Postpartum Care 33-1 Nclex and Pearson Questions And Answers Complete Solution

Postpartum Care 33-1 Nclex and Pearson Questions And Answers Complete Solution A postpartum patient demonstrates decision making regarding mothering. Which stage of maternal role attainment should the nurse note the mother has achieved? A. Informal stage B. Personal stage C. Formal stage D. Anticipatory stage - Answer-A. Informal stage The stage the mother has achieved when making decisions about the baby is the informal stage. The informal stage begins when the mother starts making choices about mothering. The personal, formal, and anticipatory stages are defined by other characteristics. The nurse is assessing the taking-in period of a patient. Which patient behavior is expected during this time? A. The patient hesitates to make decisions. B. The patient assumes self-care. C. The patient worries about the baby getting enough to eat. D. The patient requires assurance that she is doing well as a mother. - Answer-A. The patient hesitates to make decisions. Initially after birth during the taking-in period, the woman tends to be passive and somewhat dependent. She follows suggestions, hesitates to make decisions, and is still rather preoccupied with the needs. A patient that assumes self-care, worries about the baby getting enough to eat, or requires assurance that she is doing well as a mother is in the taking-hold period that occurs on the second or third day after birth. The nurse is teaching a patient who delivered vaginally about the importance of emptying the bladder. Which information should the nurse include in the teaching? A. "A full bladder places you at risk for increased bleeding." B. "A full bladder increases uterine cramping C. "A full bladder will worsen constipation." D. "A full bladder delays the healing of your perineum." - Answer-A. "A full bladder places you at risk for increased bleeding." A full bladder will cause the uterus to relax by displacing the uterus and interfering with its contractility, leading to hemorrhage. The bladder has no relationship to the perineal healing, constipation, and will not necessarily increase uterine cramping. The nurse caring for a patient who had an uncomplicated vaginal delivery 24 hours prior assesses the patient's fundus and notes that it is above the umbilicus. Which is the priority nursing intervention? Encouraging the patient to void Encouraging ambulation No intervention is necessary Performing fundal massage - Answer-Encouraging the patient to void Twenty-four hours after giving birth, the fundal height should be at the umbilicus. Deviation, most commonly to the right or elevation above the umbilicus, is an indication of bladder distention, which places the patient at risk for hemorrhage. Neither fundal massage nor ambulation will promote uterine involution in this circumstance. Involution of the uterus. A. Immediately after delivery of the placenta, the top of the fundus is in the midline and approximately halfway between the symphysis pubis and the umbilicus. Approximately 6-12 hours after birth, the fundus is at the level of the umbilicus. B: The height of the fundus then decreases about one fingerbreadth (approximately 1 cm) each day. The nurse caring for a patient who delivered 8 hours prior notes upon assessment that the fundus is midline, firm, and at the umbilicus, but the patient is experiencing heavy vaginal bleeding. Which causative factor for the bleeding should the nurse suspect? A. Laceration B. Hematoma C. Uterine atony D. Endometritis - Answer-A. Laceration Lacerations should be suspected when vaginal bleeding persists in the presence of a firmly contracted uterus. The assessment finding of a firm uterus with heavy vaginal bleeding is not associated with a hematoma, uterine atony, or endometritis. The nurse has received handoff report for four postpartum patients. Which patient should the nurse assess first? A. Vaginal delivery with an episiotomy delivered 8 hours prior that has not voided B. Cesarean birth delivered 4 hours ago, medicated for pain 30 minutes ago, not tolerating clear liquids C. Vaginal delivery 24 hours prior, ambulating well that has docusate sodium (Colace) due in 30 minutes D. Cesarean birth delivered twins 12 hours prior who is requesting assistance with breastfeeding - Answer-Vaginal delivery with an episiotomy delivered 8 hours prior that has not voided The nurse will assess first the vaginal delivery with an episiotomy delivered 8 hours prior who has not voided. It is generally expected that a postpartum patient will void within 6 hours of delivery. The risks of not voiding include hemorrhage or excessive vaginal bleeding or both. The patient at risk for hemorrhage takes priority over the patient who was medicated for pain, the patient with docusate sodium due, and the patient requesting assistance with breastfeeding. Additional Learning The postpartum nurse is reviewing charts of patients who have delivered. Which patient should the nurse identify as having the greatest risk factor for developing a thromboembolism? A. A patient of advanced maternal age that delivered vaginally 1 day prior B. An adolescent patient 2 days post vaginal delivery C. A patient with vaginal delivery of twins 18 hours prior D. A patient with gestational diabetes that delivered vaginally 1 day prior - Answer-A. A patient of advanced maternal age that delivered vaginally 1 day prior Pregnancy-associated activation of coagulation factors may continue for variable amounts of time after birth. This condition, in conjunction with advanced maternal age, increase the patient's risk for a thromboembolism after delivery. Adolescence, multiple gestation, and gestational diabetes are not risk factors associated with a thromboembolism. The nurse is conducting a home visit for a patient 10 days postpartum. Upon assessment of the patient's breasts, the nurse notes that the left breast is tender, reddened, and swollen. Which statement by the nurse reflects an appropriate nursing intervention for this patient? A. "I am going to get you in to see your healthcare provider immediately." B. "You will need to stop breastfeeding your newborn." C. "This is normal breast engorgement; there is nothing to worry about." D. "You should mention this when you have your follow-up appointment with the healthcare provider." - Answer-"I am going to get you in to see your healthcare provider immediately." Erythema, swelling, and localized tenderness are symptomatic of mastitis. Without intervention, it is likely the condition will worsen, so waiting until a follow-up visit is delaying care. The patient with mastitis should be encouraged to empty the breasts by beginning the baby's feedings on the affected side unless there is an abscess present. A patient requests information about birth control that can be initiated before discharge from the hospital. Which question asked by the nurse is the most appropriate? A. "Are you breastfeeding?" B. "Have you discussed this with your healthcare provider?" C. "Are aware that you are not supposed to have intercourse until 6 weeks postpartum?" D. "What type of birth control were you using prior to getting pregnant?" - Answer-A. "Are you breastfeeding?" Information on contraception is an important part of postpartum care. Prior to providing information to the patient, it is important to ascertain whether the patient is breastfeeding. Breastfeeding women should be given available options and choose the method that best fits their lifestyle, financial situation, and personal preference. Asking the patient if they had discussed birth control with their healthcare provider does not answer the patient's question. The patient should be instructed to abstain from intercourse until cleared by the healthcare practitioner, but this question does not address the patient's concern about birth control. The nurse should objectively offer the patient information on all of the different forms of birth control available. The nurse is caring for a 3-day postpartum breastfeeding patient that states, "I wonder when my milk will come in?" Which best describes the nurse's understanding of transitional milk production in breastfeeding patients? A. By day 5, mothers produce approximately 500 mL/day. B. By day 10, the mother is producing approximately 800 mL/day. C. Transitional milk production begins after 24 hours of breastfeeding. D. The initial milk is immediately available to the baby after birth. - Answer-A. By day 5, mothers produce approximately 500 mL/day By day 5, mothers produce approximately 500 mL/day of transitional milk. By 6 months postpartum, the mother produces 800 mL/day of mature milk. The transitional milk production does not begin 24 hours after breastfeeding and colostrum is immediately available to the newborn after birth. The nurse is caring for a patient who delivered vaginally at 2:00 p.m. The patient was straight catheterized after delivery but has not voided since. At which time should the nurse report the patient's inability to void? A. 8:00 p.m. B. 4:00 p.m. C. 12:00 a.m. D. 2:00 a.m. - Answer-A. 8:00 p.m. The nurse will report the patient's inability to void at 8:00 p.m. A patient who has had a vaginal delivery should spontaneously void within 6 hours after giving birth; 4:00 p.m. is still within normal limits. Waiting to intervene until 12:00 a.m. or 2:00 a.m. places the patient at risk for bladder distention and postpartum hemorrhage. A newly delivered patient experienced a prolonged second stage of delivery. The baby was not able to breastfeed after delivery. Which action by the nurse is most appropriate? Continues...