Saunders Ch.25 - Postpartum Period Questions w/
Rationale(100% Correct answers)
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4
hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing
action?
1. Document the findings.
2. Notify the obstetrician.
3. Retake the temperature in 15 minutes.
4. Increase hydration by encouraging oral fluids. correct answers Answer:
4. Increasing hydration by encouraging oral fluids.
Rationale:
The client's temperature should be taken every 4 hours while she is awake. Temperatures up to
100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of
labor. The appropriate action is to increase hydration by encouraging oral fluids, which should
bring the temperature to a normal reading. Although the nurse also would document the findings,
the appropriate action would be to increase hydration. Taking the temperature in another 15
minutes is an unnecessary action. Contacting the obstetrician is not necessary.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy
newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing
action is most appropriate?
1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit levels.
3. Instruct the client to request help when getting out of bed.
4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's
symptoms have subsided. correct answers Answer:
3. Instruct the client to request help when getting out of bed.
Rationale:
Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness
or dizziness are signs that caution the nurse to focus interventions on the client's safety. The
nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a
helpful action in this situation and would not relieve the symptoms. Option 2 requires a
prescription. Option 4 is unnecessary.
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which
time frame should the nurse relay to the client regarding the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of birth
, 4. Within 2 weeks postpartum correct answers Answer:
1. 3 days postpartum
Rationale:
After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the
return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum.
Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer
period of altered bowel functions. Options 2, 3, and 4 are incorrect.
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The
client required an episiotomy and has several hemorrhoids. What is the priority nursing
consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid volume correct answers Answer:
1. Client pain level
Rationale:
The priority nursing consideration for a client who delivered 2 hours ago and who has an
episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort
during the immediate postpartum period. There are no data in the question that indicate
inadequate urinary output, the presence of client perception of body changes, and potential for
imbalanced body fluid volume.
The nurse is providing postpartum instructions to a client who will be breast-feeding her
newborn. The nurse determines that the client has understood the instructions if she makes which
statements? (Select all that apply)
1. "I should wear a bra that provides support."
2. "Drinking alcohol can affect my milk supply."
3. "The use of caffeine can decrease my milk supply."
4. "I will start my estrogen birth control pills again as soon as I get home."
5. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby."
6. "I plan on having bottled water available in the refrigerator so I can get additional fluids
easily." correct answers Answer:
1. "I should wear a bra that provides support."
2. "Drinking alcohol can affect my milk supply."
3. "The use of caffeine can decrease my milk supply."
6. "I plan on having bottled water available in the refrigerator so I can get additional fluids
easily."
Rationale:
The postpartum client should wear a bra that is well fitted and supportive. Common causes of
decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or
Rationale(100% Correct answers)
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4
hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing
action?
1. Document the findings.
2. Notify the obstetrician.
3. Retake the temperature in 15 minutes.
4. Increase hydration by encouraging oral fluids. correct answers Answer:
4. Increasing hydration by encouraging oral fluids.
Rationale:
The client's temperature should be taken every 4 hours while she is awake. Temperatures up to
100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of
labor. The appropriate action is to increase hydration by encouraging oral fluids, which should
bring the temperature to a normal reading. Although the nurse also would document the findings,
the appropriate action would be to increase hydration. Taking the temperature in another 15
minutes is an unnecessary action. Contacting the obstetrician is not necessary.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy
newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing
action is most appropriate?
1. Raise the head of the client's bed.
2. Obtain hemoglobin and hematocrit levels.
3. Instruct the client to request help when getting out of bed.
4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's
symptoms have subsided. correct answers Answer:
3. Instruct the client to request help when getting out of bed.
Rationale:
Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness
or dizziness are signs that caution the nurse to focus interventions on the client's safety. The
nurse should advise the client to get help the first few times she gets out of bed. Option 1 is not a
helpful action in this situation and would not relieve the symptoms. Option 2 requires a
prescription. Option 4 is unnecessary.
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which
time frame should the nurse relay to the client regarding the return of bowel function?
1. 3 days postpartum
2. 7 days postpartum
3. On the day of birth
, 4. Within 2 weeks postpartum correct answers Answer:
1. 3 days postpartum
Rationale:
After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the
return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum.
Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer
period of altered bowel functions. Options 2, 3, and 4 are incorrect.
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The
client required an episiotomy and has several hemorrhoids. What is the priority nursing
consideration for this client?
1. Client pain level
2. Inadequate urinary output
3. Client perception of body changes
4. Potential for imbalanced body fluid volume correct answers Answer:
1. Client pain level
Rationale:
The priority nursing consideration for a client who delivered 2 hours ago and who has an
episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort
during the immediate postpartum period. There are no data in the question that indicate
inadequate urinary output, the presence of client perception of body changes, and potential for
imbalanced body fluid volume.
The nurse is providing postpartum instructions to a client who will be breast-feeding her
newborn. The nurse determines that the client has understood the instructions if she makes which
statements? (Select all that apply)
1. "I should wear a bra that provides support."
2. "Drinking alcohol can affect my milk supply."
3. "The use of caffeine can decrease my milk supply."
4. "I will start my estrogen birth control pills again as soon as I get home."
5. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby."
6. "I plan on having bottled water available in the refrigerator so I can get additional fluids
easily." correct answers Answer:
1. "I should wear a bra that provides support."
2. "Drinking alcohol can affect my milk supply."
3. "The use of caffeine can decrease my milk supply."
6. "I plan on having bottled water available in the refrigerator so I can get additional fluids
easily."
Rationale:
The postpartum client should wear a bra that is well fitted and supportive. Common causes of
decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or
