MATERNITY CASE 5 FATIME SANOGO
DOCUMENTATION REVIEW STUDY SHEET 2026
ACCURATE RESPONSES FULL SOLUTION
◉ The nurse is teaching a new mother about diet and breastfeeding.
Which instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day.. Answer:
A.Avoid alcohol because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it
is excreted in breast milk and may cause a variety of problems,
including slower growth and cognitive impairment for the infant.
Options B, C, and D should also be included in diet teaching for a
breastfeeding mother; however, because these do not involve safety
of the infant, they do not have the same degree of importance as
option A.
,◉ A client at 28 weeks of gestation calls the antepartal clinic and
states that she has just experienced a small amount of vaginal
bleeding, which she describes as bright red. The bleeding has
subsided. She further states that she is not experiencing any uterine
contractions or abdominal pain. What instruction should the nurse
provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a
urinary tract infection (UTI).. Answer: A.Come to the clinic today for
an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in
gushes, or be continuous. Rarely is the first incident life threatening
or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta,
which is life threatening to the mother and fetus. If those symptoms
,were described, option B would be appropriate. Option C does not
address the cause of the symptoms. The client is not describing
symptoms of a UTI.
◉ A 41-week multigravida is receiving oxytocin (Pitocin) to augment
labor. Contractions are firm and occurring every 5 minutes, with a
30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which
action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion.. Answer:
B.Determine cervical dilation and effacement.
Rationale: The goal of labor augmentation is to produce firm
contractions that occur every 2 to 3 minutes, with a duration of 60 to
70 seconds, and without evidence of fetal stress. FHR accelerations
are a normal response to contractions, so the oxytocin (Pitocin)
infusion should be increased per protocol to stimulate the frequency
and intensity of contractions. Options A and C are indicated for fetal
, stress. A sterile vaginal examination places the client at risk for
infection and should be performed when the client exhibits signs of
progressing labor, which is not indicated at this time.
◉ A client who delivered by cesarean section 24 hours ago is using a
patient-controlled analgesia (PCA) pump for pain control. Her oral
intake has been ice chips only since surgery. She is now complaining
of nausea and bloating and states that because she has had nothing
to eat, she is too weak to breastfeed her infant. Which nursing
diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and
immobility
D.Fatigue related to cesarean delivery and physical care demands of
infant. Answer: C.Impaired bowel motility related to pain medication
and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia,
pain medication, and immobility is the priority nursing diagnosis
and addresses the potential problem of a paralytic ileus. Options A
DOCUMENTATION REVIEW STUDY SHEET 2026
ACCURATE RESPONSES FULL SOLUTION
◉ The nurse is teaching a new mother about diet and breastfeeding.
Which instruction is most important to include in the teaching plan?
A.Avoid alcohol because it is excreted in breast milk.
B.Eat a high-roughage diet to help prevent constipation.
C.Increase caloric intake by approximately 500 cal/day.
D.Increase fluid intake to at least 3 quarts each day.. Answer:
A.Avoid alcohol because it is excreted in breast milk.
Rationale: Alcohol should be avoided while breastfeeding because it
is excreted in breast milk and may cause a variety of problems,
including slower growth and cognitive impairment for the infant.
Options B, C, and D should also be included in diet teaching for a
breastfeeding mother; however, because these do not involve safety
of the infant, they do not have the same degree of importance as
option A.
,◉ A client at 28 weeks of gestation calls the antepartal clinic and
states that she has just experienced a small amount of vaginal
bleeding, which she describes as bright red. The bleeding has
subsided. She further states that she is not experiencing any uterine
contractions or abdominal pain. What instruction should the nurse
provide?
A.Come to the clinic today for an ultrasound.
B.Go immediately to the emergency department.
C.Lie on your left side for about 1 hour and see if the bleeding stops.
D.Take a urine specimen to the laboratory to see if you have a
urinary tract infection (UTI).. Answer: A.Come to the clinic today for
an ultrasound.
Rationale:Third-trimester painless bleeding is characteristic of a
placenta previa. Bright red bleeding may be intermittent, occur in
gushes, or be continuous. Rarely is the first incident life threatening
or cause for hypovolemic shock. Diagnosis is confirmed by
transabdominal ultrasound. Bleeding that has a sudden onset and is
accompanied by intense uterine pain indicates abruptio placenta,
which is life threatening to the mother and fetus. If those symptoms
,were described, option B would be appropriate. Option C does not
address the cause of the symptoms. The client is not describing
symptoms of a UTI.
◉ A 41-week multigravida is receiving oxytocin (Pitocin) to augment
labor. Contractions are firm and occurring every 5 minutes, with a
30- to 40-second duration. The fetal heart rate increases with each
contraction and returns to baseline after the contraction. Which
action should the nurse implement?
A.Place a wedge under the client's left side.
B.Determine cervical dilation and effacement.
C.Administer 10 L of oxygen via facemask.
D.Increase the rate of the oxytocin (Pitocin) infusion.. Answer:
B.Determine cervical dilation and effacement.
Rationale: The goal of labor augmentation is to produce firm
contractions that occur every 2 to 3 minutes, with a duration of 60 to
70 seconds, and without evidence of fetal stress. FHR accelerations
are a normal response to contractions, so the oxytocin (Pitocin)
infusion should be increased per protocol to stimulate the frequency
and intensity of contractions. Options A and C are indicated for fetal
, stress. A sterile vaginal examination places the client at risk for
infection and should be performed when the client exhibits signs of
progressing labor, which is not indicated at this time.
◉ A client who delivered by cesarean section 24 hours ago is using a
patient-controlled analgesia (PCA) pump for pain control. Her oral
intake has been ice chips only since surgery. She is now complaining
of nausea and bloating and states that because she has had nothing
to eat, she is too weak to breastfeed her infant. Which nursing
diagnosis has the highest priority?
A.Altered nutrition, less than body requirements for lactation
B.Alteration in comfort related to nausea and abdominal distention
C.Impaired bowel motility related to pain medication and
immobility
D.Fatigue related to cesarean delivery and physical care demands of
infant. Answer: C.Impaired bowel motility related to pain medication
and immobility
Rationale: Impaired bowel motility caused by surgical anesthesia,
pain medication, and immobility is the priority nursing diagnosis
and addresses the potential problem of a paralytic ileus. Options A
