Normal Postpartum- Davis Practice Q's(All Accurately
solved)
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at
discharge. Which of the following must the nurse include in her discharge teaching regarding the
vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. correct answers 1. This
statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can
develop if the woman becomes pregnant within 4 weeks of receiving the injection.
If rubella is contracted
during pregnancy, the fetus is at very high
risk for injury. Whenever gravid clients
are found to be nonimmune to rubella—
defined as a titer of 1:8 or lower—they
are advised to receive the vaccine during
the early postpartum period and are
counseled regarding the teratogenic
properties of the vaccine.
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the
hospital. Which of the following rationales should guide the nurse's response?
1. The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum period.
3. The client's baby will be high risk for acquiring rubella if the woman does not receive the
vaccine.
4. The client's insurance company will pay for the shot if it is given during the immediate
postpartum period. correct answers 1. This statement is correct. Because the
vaccine is teratogenic, the best time to
administer it is when the client is not
pregnant.
The correct answer did
not explicitly state that the vaccine is
administered during the immediate post-
partum period because the woman is not
pregnant and is unlikely to become preg-
nant within the next 4 weeks. But the test
taker must know that a woman's obstetric
status immediately after delivery is opti-
mal for receiving the medication precisely
because she is not pregnant and very
,unlikely to become pregnant.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F.
Which of the following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. correct answers 4. It is likely that this client is
dehydrated.
She should be advised to drink fluids.
In the early postpartum
period, up to 24 hours after delivery, the
most common reason for clients to have
slight temperature elevations is dehydra-
tion. During labor, clients work very hard,
often utilizing breathing techniques as a
form of pain control. As a result, the
clients lose fluids through insensible loss
via the respiratory system.
To prevent infection, the nurse teaches the postpartum client to perform which of the following
tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. correct answers 2. Clients should be
advised to change
their pads at each voiding.
Postpartum women
should be advised to perform three actions
to prevent infections: (1) change their
peripads at each toileting because blood is
an excellent medium for bacterial growth;
(2) spray the perineum from front to back
with clear water to cleanse the area; and
(3) wipe the perineum after toileting from
front to back to prevent the rectal flora
from contaminating sterile sites.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to
the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let
the nurses feed him in the nursery last night. I needed to rest."
Which of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
,2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. correct answers 1. Clients should be
strongly encouraged
exclusively to breastfeed their babies to
prevent engorgement.
The lactating breast
produces milk in response to being
stimulated. When a feeding is skipped,
milk is still produced for the baby. When
the baby is not fed, breast congestion
or engorgement results. Not only is
engorgement uncomfortable, it also gives
the body the message to stop producing
milk, resulting in an insufficient milk
supply.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the
following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. correct answers 2. This statement is true. The
best way to
prevent engorgement is to feed the
baby every 2 to 3 hours.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a
diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of milk."
2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding."
3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby."
4. "Many mothers lose weight when they breastfeed because the baby consumes about 600
calories a day." correct answers 4. Many mothers who consume approxi-
mately the same number of calories
while breastfeeding as they did when
they were pregnant do lose weight
while breastfeeding.
Mothers should be
advised to eat a well-balanced diet and
drink sufficient quantities of fluids while
breastfeeding. There is no absolute
number of calories that the mother
should consume, but if she does go on a
, restrictive diet, it is likely that her milk supply may dwindle. Babies do take in
about 600 calories a day at the breast;
therefore, mothers can be advised that
breastfeeding alone is a form of dieting.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The
nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal
sutures are intact. Which of the following actions should the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman's fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman's primary health care provider. correct answers 4. Because of the heavy
lochia, the nurse
should notify the woman's health care
provider.
The nurse must do some
detective work when observing unexpected
signs/symptoms. This client is bleeding
more heavily than the nurse would expect.
When the nurse assesses the two most
likely sources of the bleeding—the fundus
and the perineal sutures—normal findings
are noted. The next most likely source of
the bleeding —a laceration in the birth
canal—is unobservable to the nurse
because performing a postpartum internal
examination is not a nursing function. The
nurse, therefore, must notify the health
care practitioner of the problem.
A client informs the nurse that she intends to bottle feed her baby. Which of the following
actions should the nurse encourage the client to perform? Select all that apply.
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
5. Stand with her back toward the shower water. correct answers 4. The mother should be
advised to wear
a supportive bra 24 hours a day for a
week or so.
5. The mother should be advised to stand
with her back toward the warm shower
water.
The postpartum body
solved)
A 3-day-breastfeeding client who is not immune to rubella is to receive the rubella vaccine at
discharge. Which of the following must the nurse include in her discharge teaching regarding the
vaccine?
1. The woman should not become pregnant for at least 4 weeks.
2. The woman should pump and dump her breast milk for 1 week.
3. Surgical masks must be worn by the mother when she holds the baby.
4. Antibodies transported through the breast milk will protect the baby. correct answers 1. This
statement is correct. The rubella vaccine is a live attenuated vaccine. Severe birth defects can
develop if the woman becomes pregnant within 4 weeks of receiving the injection.
If rubella is contracted
during pregnancy, the fetus is at very high
risk for injury. Whenever gravid clients
are found to be nonimmune to rubella—
defined as a titer of 1:8 or lower—they
are advised to receive the vaccine during
the early postpartum period and are
counseled regarding the teratogenic
properties of the vaccine.
A 3-day-postpartum client questions why she is to receive the rubella vaccine before leaving the
hospital. Which of the following rationales should guide the nurse's response?
1. The client's obstetric status is optimal for receiving the vaccine.
2. The client's immune system is highly responsive during the postpartum period.
3. The client's baby will be high risk for acquiring rubella if the woman does not receive the
vaccine.
4. The client's insurance company will pay for the shot if it is given during the immediate
postpartum period. correct answers 1. This statement is correct. Because the
vaccine is teratogenic, the best time to
administer it is when the client is not
pregnant.
The correct answer did
not explicitly state that the vaccine is
administered during the immediate post-
partum period because the woman is not
pregnant and is unlikely to become preg-
nant within the next 4 weeks. But the test
taker must know that a woman's obstetric
status immediately after delivery is opti-
mal for receiving the medication precisely
because she is not pregnant and very
,unlikely to become pregnant.
A patient, G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2°F.
Which of the following is the appropriate nursing intervention at this time?
1. Notify the doctor to get an order for acetaminophen.
2. Request an infectious disease consult from the doctor.
3. Provide the woman with cool compresses.
4. Encourage intake of water and other fluids. correct answers 4. It is likely that this client is
dehydrated.
She should be advised to drink fluids.
In the early postpartum
period, up to 24 hours after delivery, the
most common reason for clients to have
slight temperature elevations is dehydra-
tion. During labor, clients work very hard,
often utilizing breathing techniques as a
form of pain control. As a result, the
clients lose fluids through insensible loss
via the respiratory system.
To prevent infection, the nurse teaches the postpartum client to perform which of the following
tasks?
1. Apply antibiotic ointment to the perineum daily.
2. Change the peripad at each voiding.
3. Void at least every two hours.
4. Spray the perineum with povidone-iodine after toileting. correct answers 2. Clients should be
advised to change
their pads at each voiding.
Postpartum women
should be advised to perform three actions
to prevent infections: (1) change their
peripads at each toileting because blood is
an excellent medium for bacterial growth;
(2) spray the perineum from front to back
with clear water to cleanse the area; and
(3) wipe the perineum after toileting from
front to back to prevent the rectal flora
from contaminating sterile sites.
A 3-day-postpartum breastfeeding woman is being assessed. Her breasts are firm and warm to
the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let
the nurses feed him in the nursery last night. I needed to rest."
Which of the following actions should the nurse take at this time?
1. Encourage the woman exclusively to breastfeed her baby.
,2. Have the woman massage her breasts hourly.
3. Obtain an order to culture her expressed breast milk.
4. Take the temperature and pulse rate of the woman. correct answers 1. Clients should be
strongly encouraged
exclusively to breastfeed their babies to
prevent engorgement.
The lactating breast
produces milk in response to being
stimulated. When a feeding is skipped,
milk is still produced for the baby. When
the baby is not fed, breast congestion
or engorgement results. Not only is
engorgement uncomfortable, it also gives
the body the message to stop producing
milk, resulting in an insufficient milk
supply.
A breastfeeding woman has been counseled on how to prevent engorgement. Which of the
following actions by the mother shows that the teaching was effective?
1. She pumps her breasts after each feeding.
2. She feeds her baby every 2 to 3 hours.
3. She feeds her baby 10 minutes on each side.
4. She supplements each feeding with formula. correct answers 2. This statement is true. The
best way to
prevent engorgement is to feed the
baby every 2 to 3 hours.
A 2-day-postpartum breastfeeding woman states, "I am sick of being fat. When can I go on a
diet?" Which of the following responses is appropriate?
1. "It is fine for you to start dieting right now as long as you drink plenty of milk."
2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding."
3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby."
4. "Many mothers lose weight when they breastfeed because the baby consumes about 600
calories a day." correct answers 4. Many mothers who consume approxi-
mately the same number of calories
while breastfeeding as they did when
they were pregnant do lose weight
while breastfeeding.
Mothers should be
advised to eat a well-balanced diet and
drink sufficient quantities of fluids while
breastfeeding. There is no absolute
number of calories that the mother
should consume, but if she does go on a
, restrictive diet, it is likely that her milk supply may dwindle. Babies do take in
about 600 calories a day at the breast;
therefore, mothers can be advised that
breastfeeding alone is a form of dieting.
A G2 P2002, who is postpartum 6 hours from a spontaneous vaginal delivery, is assessed. The
nurse notes that the fundus is firm at the umbilicus, there is heavy lochia rubra, and perineal
sutures are intact. Which of the following actions should the nurse take at this time?
1. Do nothing. This is a normal finding.
2. Massage the woman's fundus.
3. Take the woman to the bathroom to void.
4. Notify the woman's primary health care provider. correct answers 4. Because of the heavy
lochia, the nurse
should notify the woman's health care
provider.
The nurse must do some
detective work when observing unexpected
signs/symptoms. This client is bleeding
more heavily than the nurse would expect.
When the nurse assesses the two most
likely sources of the bleeding—the fundus
and the perineal sutures—normal findings
are noted. The next most likely source of
the bleeding —a laceration in the birth
canal—is unobservable to the nurse
because performing a postpartum internal
examination is not a nursing function. The
nurse, therefore, must notify the health
care practitioner of the problem.
A client informs the nurse that she intends to bottle feed her baby. Which of the following
actions should the nurse encourage the client to perform? Select all that apply.
1. Increase her fluid intake for a few days.
2. Massage her breasts every 4 hours.
3. Apply heat packs to her axillae.
4. Wear a supportive bra 24 hours a day.
5. Stand with her back toward the shower water. correct answers 4. The mother should be
advised to wear
a supportive bra 24 hours a day for a
week or so.
5. The mother should be advised to stand
with her back toward the warm shower
water.
The postpartum body
