birth was vaginal, and the
estimated blood loss (EBL) was approximately 1500 mL. When assessing the woman’s vital signs, the nurse would be concerned to see:
a. temperature 37.9° C, heart rate 120, respirations 20, blood pressure (BP) 90/50.
b. temperature 37.4° C, heart rate 88, respirations 36, BP 126/68.
c. temperature 38° C, heart rate 80, respirations 16, BP 110/80.
d. temperature 36.8° C, heart rate 60, respirations 18, BP 140/90.

Answer 8

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

Question 9

Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?
a. “My first menstrual cycle will be lighter than normal and then will get heavier
every month thereafter.”
b. “My first menstrual cycle will be heavier than normal and will return to my
prepregnant volume within three or four cycles.”
c. “I will not have a menstrual cycle for 6 months after childbirth.”
d. “My first menstrual cycle will be heavier than normal and then will be light for
several months after.”

Answer 9

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

Question 10

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

a. involutionary period because of what happens to the uterus.
b. lochia period because of the nature of the vaginal discharge.
c. mini-tri period because it lasts only 3 to 6 weeks.
d. puerperium, or fourth trimester of pregnancy.

Answer 10

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

Question 11

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

b. subinvolution. c. afterpain.
d. diastasis.

Answer 11

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

Question 12

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

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

Answer 12

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

Question 13

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

a. caused by mild, continuous contractions for the duration of the after birth period.
b. more common in first-time mothers.
c. more noticeable in births in which the uterus was overdistended.
d. alleviated somewhat when the mother breastfeeds.

Answer 13

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

Question 14

Post birth uterine/vaginal discharge, called lochia: NURSINGTB.COM

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

Answer 14

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

Question 15

With regard to after birth ovarian function, nurses should be aware that:
a. almost 75% of women who do not breastfeed resume menstruating within a month
after birth.
b. ovulation occurs slightly earlier for breastfeeding women.
c. because of menstruation/ovulation schedules, contraception considerations can be
postponed until after the puerperium.
d. the first menstrual flow after childbirth usually is heavier than normal.

Answer 15

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

Question 16

As relates to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

a. kidney function returns to normal a few days after birth.
b. diastasis recti abdominis is a common condition that alters the voiding reflex.
c. fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium.
d. with adequate emptying of the bladder, bladder tone usually is restored 2 to 3 weeks after childbirth.

Answer 16

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

Question 17

Knowing that the condition of the new mother’s breasts will be affected by whether she is breastfeeding, nurses should be able to tell their patients all the following statements except:
a. breast tenderness is likely to persist for about a week after the start of lactation.
b. as lactation is established, a mass may form that can be distinguished from cancer by its position shift from day to day.rom day to day.
c. in nonlactating mothers colostrum is present for the first few days after childbirth. d. if suckling is never begun (or is discontinued), lactation ceases within a few days
to a week.

Answer 17

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

Question 18

With regard to the after birth changes and developments in a woman’s cardiovascular system, nurses should be aware that:
a. cardiac output, the pulse rate, and stroke volume all return to prepregnancy normal
values within a few hours of childbirth.
b. respiratory function returns to nonpregnant levels by 6 to 8 weeks after birth.
NURSINGTB.COM
17. Knowing that the condition of the new mother’s breasts will be affected by whether she is breastfeeding, nurses should be able to tell their patients all the following statements except:
a. breast tenderness is likely to persist for about a week after the start of lactation.
b. as lactation is established, a mass may form that can be distinguished from cancer
c. the lowered white blood cell count after pregnancy can lead to false-positive results on tests for infections.
d. a hypercoagulable state protects the new mother from thromboembolism, especially after a cesarean birth.

Answer 18

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

Question 19

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

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

Answer 19

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

Question 20

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

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

Answer 20

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

Question 21

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

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

Answer 21

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

Question 22

Which maternal event is abnormal in the early after birth period?

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

Answer 22

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

Question 23

Which finding 12 hours after birth requires further assessment?

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

Answer 23

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

Question 24

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

a. tell the physician immediately.
b. have the laboratory draw blood for reanalysis.
c. recognize that this is an acceptable range at this point after birth.
d. begin antibiotic therapy immediately.

Answer 24

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

Question 25

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

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

Answer 25

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

Question 26

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

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

Answer 26

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

Question 27

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of after birth hemorrhage in this woman is:

a. retained placental fragments.
b. unrepaired vaginal lacerations.
c. uterine atony.
d. puerperal infection.

Answer 27

ANS: C
This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause after birth hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.

Question 28

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to:

a. begin an intravenous (IV) infusion of Ringer’s lactate solution.
b. assess the woman’s vital signs.
c. call the woman’s primary health care provider.
d. massage the woman’s fundus.

Answer 28

ANS: D
The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.

Question 29

A woman gave birth vaginally to a 9-lb, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia
d. The woman has an episiotomy.

Answer 29

ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.

Question 30

The laboratory results for a after birth woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?

a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.

Answer 30

ANS: A
This patient’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the patient needs a blood transfusion. Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.

Question 31

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:

a. running warm water on her breasts during a shower.
b. applying ice to the breasts for comfort.
c. expressing small amounts of milk from the breasts to relieve pressure.
d. wearing a loose-fitting bra to prevent nipple irritation.

Answer 31

ANS: B
Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.

Question 32

A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:

a. “Didn’t you like your lunch?”
b. “Does your doctor know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”

Answer 32

ANS: D
“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.

Question 33

In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice:

a. is inconsistent with the Baby-Friendly Hospital Initiative.
b. promotes longer periods of breastfeeding.
c. is perceived as supportive to both bottle-feeding and breastfeeding mothers.
d. is associated with earlier cessation of breastfeeding.

Answer 33

ANS: A
Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated
with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers.

Question 34

A after birth woman overhears the nurse tell the obstetrics clinician that she has a positive Homans’ sign and asks what it means. The nurse’s best response is:

a. “You have pitting edema in your ankles.”
b. “You have deep tendon reflexes rated 2+.”
c. “You have calf pain when the nurse flexes your foot.”
d. “You have a ‘fleshy’ odor to your vaginal drainage.”

Answer 34

ANS: C
Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A “fleshy” odor, not a foul odor, is within normal limits.

Question 35

In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:

a. has recovered from epidural or spinal anesthesia.
b. has hidden bleeding underneath her.
c. has regained some flexibility.
d. is a candidate to go home after 6 hours.

Answer 35

ANS: A
If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.

Question 36

Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.

a. 24, 73
b. 24, 96
c. 48, 96
d. 48, 120

Answer 36

ANS: C
The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.

Question 37

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:

a. the father of the infant.
b. her mother (the infant’s grandmother).
c. her eldest daughter (the infant’s sister).
d. the nurse.

Answer 37

ANS: D
In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.

Question 38

Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. formally initializing individualized care by confirming the woman’s and infant’s
identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
b. teaching the mother to check the identity of any person who comes to remove the
baby from the room. (“It’s a dangerous world out there.”)
c. including other family members in the teaching of self-care and child care.
(“We’re all in this together.”)
d. nurturing the woman by providing encouragement and support as she takes on the
many tasks of motherhood.

Answer 38

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

Question 39

Excessive blood loss after childbirth can have several causes; the most common is:

a. vaginal or vulvar hematomas.
b. unrepaired lacerations of the vagina or cervix.
c. failure of the uterine muscle to contract firmly.
d. retained placental fragments.

Answer 39

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

Question 40

A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. improve the accuracy of blood loss estimation, which usually is a subjective
assessment.
b. determine which pad is best.
c. demonstrate that other nurses usually underestimate blood loss.
d. reveal to the nurse supervisor that one of them needs some time off.

Answer 40

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

Question 41

Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is:

a. pouring water from a squeeze bottle over the woman’s perineum.
b. placing oil of peppermint in a bedpan under the woman.
c. asking the physician to prescribe analgesics.
d. inserting a sterile catheter.

Answer 41

ANS: D
Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.

Question 42

If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?
a. Putting the patient in antiembolic stockings (TED hose) and/or sequential
compression device (SCD) boots.
b. Having the patient flex, extend, and rotate her feet, ankles, and legs.
c. Having the patient sit in a chair.
d. Notifying the physician immediately if a positive Homans’ sign occurs.

Answer 42

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

Question 43

As relates to rubella and Rh issues, nurses should be aware that:
a. breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
b. women should be warned that the rubella vaccination is teratogenic, and that they
must avoid pregnancy for 1 month after vaccination.
c. Rh immune globulin is safely administered intravenously because it cannot harm a
nursing infant.
d. Rh immune globulin boosts the immune system and thereby enhances the
effectiveness of vaccinations.

Answer 43

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

Question 44

Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

a. at the time of admission to the nurse’s unit.
b. when the infant is presented to the mother at birth.
c. during the first visit with the physician in the unit.
d. when the take-home information packet is given to the couple.

Answer 44

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

Question 45

A recently delivered mother and her baby are at the clinic for a 6-week after birth checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:

a. discusses her labor and birth experience excessively.
b. believes that her baby is more attractive and clever than any others.
c. has not given the baby a name.
d. has a partner or family members who react very positively about the baby.

Answer 45

ANS: C
If the mother is having difficulty naming her new infant, it may be a signal that she is not
adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of
interaction with the infant, and becoming upset when the baby vomits or needs a diaper
change. A new mother who is having difficulty would be unwilling to discuss her labor and
birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor, or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The patient may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

Question 46

Postpartal overdistention of the bladder and urinary retention can lead to which complications?

a. After birth hemorrhage and eclampsia
b. Fever and increased blood pressure
c. After birth hemorrhage and urinary tract infection
d. Urinary tract infection and uterine rupture

Answer 46

ANS:C
Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to after birth hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant

Question 47

Rho immune globulin will be ordered after birth if which situation occurs?

a. Mother Rh–, baby Rh+
b. Mother Rh–, baby Rh–
c. Mother Rh+, baby Rh+
d. Mother Rh+, baby Rh–

Answer 47

ANS: A
An Rh– mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh– the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh– blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.

Question 48

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

a. overproduction of colostrum.
b. accumulation of milk in the lactiferous ducts and glands.
c. hyperplasia of mammary tissue.
d. congestion of veins and lymphatics.

Answer 48

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

Question 49

After giving birth to a healthy infant boy, a primiparous woman, 16 years old, is admitted to the after birth unit. An appropriate nursing diagnosis for her at this time is risk for impaired parenting related to deficient knowledge of newborn care. In planning for the woman’s discharge, what should the nurse be certain to include in the plan of care?
a. Instruct the patient how to feed and bathe her infant.
b. Give the patient written information on bathing her infant.
c. Advise the patient that all mothers instinctively know how to care for their infants.
d. Provide time for the patient to bathe her infant after she views an infant bath
demonstration.

Answer 49

ANS: D
Having the mother demonstrate infant care is a valuable method of assessing the patient’s understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of patient education, it is not the most developmentally appropriate teaching for a teenage mother. Advising the patient that all mothers instinctively know how to care for their infants is an inappropriate statement; it is belittling and false.

Question 50

The nurse observes several interactions between a after birth woman and her new son. What behavior, if exhibited by this woman, would the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?

a. Talks and coos to her son
b. Seldom makes eye contact with her son
c. Cuddles her son close to her
d. Tells visitors how well her son is feeding

Answer 50

ANS: B
The woman should be encouraged to hold her infant in the en face position and make eye contact with the infant. Normal infant-parent interactions include talking and cooing to her son, cuddling her son close to her, and telling visitors how well her son is feeding.

Question 51

The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to:

a. tell the mother she must pay attention to her infant.
b. show the mother how the infant initiates interaction and pays attention to her.
c. demonstrate for the mother different positions for holding her infant while feeding.
d. arrange for the mother to watch a video on parent-infant interaction.

Answer 51

ANS: B
Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Telling the mother that she must pay attention to her infant may be perceived as derogatory and is not appropriate. Educating the young mother in infant care is important; however, pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant’s responsiveness is more appropriate.

Question 52

The nurse hears a primiparous woman talking to her son and telling him that his chin is just like his dad’s chin. This woman’s statement reflects:

a. mutuality.
b. synchrony.
c. claiming.
d. reciprocity.

Answer 52

ANS: C
Claiming refers to the process by which the child is identified in terms of likeness to other family members. Mutuality occurs when the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics. Synchrony refers to the “fit” between the infant’s cues and the parent’s responses. Reciprocity is a type of body movement or behavior that provides the observer with cues.

Question 53

New parents express concern that, because of the mother’s emergency cesarean birth under general anesthesia, they did not have the opportunity to hold and bond with their daughter immediately after her birth. The nurse’s response should convey to the parents that:
a. attachment, or bonding, is a process that occurs over time and does not require
early contact.
b. the time immediately after birth is a critical period for people.
c. early contact is essential for optimum parent-infant relationships.
d. they should just be happy that the infant is healthy

Answer 53

ANS: A
Attachment, or bonding, is a process that occurs over time and does not require early contact. The formerly accepted definition of bonding held that the period immediately after birth was a critical time for bonding to occur. Research since has indicated that parent-infant attachment occurs over time. A delay does not inhibit the process. Parent-infant attachment involves activities such as touching, holding, and gazing; it is not exclusively eye contact. A response that conveys that the parents should just be happy that the infant is healthy is inappropriate because it is derogatory and belittling.

Question 54

During a phone follow-up conversation with a woman who is 4 days’ after birth, the woman tells the nurse, “I don’t know what’s wrong. I love my son, but I feel so let down. I seem to cry for no reason!” The nurse would recognize that the woman is experiencing:

a. taking-in.
b. postpartum depression (PPD).
c. postpartum (PP) blues.
d. attachment difficulty.

Answer 54

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

Question 55

The nurse can help a father in his transition to parenthood by:

a. pointing out that the infant turned at the sound of his voice.
b. encouraging him to go home to get some sleep.
c. telling him to tape the infant’s diaper a different way.
d. suggesting that he let the infant sleep in the bassinet.

Answer 55

ANS: A
Infants respond to the sound of voices. Because attachment involves a reciprocal interchange, observing the interaction between parent and infant is very important. Separation of the parent and infant does not encourage parent-infant attachment. Educating the parent in infant care techniques is important; however, the manner in which a diaper is taped is not relevant and does not enhance parent-infant interactions. Parent-infant attachment involves touching, holding, and cuddling. It is appropriate for a father to want to hold the infant as the baby sleeps.

Question 56

The nurse notes that a Vietnamese woman does not cuddle or interact with her newborn other than to feed him, change his diapers or soiled clothes, and put him to bed. In evaluating the woman’s behavior with her infant, the nurse realizes that:
a. what appears to be a lack of interest in the newborn is in fact the Vietnamese way
of demonstrating intense love by attempting to ward off evil spirits.
b. the woman is inexperienced in caring for newborns.
c. the woman needs a referral to a social worker for further evaluation of her
parenting behaviors once she goes home with the newborn.
d. extra time needs to be planned for assisting the woman in bonding with her
newborn.

Answer 56

ANS:A
The nurse may observe a Vietnamese woman who gives minimal care to her infant and refuses to cuddle or interact with her infant. The apparent lack of interest in the newborn is this cultural group’s attempt to ward off evil spirits and actually reflects an intense love and concern for the infant. It is important to educate the woman in infant care, but it is equally important to acknowledge her cultural beliefs and practices.

Question 57

Many first-time parents do not plan on their parents’ help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents?

a. “You should tell your parents to leave you alone.”
b. “Grandparents can help you with parenting skills and also help preserve family traditions.”
c. “Grandparent involvement can be very disruptive to the family.”
d. “They are getting old. You should let them be involved while they can.”

Answer 57

ANS: B
“Grandparents can help you with parenting skills and also help preserve family traditions” is the most appropriate response. Intergenerational help may be perceived as interference; however, a statement of this sort is not therapeutic to the adaptation of the family. Not only is “Grandparent involvement can be very disruptive to the family” invalid, it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and preserve family traditions. Talking about the age of the grandparents is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.

Question 58

When the infant’s behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called:

a. mutuality.
b. bonding.
c. claiming.
d. acquaintance.

Answer 58

ANS: A
Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate after birth period through eye contact, touching, and talking

Question 59

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. Which one is a facilitating behavior?
a. The parents have difficulty naming the infant.
b. The parents hover around the infant, directing attention to and pointing at the
infant.
c. The parents make no effort to interpret the actions or needs of the infant.
d. The parents do not move from fingertip touch to palmar contact and holding

Answer 59

ANS: B
Hovering over the infant and obviously paying attention to the baby are facilitating behaviors. Inhibiting behaviors include difficulty naming the infant, making no effort to interpret the actions or needs of the infant, and not moving from fingertip touch to palmar contact and holding.

Question 60

With regard to parents’ early and extended contact with their infant and the relationships built, nurses should be aware that:
a. immediate contact is essential for the parent-child relationship.
b. skin-to-skin contact is preferable to contact with the body totally wrapped in a
blanket.
c. extended contact is especially important for adolescents and low-income women
because they are at risk for parenting inadequacies.
d. mothers need to take precedence over their partners and other family matters.

Answer 60

ANS: C
Nurses should encourage any activity that optimizes family extended contact. Immediate contact facilitates the attachment process but is not essential; otherwise, adopted infants would not establish the affectionate ties they do. The mode of infant-mother contact does not appear to have any important effect. Mothers and their partners are considered equally important.

Question 61

In the United States the en face position is preferred immediately after birth. Nurses can facilitate this process by all of these actions except:
a. washing both the infant’s face and the mother’s face.
b. placing the infant on the mother’s abdomen or breast with their heads on the same
plane.
c. dimming the lights.
d. delaying the instillation of prophylactic antibiotic ointment in the infant’s eyes.

Answer 61

ANS: A
To facilitate the position in which the parent’s and infant’s faces are approximately 8 inches apart on the same plane, allowing them to make eye contact, the nurse can place the infant at the proper height on the mother’s body, dim the light so that the infant’s eyes open, and delay putting ointment in the infant’s eyes.

Question 62

Other early sensual contacts between infant and mother involve sound and smell. Nurses should be aware that, despite what folk wisdom may say:

a. high-pitched voices irritate newborns.
b. infants can learn to distinguish their mother’s voice from others soon after birth.
c. all babies in the hospital smell alike.
d. a mother’s breast milk has no distinctive odor

Answer 62

ANS: B
Infants know the sound of their mother’s voice early. Infants respond positively to high-pitched voices. Each infant has a unique odor. Infants quickly learn to distinguish the odor of their mother’s breast milk.

Question 63

After they are born, a crying infant may be soothed by being held in a position in which the newborn can hear the mother’s heartbeat. This phenomenon is known as:

a. entrainment.
b. reciprocity.
c. synchrony.
d. biorhythmicity.

Answer 63

ANS: D
The newborn is in rhythm with the mother. The infant develops a personal biorhythm with the parents’ help over time. Entrainment is the movement of newborns in time to the structure of adult speech. Reciprocity is body NmUoRvSeImNeGnTtBo.Cr ObeMhavior that gives cues to the person’s desires. These take several weeks to develop with a new baby. Synchrony is the fit between the infant’s behavioral cues and the parent’s responses.

Question 64

Of the many factors that influence parental responses, nurses should be conscious of negative stereotypes that apply to specific patient populations. Which response could be an inappropriate stereotype of adolescent mothers?
a. An adolescent mother’s egocentricity and unmet developmental needs interfere
with her ability to parent effectively.
b. An adolescent mother is likely to use less verbal instruction, be less responsive,
and interact less positively than other mothers.
c. Adolescent mothers have a higher documented incidence of child abuse.
d. Mothers older than 35 often deal with more stress related to work and career issues
and decreasing libido

Answer 64

ANS: C
Adolescent mothers are more inclined to have a number of parenting difficulties that benefit from counseling; however, a higher incidence of child abuse is not one of them. Midlife mothers have many competencies, but they are more likely to have to deal with career issues and the accompanying stress.

Question 65

When working with parents who have some form of sensory impairment, nurses should understand that ________ is an inaccurate statement.
a. “One of the major difficulties visually impaired parents experience is the
skepticism of health care professionals.”
b. “Visually impaired mothers cannot overcome the infant’s need for eye-to-eye
contact.”
c. “The best approach for the nurse is to assess the parents’ capabilities rather than
focusing on their disabilities.”
d. “Technologic advances, including the Internet, can provide deaf parents with a full
range of parenting activities and information.”

Answer 65

ANS: B
Other sensory output can be provided by the parent, other people can participate, and other coping devices can be used. The skepticism, open or hidden, of health care professionals places an additional and unneeded hurdle for the parents. After the parents’ capabilities have been assessed (including some the nurse may not have expected), the nurse can help find ways to assist the parents that play to their strengths. The Internet affords an extra teaching tool for the deaf, as do videos with subtitles or nurses signing. A number of electronic devices can turn sound into light flashes to help pick up a child’s cry. Sign language is readily acquired by young children.

Question 66

The early after birth period is a time of emotional and physical vulnerability. Many mothers
can easily become psychologically overwhelmed by the reality of their new parental
responsibilities. Fatigue compounds these issues. Although the baby blues are a common
occurrence in the after birth period, about one-half million women in America experience a
more severe syndrome known as postpartum depression (PPD). Which statement regarding
PPD is essential for the nurse to be aware of when attempting to formulate a nursing
diagnosis?
a. PPD symptoms are consistently severe.
b. This syndrome affects only new mothers.
c. PPD can easily go undetected.
d. Only mental health professionals should teach new parents about this condition

Answer 66

ANS: C
PPD can go undetected because parents do not voluntarily admit to this type of emotional distress out of embarrassment, fear, or guilt. PPD symptoms range from mild to severe, with women having both good and bad days. Both mothers and fathers should be screened. PPD may also affect new fathers. The nurse should include information on PPD and how to differentiate this from the baby blues for all patients on discharge. Nurses also can urge new parents to report symptoms and seek follow-up care promptly if symptoms occur.

Question 67

The after birth woman who continually repeats the story of her labor, delivery, and recovery experience is:

a. providing others with her knowledge of events.
b. making the birth experience “real.”
c. taking hold of the events leading to her labor and delivery.
d. accepting her response to labor and delivery.

Answer 67

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

Question 68

On observing a woman on her first after birth day sitting in bed while her newborn lies awake in the bassinet, the nurse should:

a. realize that this situation is perfectly acceptable.
b. offer to hand the baby to the woman.
c. hand the baby to the woman.
d. explain “taking in” to the woman.

Answer 68

ANS: C
During the “taking-in” phase of maternal adaptation (the mother may be passive and dependent), the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. The patient is exhibiting expected behavior during the taking-in phase; however, interventions by the nurse can facilitate infant bonding. The patient will learn best during the taking-hold phase.

Question 69

A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should:

a. report the incident to the social services department.
b. advise the parents that the toddler needs to be reprimanded.
c. report to oncoming staff that the mother is probably not a good disciplinarian.
d. realize that this is a normal family adjusting to family change.

Answer 69

ANS:D
The observed behaviors are normal variations of families adjusting to change. There is no need to report this one incident. Giving advice at this point would make the parents feel inadequate.

Question 70

During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby?

a. Letting go
b. Taking hold
c. Taking in
d. Taking on

Answer 70

ANS: A
Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. In the taking-in phase the mother is primarily focused on her own needs. There is no taking-on phase of maternal adjustment.

Question 71

A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to:

a. assess her for pain.
b. point out how lucky she is to have a healthy baby.
c. explain that she is experiencing after birth blues.
d. allow her time to express her feeling

Answer 71

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

Question 72

A man calls the nurse’s station and states that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, “She was never like this before the baby was born.” The nurse’s initial response could be to:

a. tell him to ignore the mood swings, as they will go away.
b. reassure him that this behavior is normal.
c. advise him to get immediate psychological help for her.
d. instruct him in the signs, symptoms, and duration of after birth blues.

Answer 72

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

Question 73

Which concerns about parenthood are often expressed by visually impaired mothers? (Select all that apply.)

a. Infant safety
b. Transportation
c. The ability to care for the infant
d. Missing out visually
e. Needing extra time for parenting activities to accommodate the visual limitations

Answer 73

ANS: A, B, D, E
Concerns expressed by visually impaired mothers include infant safety, extra time needed for
parenting activities, transportation, handling other people’s reactions, providing proper
discipline, and missing out visually. Blind people sense reluctance on the part of others to
acknowledge that they have a right to be parents; however, blind parents are fully capable of
caring for their infants.

Question 74

A parent who has a hearing impairment is presented with a number of challenges in parenting. Which nursing approaches are appropriate for working with hearing-impaired new parents? (Select all that apply.)

a. Use devices that transform sound into light.
b. Assume that the patient knows sign language.
c. Speak quickly and loudly.
d. Ascertain whether the patient can read lips before teaching.
e. Written messages aid in communication.

Answer 74

ANS:A,D,E
Section 504 of the Rehabilitation Act of 1973 requires that hospitals use various communication techniques and resources with the deaf and hard of hearing patient. This includes devices such as door alarms, cry alarms, and amplifiers. Before initiating communication, the nurse needs to be aware of the parents’ preferences for communication. Not all hearing-impaired patients know sign language. Do they wear a hearing aid? Do they read lips? Do they wish to have a sign language interpreter? If the parent relies on lipreading, the nurse should sit close enough so that the parent can visualize lip movements. The nurse should speak clearly in a regular voice volume, in short, simple sentences. Written messages such as on a black or white erasable board can be useful. Written materials should be reviewed with the parents before discharge.

Question 75

A primary nursing responsibility when caring for a woman experiencing an obstetric hemorrhage associated with uterine atony is to:

a. establish venous access.
b. perform fundal massage.
c. prepare the woman for surgical intervention.
d. catheterize the bladder.

Answer 75

ANS: B
The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, the initial intervention would be fundal massage. The woman may need surgical intervention to treat her after birth hemorrhage, but the initial nursing intervention would be to assess the uterus. After uterine massage the nurse may want to catheterize the patient to eliminate any bladder distention that may be preventing the uterus from contracting properly.

Question 76

The perinatal nurse caring for the after birth woman understands that late postpartum hemorrhage (PPH) is most likely caused by:

a. subinvolution of the placental site.
b. defective vascularity of the decidua.
c. cervical lacerations.
d. coagulation disorders.

Answer 76

ANS: A
Late PPH may be the result of subinvolution of the uterus, pelvic infection, or retained placental fragments. Late PPH is not typically a result of defective vascularity of the decidua, cervical lacerations, or coagulation disorders.

Question 77

Which woman is at greatest risk for early postpartum hemorrhage (PPH)?
a. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean
birth for fetal distress.
b. A woman with severe preeclampsia who is receiving magnesium sulfate and
whose labor is being induced.
c. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor.
d. A primigravida in spontaneous labor with preterm twins.

Answer 77

ANS: B
Magnesium sulfate administration during labor poses a risk for PPH. Magnesium acts as a smooth muscle relaxant, thereby contributing to uterine relaxation and atony. Although many causes and risk factors are associated with PPH, the primiparous woman being prepared for an emergency C-section, the multiparous woman with 8-hour labor, and the primigravida in spontaneous labor do not pose risk factors or causes of early PPH.

Question 78

The first and most important nursing intervention when a nurse observes profuse after birth bleeding is to:

a. call the woman’s primary health care provider.
b. administer the standing order for an oxytocic.
c. palpate the uterus and massage it if it is boggy.
d. assess maternal blood pressure and pulse for signs of hypovolemic shock.

Answer 78

ANS: C
The initial management of excessive after birth bleeding is firm massage of the uterine fundus. Although calling the health care provider, administering an oxytocic, and assessing maternal BP are appropriate interventions, the primary intervention should be to assess the uterus. Uterine atony is the leading cause of postpartum hemorrhage (PPH).

Question 79

When caring for a after birth woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:

a. absence of cyanosis in the buccal mucosa.
b. cool, dry skin.
c. diminished restlessness.
d. urinary output of at least 30 mL/h

Answer 79

ANS: D
Hemorrhage may result in hemorrhagic shock. Shock is an emergency situation in which the perfusion of body organs may become severely compromised and death may occur. The presence of adequate urinary output indicates adequate tissue perfusion. The assessment of the buccal mucosa for cyanosis can be subjective. The presence of cool, pale, clammy skin would be an indicative finding associated with hemorrhagic shock. Hemorrhagic shock is associated with lethargy, not restlessness.

Question 80

One of the first symptoms of puerperal infection to assess for in the after birth woman is:

a. fatigue continuing for longer than 1 week.
b. pain with voiding.
c. profuse vaginal bleeding with ambulation.
d. temperature of 38° C (100.4° F) or higher on two successive days starting 24 hours after birth.

Answer 80

ANS: D
After birth or puerperal infection is any clinical infection of the genital canal that occurs within 28 days after miscarriage, induced abortion, or childbirth. The definition used in the United States continues to be the presence of a fever of 38° C (100.4° F) or higher on two successive days of the first 10 after birth days, starting 24 hours after birth. Fatigue would be a late finding associated with infection. Pain with voiding may indicate a urinary tract infection, but it is not typically one of the earlier symptoms of infection. Profuse lochia may be associated with endometritis, but it is not the first symptom associated with infection

Question 81

Nurses need to know the basic definitions and incidence data about postpartum hemorrhage (PPH). For instance:
a. PPH is easy to recognize early; after all, the woman is bleeding.
b. traditionally it takes more than 1000 mL of blood after vaginal birth and 2500 mL
after cesarean birth to define the condition as PPH.
c. if anything, nurses and doctors tend to overestimate the amount of blood loss.
d. traditionally PPH has been classified as early or late with respect to birth.

Answer 81

ANS: D
Early PPH is also known as primary, or acute, PPH; late PPH is known as secondary PPH. Unfortunately PPH can occur with little warning and often is recognized only after the mother has profound symptoms. Traditionally a 500-mL blood loss after a vaginal birth and a 1000-mL blood loss after a cesarean birth constitute PPH. Medical personnel tend to underestimate blood loss by as much as 50% in their subjective observations.

Question 82

A woman who has recently given birth complains of pain and tenderness in her leg. On physical examination the nurse notices warmth and redness over an enlarged, hardened area. The nurse should suspect __________ and should confirm the diagnosis by ___________.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Comprehension
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
a. disseminated intravascular coagulation; asking for laboratory tests
b. von Willebrand disease; noting whether bleeding times have been extended
c. thrombophlebitis; using real-time and color Doppler ultrasound
d. coagulopathies; drawing blood for laboratory analysis

Answer 82

ANS: C
Pain and tenderness in the extremities, which show warmth, redness, and hardness, likely indicate thrombophlebitis. Doppler ultrasound is a common noninvasive way to confirm diagnosis.

Question 83

What PPH conditions are considered medical emergencies that require immediate treatment?

a. Inversion of the uterus and hypovolemic shock
b. Hypotonic uterus and coagulopathies
c. Subinvolution of the uterus and idiopathic thrombocytopenic purpura
d. Uterine atony and disseminated intravascular coagulation

Answer 83

ANS: A
Inversion of the uterus and hypovolemic shock are considered medical emergencies. Although hypotonic uterus and coagulopathies, subinvolution of the uterus and idiopathic thrombocytopenic purpura, and uterine atony and disseminated intravascular coagulation are serious conditions, they are not necessarily medical emergencies that require immediate treatment.

Question 84

What infection is contracted mostly by first-time mothers who are breastfeeding?

a. Endometritis
b. Wound infections
c. Mastitis
d. Urinary tract infection

Answer 84

ANS: C
Mastitis is infection in a breast, usually confined to a milk duct. Most women who suffer this are primiparas who are breastfeeding.

Question 85

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for after birth hemorrhage from birth until 4 weeks after delivery as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the patient with von Willebrand disease who experiences a after birth hemorrhage is:

a. cryoprecipitate.
b. factor VIII and vWf.
c. desmopressin.
d. hemabate.

Answer 85

ANS: C
Desmopressin is the primary treatment of choice. This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products such as factor VIII and vWf is an acceptable option for this patient. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice. Although the administration of this prostaglandin is known to promote contraction of the uterus during after birth hemorrhage, it is not effective for the patient who presents with a bleeding disorder.

Question 86

When a woman is diagnosed with postpartum depression (PPD) with psychotic features, one of the main concerns is that she may:

a. have outbursts of anger.
b. neglect her hygiene.
c. harm her infant.
d. lose interest in her husband.

Answer 86

ANS: C
Thoughts of harm to oneself’ or the infant are among the most serious symptoms of PPD and
require immediate assessment and intervention. Although outbursts of anger, hygiene neglect,
and loss of interest in her husband are attributable to PPD, the major concern would be the
potential to harm herself or her infant.

Question 87

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) without psychotic features:
a. means that the woman is experiencing the baby blues. In addition she has a visit
with a counselor or psychologist.
b. is more common among older, Caucasian women because they have higher
expectations.
c. is distinguished by irritability, severe anxiety, and panic attacks.
d. will disappear on its own without outside help.

Answer 87

ANS: C
PPD is also characterized by spontaneous crying long after the usual duration of the baby blues. PPD, even without psychotic features, is more serious and persistent than after birth baby blues. It is more common among younger mothers and African-American mothers. Most women need professional help to get through PPD, including pharmacologic intervention.

Question 88

To provide adequate after birth care, the nurse should be aware that postpartum depression (PPD) with psychotic features:

a. is more likely to occur in women with more than two children.
b. is rarely delusional and then is usually about someone trying to harm her (the
mother) .
c. although serious, is not likely to need psychiatric hospitalization.
d. may include bipolar disorder (formerly called “manic depression”)

Answer 88

ANS: D
Manic mood swings are possible. PPD is more likely to occur in first-time mothers. Delusions may be present in 50% of women with PPD, usually about something being wrong with the infant. PPD with psychosis is a psychiatric emergency that requires hospitalization.

Question 89

With shortened hospital stays, new mothers are often discharged before they begin to experience symptoms of the baby blues or after birth depression. As part of the discharge teaching, the nurse can prepare the mother for this adjustment to her new role by instructing her regarding self-care activities to help prevent after birth depression. The most accurate statement as related to these activities is to:
a. stay home and avoid outside activities to ensure adequate rest.
b. be certain that you are the only caregiver for your baby to facilitate infant
attachment.
c. keep feelings of sadness and adjustment to your new role to yourself.
d. realize that this is a common occurrence that affects many women.

Answer 89

ANS: D
Should the new mother experience symptoms of the baby blues, it is important that she be
aware that this is nothing to be ashamed of. Up to 80% of women experience this type of mild depression after the birth of their infant. Although it is important for the mother to obtain enough rest, she should not distance herself from family and friends. Her spouse or partner can communicate the best visiting times so the new mother can obtain adequate rest. It is also important that she does not isolate herself at home during this time of role adjustment. Even if breastfeeding, other family members can participate in the infant’s care. If depression occurs, the symptoms can often interfere with mothering functions, and this support will be essential. The new mother should share her feelings with someone else. It is also important that she not overcommit herself or think she has to be “superwoman.” A telephone call to the hospital warm line may provide reassurance with lactation issues and other infant care questions. Should symptoms continue, a referral to a professional therapist may be necessary.

Question 90

Complicated bereavement:

a. occurs when, in multiple births, one child dies, and the other or others live.
b. is a state in which the parents are ambivalent, as with an abortion.
c. is an extremely intense grief reaction that persists for a long time.
d. is felt by the family of adolescent mothers who lose their babies.

Answer 90

ANS:C
Parents showing signs of complicated grief should be referred for counseling. Multiple births in which not all the babies survive creates a complicated parenting situation, but this is not complicated bereavement. Abortion can generate complicated emotional responses, but they do not constitute complicated bereavement. Families of lost adolescent pregnancies may have to deal with complicated issues, but this is not complicated bereavement.

Question 91

Early after birth hemorrhage is defined as a blood loss greater than:

a. 500 mL in the first 24 hours after vaginal delivery.
b. 750 mL in the first 24 hours after vaginal delivery.
c. 1000 mL in the first 48 hours after cesarean delivery.
d. 1500 mL in the first 48 hours after cesarean delivery.

Answer 91

ANS: A
The average amount of bleeding after a vaginal birth is 500 mL. Blood loss after a cesarean birth averages 1000 mL. Early after birth hemorrhage occurs in the first 24 hours, not 48 hours. Late after birth hemorrhage is 48 hours and later.

Question 92

A woman delivered a 9-lb, 10-ounce baby 1 hour ago. When you arrive to perform her 15-minute assessment, she tells you that she “feels all wet underneath.” You discover that both pads are completely saturated and that she is lying in a 6-inch-diameter puddle of blood. What is your first action?

a. Call for help.
b. Assess the fundus for firmness.
c. Take her blood pressure.
d. Check the perineum for lacerations.

Answer 92

ANS: B
Firmness of the uterus is necessary to control bleeding from the placental site. The nurse should first assess for firmness and massage the fundus as indicated. Assessing blood pressure is an important assessment with a bleeding patient; however, the top priority is to control the bleeding. If bleeding continues in the presence of a firm fundus, lacerations may be the cause.

Question 93

A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:

a. uterine atony.
b. lacerations of the genital tract.
c. perineal hematoma.
d. infection of the uterus

Answer 93

ANS:B
Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus is not firm in the presence of uterine atony. A hematoma would develop internally. Swelling and discoloration would be noticeable; however, bright bleeding would not be. With an infection of the uterus there would be an odor to the lochia and systemic symptoms such as fever and malaise.

Question 94

Which instruction should be included in the discharge teaching plan to assist the patient in recognizing early signs of complications?
a. Palpate the fundus daily to ensure that it is soft.
b. Notify the physician of any increase in the amount of lochia or a return to bright
red bleeding.
c. Report any decrease in the amount of brownish red lochia.
d. The passage of clots as large as an orange can be expected.

Answer 94

ANS: B
An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. The lochia should decrease in amount over time. Large clots after discharge are a sign of complications and should be reported.

Question 95

If nonsurgical treatment for late after birth hemorrhage is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

a. Hysterectomy
b. Laparoscopy
c. Laparotomy
d. D&C

Answer 95

ANS: D
D&C allows examination of the uterine contents and removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. It is not the appropriate treatment for this condition. A laparotomy is also not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore it.

Question 96

Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?

a. After birth depression
b. After birth psychosis
c. After birth bipolar disorder
d. After birth blues

Answer 96

ANS:D
After birth blues or “baby blues” is a transient self-limiting disease that is believed to be related to hormonal fluctuations after childbirth. After birth depression is not the normal worries (blues) that many new mothers experience. Many caregivers believe that after birth depression is underdiagnosed and underreported. After birth psychosis is a rare condition that usually surfaces within 3 weeks of delivery. Hospitalization of the woman is usually necessary for treatment of this disorder. Bipolar disorder is one of the two categories of after birth psychosis, characterized by both manic and depressive episodes.

Question 97

Anxiety disorders are the most common mental disorders that affect women. While providing care to the maternity patient, the nurse should be aware that one of these disorders is likely to be triggered by the process of labor and birth. This disorder is:

a. phobias.
b. panic disorder.
c. posttraumatic stress disorder (PTSD).
d. obsessive-compulsive disorder (OCD).

Answer 97

ANS: C
In PTSD, women perceive childbirth as a traumatic event. They have nightmares and
flashbacks about the event, anxiety, and avoidance of reminders of the traumatic event.
Phobias are irrational fears that may lead a person to avoid certain objects, events, or
situations. Panic disorders include episodes of intense apprehension, fear, and terror.
Symptoms may manifest themselves as palpitations, chest pain, choking, or smothering. OCD
symptoms include recurrent, persistent, and intrusive thoughts. The mother may repeatedly
check and recheck her infant once he or she is born, even though she realizes that this is
irrational. OCD is best treated with medications.

Question 98

Medications used to manage postpartum hemorrhage (PPH) include: (Select all that apply.)

a. Pitocin.
b. Methergine.
c. Terbutaline.
d. Hemabate.
e. magnesium sulfate.

Answer 98

ANS: A, B, D
Pitocin, Methergine, and Hemabate are all used to manage PPH. Terbutaline and magnesium sulfate are tocolytics; relaxation of the uterus causes or worsens PPH.