Maternity Nursing: Postpartum NCLEX Practice Questions #8 | 55 Questions| 21/2022 LATEST UDATE

Maternity Nursing: Postpartum NCLEX Practice Questions #8 | 55 Questions 1. 1. Question A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period, the nurse plans to take the woman’s vital signs: o A. Every 30 minutes during the first hour and then every hour for the next two hours. o B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. o C. Every hour for the first 2 hours and then every 4 hours. o D. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. Incorrect Correct Answer: B. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. The initial or acute period involves the first 6–12 hours postpartum. This is a time of rapid change with a potential for immediate crises such as postpartum hemorrhage, uterine inversion, amniotic fluid embolism, and eclampsia. • Option A: The second phase is the subacute postpartum period, which lasts 2–6 weeks. During this phase, the body is undergoing major changes in terms of hemodynamics, genitourinary recovery, metabolism, and emotional status. Nonetheless, the changes are less rapid than in the acute postpartum phase and the patient is generally capable of self-identifying problems. These may run the gamut from ordinary concerns about perineal discomfort to peripartum cardiomyopathy or severe postpartum depression. • Option C: The third phase is the delayed postpartum period, which can last up to 6 months. Changes during this phase are extremely gradual, and pathology is rare. This period is used to make sure the mother is stable and to educate her in the care of her baby (especially the first-time mother). While still in the hospital, the mother is monitored for blood loss, signs of infection, abnormal blood pressure, contraction of the uterus, and ability to void. There is also attention to Rh compatibility, maternal immunization statuses, and breastfeeding. This is the time of restoration of muscle tone and connective tissue to the prepregnant state. Although change is subtle during this phase, it behooves caregivers to remember that a woman?s body is nonetheless not fully restored to prepregnant physiology until about 6 months post-delivery. • Option D: The immediate postpartum period most often occurs in the hospital setting, where the majority of women remain for approximately 2 days after a vaginal delivery and 3-4 days after a cesarean delivery. During this time, women are recovering from their delivery and are beginning to care for the newborn. 2. 2. Question A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2°F. Which of the following actions would be most appropriate? • A. Retake the temperature in 15 minutes. • B. Notify the physician. • C. Document the findings. • D. Increase hydration by encouraging oral fluids Incorrect Correct Answer: D. Increase hydration by encouraging oral fluids. The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. • Option A: A focused physical examination is important and should include vital signs, an examination of the respiratory system, breasts, abdomen, perineum, and lower extremities. A patient with endometritis typically has a fever of 38°C or greater, tachycardia, and fundal tenderness. • Option B: The new mother should be given discharge instructions and expectations/precautions to consider once leaving the hospital. The most important information is who and where to call if she has problems or questions. She also needs details about resuming her normal activity. Instructions vary, depending on whether the mother has had a vaginal or a cesarean delivery and any comorbidities that may have been part of her care. • Option C: Although the nurse would document the findings, the most appropriate action would be to increase the hydration. The woman who has had a vaginal delivery may resume all physical activity, including using stairs, riding or driving in a car, and performing muscle-toning exercises, as long as she experiences no limiting pain or discomfort. The key counseling is to progressively resume normal activity while being mindful of the common fatigue and exhaustion experienced while caring for a newborn. 3. 3. Question The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? • A. Obtain hemoglobin and hematocrit levels. • B. Instruct the mother to request help when getting out of bed. • C. Elevate the mother’s legs. • D. Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of lightheadedness and dizziness have subsided. Incorrect Correct Answer: B. Instruct the mother to request help when getting out of bed. Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. • Option A: Obtaining an H/H requires a physician’s order. This is a blood test that checks the percent of the blood (called whole blood) that’s made up of red blood cells. Bleeding can cause a low hematocrit. • Option C: With PPH, the client can lose much more blood, which is what makes it a dangerous condition. PPH can cause a severe drop in blood pressure. If not treated quickly, this can lead to shock and death. Shock is when the body organs don’t get enough blood flow. • Option D: Postpartum hemorrhage (also called PPH) is when a woman has heavy bleeding after giving birth. It’s a serious but rare condition. It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. About 1 to 5 in 100 women who have a baby (1 to 5 percent) have PPH. 4. 4. Question A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? • A. Ask the client to turn on her side. • B. Ask the client to lie flat on her back with the knees and legs flat and straight. • C. Ask the mother to urinate and empty her bladder. • D. Massage the fundus gently before determining the level of the fundus. Incorrect Correct Answer: C. Ask the mother to urinate and empty her bladder. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. The postpartum recovery period covers the time period from birth until approximately six to eight weeks after delivery. This is a time of healing and rejuvenation as the mother’s body returns to prepregnancy states. • Option A: The nurse may place the woman in a supine position or Semi Fowlers position to avoid a decrease in her blood pressure for fundal assessment. Patients or a family member can be taught to assess the firmness of the fundus and to provide massage in the event of a boggy uterus or excessive bleeding. Patients are encouraged to void before palpation of the uterine fundus because a full bladder displaces the uterus and can lead to excessive bleeding. • Option B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. • Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm. By approximately one hour post-delivery, the fundus is firm and at the level of the umbilicus. 5. 5. Question The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is: • A. Normal. • B. Indicates the presence of infection. • C. Indicates the need for increasing oral fluids. • D. Indicates the need for increasing ambulation. Incorrect Correct Answer: B. Indicates the presence of infection. Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The presence of an offensive odor or large pieces of tissue or blood clots in lochia or the absence of lochia might be a sign of infection. • Option A: Normal lochia has a fleshy odor. The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and consists of blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. • Option C: The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days. The lochia can persist up to 5 weeks postpartum. • Option D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention. The lochia can persist up to 5 weeks postpartum. The cervix and vagina may be edematous and bruised in the early postpartum period and gradually heal back to normal. 6. 6. Question When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? • A. Document the findings. • B. Notify the physician. • C. Reassess the client in 2 hours. • D. Encourage increased intake of fluids. Incorrect Correct Answer: B. Notify the physician. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. • Option A: Although the findings would be documented, the most appropriate action is to notify the physician. Early postpartum hemorrhage is described as that occurring within the first 24 hours after delivery. Late postpartum hemorrhage most frequently occurs 1-2 weeks after delivery but may occur up to 6 weeks postpartum. • Option C: The persistence of red lochia beyond one week might be an indicator of uterine subinvolution. The presence of an offensive odor or large pieces of tissue or blood clots in lochia or the absence of lochia might be a sign of infection. • Option D: The most common cause of immediate postpartum hemorrhage is atony; therefore uterotonic agents should be readily available for quick access and prompt administration in order to control bleeding. 7. 7. Question A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: • A. One peripad per day. • B. Two peripads per day. • C. Three peripads per day. • D. Eight peripads per day. Incorrect Correct Answer: D. Eight peripads per day. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day. Postpartum hemorrhage is defined as excessive blood loss during or after the third stage of labor. The average blood loss is 500 mL at vaginal delivery and 1000 mL at cesarean delivery. • Option A: Objectively, postpartum hemorrhage is defined as a 10% change in hematocrit level between admission and the postpartum period or the need for transfusion after delivery secondary to blood loss. • Option B: Early postpartum hemorrhage may result from uterine atony, retained products of conception, uterine rupture, uterine inversion, placenta accreta, lower genital tract lacerations, coagulopathy, and hematoma. In the United States, postpartum hemorrhage is responsible for 5% of maternal deaths. Other morbidities associated with hemorrhage include the need for blood transfusions and/or subsequent surgical interventions that may lead to future infertility. • Option C: Causes of late postpartum hemorrhage most commonly include retained products of conception, infection, subinvolution of placental site, and coagulopathy. Vaginal delivery is associated with a 3.9% incidence of postpartum hemorrhage. Cesarean delivery is associated with a 6.4% incidence of postpartum hemorrhage. Delayed postpartum hemorrhage occurs in 1-2% of patients. 8. 8. Question A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: • A. One the day of the delivery • B. 3 days PP • C. 7 days PP • D. within 2 weeks PP Incorrect Correct Answer: B. 3 days PP. After birth, the nurse should auscultate the woman’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function. • Option A: The mother may develop flatulence or constipation due to intestinal ileus (induced by pain or presence of placental hormone relaxin in the circulation), loss of body fluids, laxity of abdominal wall, and hemorrhoids. • Option C: The postpartum constipation is due to the progesterone-induced decrease in gastrointestinal transit time. The compressive effects of the gravid uterus on the stomach, a decrease in lower esophageal sphincter tone due to high progesterone levels, and hypersecretion of acid due to high gastrin levels cause an increase in the incidence of acid reflux during pregnancy. • Option D: After delivery, the levels of progesterone and gastrin drop within 24 hours, and the acid reflux and associated symptoms resolve in the next three to four days 9. 9. Question The following are the physiological maternal changes that occur during the PP period. Select all that apply. • A. Cervical involution occurs. • B. Vaginal distention decreases slowly. • C. Fundus begins to descend into the pelvis after 24 hours. • D. Cardiac output decreases with resultant tachycardia in the first 24 hours. • E. Digestive processes slow immediately. Incorrect Correct Answers: A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. • Option B: Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. • Option D: Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. • Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually hungry because of the energy expended during labor. 10. 10. Question A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? • A. Complaints of a tearing sensation. • B. Complaints of intense pain. • C. Changes in vital signs. • D. Signs of heavy bruising. Incorrect Correct Answer: C. Changes in vital signs. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. There may also be intermittent bleeding. Depending on the size and location of the vulvar hematoma, urological or neurological signs and symptoms may be present. • Option A: A hematoma is described as a collection of blood beneath an intact epidermis that presents as a swollen fluctuant lump. It can be extremely tender on palpation. Due to its rich blood supply, the vulva is highly vulnerable and prone to hematoma formation. Although venous bleeding is possible, arterial bleeds mainly originate from one of the branches of the pudendal artery. Vulvar hematoma, rarely, might be secondary to operative laparoscopy (especially adnexal surgery), spontaneous rupture of the internal iliac artery, or spontaneous rupture of a pseudoaneurysm of the pudendal artery. • Option B: Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Due to mechanical urethral obstruction, patients may present with urinary retention or micturition difficulties. In severe cases, the patient can be hemodynamically unstable and will require urgent fluid resuscitation or blood transfusion. Symptoms usually develop within a few hours to days of delivery, depending on the severity of the condition. • Option D: Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. As bleeding into the vulva is largely restricted only by the Colles fascia and the urogenital diaphragm, a hematoma in this area will be visible on physical examination. This is seen as a tender fluctuant lump of variable size. Since the Colles fascia exerts little resistance, vulvar hematomas can grow to become 15cm in diameter or more. The observation of a lump or swelling in the groin may be offered by the patient if asked during the consultation. Although there is no anatomical explanation, it is discovered that the right side appears to be more commonly affected. 11. 11. Question A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? • A. Assess vital signs every 4 hours. • B. Inform health care providers of assessment findings. • C. Measure fundal height every 4 hours. • D. Prepare an ice pack for application to the area. Incorrect Correct Answer: D. Prepare an ice pack for application to the area. • Option D: Application of ice will reduce swelling caused by hematoma formation in the vulvar area. During labor, a vulvar hematoma can result from either direct or indirect injury to the soft tissue. Examples of causes of direct injuries include episiotomy, vaginal laceration repairs, or instrumental deliveries, while indirect injury can result from extensive stretching of the birth canal during vaginal delivery. 12. 12. Question A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: • A. Monitor fundal height. • B. Apply perineal pressure. • C. Prepare the client for surgery. • D. Reassure the client. Incorrect Correct Answer: C. Prepare the client for surgery. The use of an epidural, prolonged second-stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding. • Option A: Interestingly, most vulvar hematomas are formed after a normal delivery instead of complicated deliveries. Risk factors for developing vulvar hematoma include instrumental delivery, episiotomy, primiparity, prolonged second stage of labor, macrosomia, use of anticoagulants, coagulopathy, hypertensive disorders of pregnancy, and vulvovaginal varicosity. • Option B: Conservative management usually involves the use of ice packs, local compressions, bed rest, and analgesics. In the event that conservative management has not been effective, surgery may be performed. In fact, conservative management of large hematomas has been found to be associated with a longer period of hospitalization, greater need for antibiotics, and blood transfusion. • Option D: Surgical management includes surgical drainage of the hematoma, evacuation of any clots present, ligation of bleeding points, and the assessment for signs of pressure necrosis (a complication of vulva hematoma). These can be done under local anesthesia. As further blood loss during surgery is anticipated, the necessary investigations such as cross-matching and preparations for a possible blood transfusion should be done. 13. 13. Question A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? • A. A temperature of 100.4°F. • B. An increase in the pulse from 88 to 102 BPM. • C. An increase in the respiratory rate from 18 to 22 breaths per minute. • D. Blood pressure changes from 130/88 to 124/80 mm Hg. Incorrect Correct Answer: B. An increase in the pulse from 88 to 102 BPM. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. • Option A: A slight rise in temperature is normal. Patients may also have signs and symptoms of shock, such as confusion, blurry vision, clammy skin, and weakness. • Option C: The respiratory rate has increased slightly. The patient may also have an increased heart rate, an increased respiratory rate, and feeling faint while standing up. • Option D: The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. As the patient continues to lose blood, they may also feel cold, have decreased blood pressure, and may lose consciousness. 14. 14. Question A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? • A. Massage the fundus until it is firm. • B. Elevate the mother's legs. • C. Push on the uterus to assist in expressing clots. • D. Encourage the mother to void. Incorrect Correct Answer: A. Massage the fundus until it is firm. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Uterine atony refers to the corpus uteri myometrial cells inadequate contraction in response to endogenous oxytocin that is released in the course of delivery. Risk factors for uterine atony include prolonged labor, precipitous labor, uterine distension (multi-fetal gestation, polyhydramnios, fetal macrosomia), fibroid uterus, chorioamnionitis, indicated magnesium sulfate infusions, and prolonged use of oxytocin. • Option B: Elevating the mother’s legs will not manage the uterine atony. Ineffective uterine contraction, either focally or diffusely, is additionally associated with a diverse range of etiologies including retained placental tissue, placental disorders (such as morbidly adherent placenta, placenta previa, and abruptio placentae), coagulopathy (increased fibrin degradation products) and uterine inversion. • Option C: Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. It leads to postpartum hemorrhage as delivery of the placenta leaves disrupted spiral arteries which are uniquely void of musculature and dependent on contractions to mechanically squeeze them into a hemostatic state. Uterine atony is a principal cause of postpartum hemorrhage, an obstetric emergency. Globally, this is one of the top 5 causes of maternal mortality. • Option D: Encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action. Contraction of the myometrium that mechanically compresses the blood vessels supplying the placental bed provides the principal mechanism uterine hemostasis after delivery of the fetus, and the placenta is concluded. The process is complemented by local decidual hemostatic factors such as tissue factor type-1 plasminogen activator inhibitor as well as by systemic coagulation factors such as platelets, circulating clotting factors. 15. 15. Question A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? • A. Paleness of the calf area • B. Enlarged, hardened veins • C. Coolness of the calf area • D. Palpable dorsalis pedis pulses Incorrect Correct Answer: B. Enlarged, hardened veins Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth. Superficial thrombophlebitis is an inflammatory disorder of superficial veins with coexistent venous thrombosis. It usually affects lower limbs, particularly the great saphenous vein (60% to 80%) or the small/short saphenous vein (10% to 20%). • Option A: Patients with superficial thrombophlebitis typically present with a reddened, warm, inflamed, tender area overlying the track of a superficial vein. There is often a palpable cord. Some surrounding edema or associated pruritus may occur. In pregnancy, the risk of SVT is akin to that of DVT, most commonly in the postpartum period. Advanced age, exogenous estrogens, autoimmune or infectious diseases, obesity, recent trauma or surgery, active malignancy, history of venous thromboembolic disease, and respiratory or cardiac failure also increase the risk of SVT. • Option C: Significant swelling of the limb is more commonly associated with DVT and should only be attributed to SVT after DVT has been excluded. Patients may have a history of antecedent trauma, which can include intravenous cannulation or infusion of irritants, such as recent sclerotherapy for varicose veins. However, it can occur at other sites (10% to 20%) and may occur bilaterally (5% to 10%). Traditionally, this relatively common process was considered benign and self-limited. • Option D: Physical examination does not adequately identify the extent of disease; it has been shown to underestimate it in up to 77% of instances. Compressive ultrasonography can identify concomitant DVT, evaluate the extent of the thrombus, and confirm the diagnosis. A careful history is critical to identify risk factors for venous thromboembolism. Initial presentation in patients older than 40 years without other risk factors should prompt consideration of underlying malignancy. 16. 16. Question A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements, if made by the mother, indicates a need for further teaching? • A. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.” • B. “I can use analgesics to assist in alleviating some of the discomfort.” • C. “I need to wear a supportive bra to relieve the discomfort.” • D. “I need to stop breastfeeding until this condition resolves.” Incorrect Correct Answer: D. “I need to stop breastfeeding until this condition resolves.” In most cases, the mother can continue to breastfeed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Continuing to fully empty the breasts has shown to decrease the duration of symptoms in patients treated both with and without antibiotics. Patients should be encouraged to continue to breastfeed, pump, or hand express. If the patient stops draining the milk, further stasis occurs, and the infection will progress. • Option A: Antibiotic therapy assists in resolving the mastitis within 24-48 hours. If the symptoms of lactational mastitis persist beyond 12 to 24 hours, antibiotics should be administered. Because S. aureus is the most common cause, antibiotic therapy should be tailored accordingly. In the setting of mild infection without MRSA risk factors, outpatient treatment can be initiated with dicloxacillin or cephalexin. • Option B: The doctor may recommend an over-the-counter pain reliever, such as acetaminophen (Tylenol, others) or ibuprofen (Advil, Motrin IB, others). Lactational mastitis occurs due to a combination of inadequate drainage of milk, and the introduction of bacteria. Common scenarios leading to poor milk drainage include infrequent feeding, an oversupply of milk, rapid weaning, illness in mother or child, and a clogged duct. The inadequately drained milk stagnates, and organisms grow, leading to infection. It is thought that bacteria (usually from the infant’s mouth, or mother’s skin) gain entry to the milk via cracks in the nipple. • Option C: Additional supportive measures include ice packs, breast supports, and analgesics. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain control. Heat applied to the breast just before emptying can help increase milk letdown and facilitate emptying. Cold packs applied to the breast after emptying can help reduce edema and pain. 17. 17. Question A postpartum (PP) client is being treated for DVT. The nurse understands that the client’s response to treatment will be evaluated by regularly assessing the client for: • A. Dysuria, ecchymosis, and vertigo • B. Epistaxis, hematuria, and dysuria • C. Hematuria, ecchymosis, and epistaxis • D. Hematuria, ecchymosis, and vertigo Incorrect Correct Answer: C. Hematuria, ecchymosis, and epistaxis. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding. The cornerstone of treatment is anticoagulation. NICE guidelines only recommend treating proximal DVT (not distal) and those with pulmonary emboli. In each patient, the risks of anticoagulation need to be weighed against the benefits. • Option A: Low-molecular-weight heparin or fondaparinux for five days or until INR is greater than 2 for 24 hours (unfractionated heparin for patients with renal failure and increased risk of bleeding). If platelet count drops to less than 75,000, switch from heparin to fondaparinux, which is not associated with heparin-induced thrombocytopenia. • Option B: The use of thrombolytic therapy can result in an intracranial bleed, and hence, careful patient selection is vital. Recently endovascular interventions like catheter-directed extraction, stenting, or mechanical thrombectomy have been tried with moderate success. The duration of treatment for DVT is for 3-6 months, but recurrent episodes may require at least 12 months of treatment. Patients with cancer need long term treatment. • Option D: Inferior vena cava filters are not recommended in acute DVT. There are both permanent and temporary inferior vena cava filters available. These devices may decrease the rate of recurrent DVT but do not affect survival. Today, only patients with contraindications to anticoagulation with an increased risk of bleeding should have these filters inserted. 18. 18. Question A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: • A. Assess for hypovolemia and notify the health care provider. • B. Begin hourly pad counts and reassure the client. • C. Begin fundal massage and start oxygen by mask. • D. Elevate the head of the bed and assess vital signs. Incorrect Correct Answer: A. Assess for hypovolemia and notify the health care provider. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider. Patients with hypovolemic shock have severe hypovolemia with decreased peripheral perfusion. If left untreated, these patients can develop ischemic injury of vital organs, leading to multi-system organ failure. • Option B: The first factor to be considered is whether the hypovolemic shock has resulted from hemorrhage or fluid losses, as this will dictate treatment. When etiology of hypovolemic shock has been determined, replacement of blood or fluid loss should be carried out as soon as possible to minimize tissue ischemia. • Option C: Medical management with uterotonic and pharmacologic agents is typically the first step if uterine atony is identified. While oxytocin is given routinely by most institutions at the time of delivery (see prevention), additional uterotonic medications may be given with bimanual massage in an initial response to hemorrhage. Uterotonic agents include oxytocin, ergot alkaloids, and prostaglandins. • Option D: Initial evaluation of the patient should include a rapid assessment of the patient’s status and risk factors. In postpartum women, signs or symptoms of blood loss such as tachycardia and hypotension may be masked, so if these signs are present, there should be a concern for considerable blood volume loss (greater than 25% of total blood volume). Continuous assessment of vital signs and on-going estimation of total blood loss is an important factor in ensuring safe care of the patient with PPH. 19. 19. Question A nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? • A. Massage the fundus • B. Place the mother in Trendelenburg's position • C. Notify the physician • D. Record the findings Incorrect Correct Answer: C. Notify the physician If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Perineal trauma is an extremely common and expected complication of vaginal birth. Lacerations can occur spontaneously or iatrogenically, as with an episiotomy, on the perineum, cervix, vagina, and vulva. • Option A: Massaging the fundus if it is firm will not assist in controlling the bleeding. Perineal massage has been shown to decrease the incidence of lacerations requiring suture, although the reduction was minor. Additional studies have shown a decrease in third- and fourth-degree lacerations when massage was performed during the second stage of labor, however, there is no consistently proven benefit. • Option B: Trendelenburg’s position is to be avoided because it may interfere with cardiac function. Delayed or immediate pushing after a woman reached ten centimeters of dilation showed no difference in the incidence of perineal lacerations. However, there was a higher incidence of delivery with intact perineum in women who delivered in the lateral position with delayed pushing compared to immediate pushing in the lithotomy position. • Option D: The most common complication of a perineal laceration is bleeding. Most bleeding can be quickly controlled with pressure and surgical repair. However, hematoma formation can lead to large amounts of blood loss in a very short time. Perineal support or a “hands-on” approach, can be protective of the perineum and decrease the severity of perineal lacerations at the time of delivery. However, studies are conflicting on the significant benefit to this measure. 20. 20. Question A nurse is caring for a postpartum (PP) client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? • A. Prothrombin time • B. International normalized ratio • C. Activated partial thromboplastin time • D. Platelet count Incorrect Correct Answer: C. Activated partial thromboplastin time. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. Anticoagulants derive their effect by acting at different sites of the coagulation cascade. Some act directly by enzyme inhibition, while others indirectly, by binding to antithrombin or by preventing their synthesis from the liver (vitamin K dependent factors). • Option A: This is the initial test used to identify defects in secondary hemostasis. It is the time taken for blood to clot and generates thrombin. A delay in the PT or aPTT indicates the presence of either a deficiency or inhibitor of the clotting factor, except for the antiphospholipid antibody, which can result in delayed aPTT. The normal range for PT levels is approximately 11 to 13 seconds, although levels may vary depending on the laboratory. • Option B: The INR are used to monitor coagulation time when warfarin (Coumadin) is used. The clotting time is the time it takes for plasma to clot after the addition of different substrates in vitro under standard conditions using the capillary method. The average clotting time is between 8 to 15 minutes. Some studies have disputed the use of clotting time as a screening test. • Option D: Although thrombocytopenia increases bleeding risk, it has been shown to predispose patients to venous thromboembolism. Heparin-induced thrombocytopenia is antibody-mediated with complications that include pulmonary embolism, acute myocardial infarction, and ischemic limb necrosis. Therefore, estimation of the bleeding risk before initiation of anticoagulation is essential. The use of argatroban, lepirudin, or danaparoid is recommended over other non-heparin anticoagulants. 21. 21. Question A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Which of the following instructions would be included on the list. Select all that apply. • A. Take the prescribed antibiotics until the soreness subsides. • B. Wear a supportive bra. • C. Avoid decompression of the breasts by breastfeeding or breast pump. • D. Rest during the acute phase. • E. Continue to breastfeed if the breasts are not too sore. Incorrect Correct Answer: B, D, and E. Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3 L a day, and taking analgesics to relieve discomfort. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Non-steroidal anti-inflammatory drugs (NSAIDs) can be used for pain control. Heat applied to the breast just before emptying can help increase milk letdown and facilitate with emptying. Cold packs applied to the breast after emptying can help reduce edema and pain. Providers should ensure the patient that breastfeeding with mastitis is safe and that they should continue to do so if desired. If the patient does not wish to continue to breastfeed, they should be counseled on the importance of continuing to empty the breasts and taught alternative methods such as the use of a breast pump or manual expression. • Option A: Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. If the symptoms of lactational mastitis persist beyond 12 to 24 hours, antibiotics should be administered. Because S. aureus is the most common cause, antibiotic therapy should be tailored accordingly. In the setting of mild infection without MRSA risk factors, outpatient treatment can be initiated with dicloxacillin or cephalexin. • Option C: Continued decompression of the breast by breastfeeding or pumping is important to empty the breast and prevent formation of an abscess. The initial management of lactational mastitis is symptomatic treatment. Continuing to fully empty the breasts has shown to decrease the duration of symptoms in patients treated both with and without antibiotics. Patients should be encouraged to continue to breastfeed, pump, or hand express. If the patient stops draining the milk, further stasis occurs, and the infection will progress. 22. 22. Question Methergine or Pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: • A. Amount of lochia • B. Blood pressure • C. Deep tendon reflexes • D. Uterine tone Incorrect Correct Answer: B. Blood pressure Methergine and Pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present. Methergine is in a group of drugs called ergot alkaloids. It affects the smooth muscle of a woman’s uterus, improving the muscle tone as well as the strength and timing of uterine contractions. Methergine is used just after a baby is born, to help deliver the placenta (also called the “afterbirth”). • Option A: Methergine is administered in the postpartum period to help deliver the placenta and to help control bleeding and other uterine problems after childbirth. It is indicated following delivery of the placenta, for routine management of uterine atony, hemorrhage, and subinvolution of the uterus. For control of uterine hemorrhage in the second stage of labor following delivery of the anterior shoulder. • Option C: Methergine (methylergonovine maleate) acts directly on the smooth muscle of the uterus and increases the tone, rate, and amplitude of rhythmic contractions. Thus, it induces a rapid and sustained titanic uterotonic effect which shortens the third stage of labor and reduces blood loss. • Option D: Caution should be exercised in the presence of sepsis, obliterative vascular disease. Also, use caution during the second stage of labor. The necessity for manual removal of a retained placenta should occur only rarely with proper technique and adequate allowance of time for its spontaneous separation. 23. 23. Question Methergine or Pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client’s medical history? • A. Peripheral vascular disease • B. Hypothyroidism • C. Hypotension • D. Type 1 diabetes Incorrect Correct Answer: A. Peripheral vascular disease. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications. Patients with coronary artery disease or risk factors for coronary artery disease (e.g., smoking, obesity, diabetes, high cholesterol) may be more susceptible to developing myocardial ischemia and infarction associated with methylergonovine-induced vasospasm. • Option B: Before using this medication, tell the doctor or pharmacist about the medical history, especially of: kidney disease, liver disease, high blood pressure, heart disease (such as venoatrial shunts, mitral valve stenosis, chest pain, recent heart attack), diabetes, high cholesterol, smoking/tobacco use, blood vessel disease (such as Raynaud’s disease), complications during pregnancy (such as preeclampsia, eclampsia). • Option C: This drug may make the client dizzy. Do not drive, use machinery, or do any activity that requires alertness until the client is sure he can perform such activities safely. Limit alcoholic beverages. • Option D: This medication may decrease the amount of breast milk. Methylergonovine passes into breast milk in small amounts and may have undesirable effects on a nursing infant. Consult your doctor before breast-feeding. 24. 24. Question Which of the following factors might result in a decreased supply of breastmilk in a postpartum (PP) mother? • A. Supplemental feedings with formula • B. Maternal diet high in vitamin C • C. An alcoholic drink • D. Frequent feedings Incorrect Correct Answer: A. Supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother’s nipples affects hormonal levels and milk production. Especially in the first couple of weeks, supplementing with formula tricks the breasts into producing less milk. “In the early weeks, the breasts’ capacity for milk production is calibrated in response to the amount of milk that is removed,” says lactation consultant Diana West. “If less milk is removed, the breasts assume that less milk is needed, so the capacity is set at a lower point.” When the baby is given formula supplements, she naturally eats less at the breast, and the breasts respond by making less milk. If supplementation is necessary, pumping as well as breastfeeding can help to promote a higher volume of milk production. • Option B: A high diet in Vit C does not decrease the supply of breastmilk in the mother. Another cause is the use of birth control. Many mothers who breastfeed and take birth control pills find their milk production doesn’t change, but for some, any form of hormonal birth control (the pill, patch or injections) can cause a significant drop in their milk. This is more likely to happen if they start using these contraceptives before the baby is four months old, but it can happen later as well. The first step to increasing the milk supply again is to stop the medication, but talk to a doctor before doing so and be prepared to change birth control methods. Some mothers also need extra help (such as prescription medication, herbal supplements, and/or pumping) to boost milk production. • Option C: Alcohol levels are usually highest in breast milk 30-60 minutes after an alcoholic beverage is consumed, and can be generally detected in breast milk for about 2-3 hours per drink after it is consumed. However, the length of time alcohol can be detected in breast milk will increase the more alcohol a mother consumes. For example, alcohol from 1 drink can be detected in breast milk for about 2-3 hours, alcohol from 2 drinks can be detected for about 4-5 hours, and alcohol from 3 drinks can be detected for about 6-8 hours, and so on. • Option D: The breasts make milk continuously, but the rate at which milk is made depends on how empty they are. The woman will make more milk when her breasts are close to empty and less milk when they are already filled up. When the baby is feeding infrequently, because the mother has put him on a three- or four-hour schedule for example, or because she is giving him a pacifier to stretch out the time between feedings, the breasts are fuller for longer periods of time. That means milk production slows down. When babies are breastfed in response to their cues, they tend to have shorter, frequent feedings and this means the breasts are emptier most of the time and so they continue to produce plenty of milk. 25. 25. Question Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? • A. Applying ice • B. Applying a breast binder • C. Teaching how to express her breasts in a warm shower • D. Administering bromocriptine (Parlodel) Incorrect Correct Answer: C. Teaching how to express her breasts in a warm shower. Teaching the client how to express her breasts in warm shower aid with let-down and will give temporary relief. Breast engorgement is the result of increased blood flow in the breasts in the days after the delivery of a baby. The increased blood flow helps the breasts make ample milk, but it can also cause pain and discomfort. • Option A: Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk. Using a warm compress, or taking a warm shower would encourage milk let down. The mother may also massage her breasts while nursing, or feed more regularly, or at least every one to three hours. • Option B: For those who don’t breastfeed, painful engorgement typically lasts about one day. After that period, the breasts may still feel full and heavy, but the discomfort and pain should subside. The mother may wear a supportive bra that prevents her breasts from moving significantly. • Option D: Breast engorgement is swelling and inflammation that occurs in the breasts because of increased blood flow and milk supply. In the days and weeks after giving birth, the body will begin to produce milk. The mother may take pain medication approved by her doctor. Bromocriptine (Parlodel) is used to treat symptoms of hyperprolactinemia (high levels of a natural substance called prolactin in the body) including lack of menstrual periods, discharge from the nipples, infertility (difficulty becoming pregnant), and hypogonadism (low levels of certain natural substances needed for normal development and sexual function). 26. 26. Question On completing a fundal assessment, the nurse notes the fundus is situated on the client’s left abdomen. Which of the following actions is appropriate? • A. Ask the client to empty her bladder. • B. Straight catheterize the client immediately. • C. Call the client’s health provider for direction. • D. Straight catheterize the client for half of her uterine volume. Incorrect Correct Answer: A. Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right side of the abdomen. Massage the fundus every 15 minutes during the first hour, every 30 minutes during the next hour, and then, every hour until the patient is ready for transfer. • Option B: Catheterization is unnecessary invasive if the woman can void on her own. Chart fundal height. Evaluate from the umbilicus using fingerbreadths. This is recorded as two fingers below the umbilicus (U/2), one finger above the umbilicus (1/U), and so forth. The fundus should remain in the midline. If it deviates from the middle, identify this and evaluate for a distended bladder. • Option C: Be able to recognize the difference between a full bladder and a fundus. Full bladders may actually cause postpartum hemorrhage because it prevents the uterus from contracting appropriately. Nerve blocks may alter the sensation of a full bladder to the patient and prevent her from urinating. • Option D: If at all possible, ambulate the patient to the bathroom. Urine output less than 300cc on initial void after delivery may suggest urinary retention. Document the fundal height and bladder status before the patient urinates. Reevaluate and document the fundal height and bladder status after the patient urinates to accurately document an empty bladder. 27. 27. Question The nurse is about to give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? • A. Lower than during her pregnancy • B. Higher than during her pregnancy • C. Lower than before she became pregnant • D. Higher than before she became pregnant Incorrect Correct Answer: C. Lower than before she became pregnant PP insulin requirements are usually significantly lower than pre-pregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum. Immediately after delivery, postpartum insulin requirements decrease dramatically as a result of the rapid decrease in diabetogenic placental hormone levels and resulting dissipation of pregnancy-induced insulin resistance. • Option A: The policy specifies that women with type 1 or type 2 diabetes who require ongoing insulin administration should decrease insulin doses and undergo monitoring of preprandial blood glucose values while on the postpartum unit. Glycemic targets approximating nonpregnant targets are utilized. Among women with type 1 diabetes, insulin requirements typically return to prepregnancy levels or lower following delivery. • Option B: Women are typically advised to decrease basal and prandial insulin doses to 50 to 80% of their preconception doses, but recommendations are individualized. If preconception insulin doses are not known, one-third to one-half of the term pregnancy dose or weight-based dosing may be used as a starting point. • Option D: Among women with type 2 diabetes, postpartum medication requirements vary depending on the severity of hyperglycemia postpartum and the prepregnancy diabetes therapeutic regimen, ranging from no medical therapy to resumption of insulin therapy at reduced doses (as above) or noninsulin therapies following delivery. 28. 28. Question Which of the following findings would be expected when assessing the postpartum client? • A. Fundus 1 cm above the umbilicus 1 hour postpartum. • B. Fundus 1 cm above the umbilicus on a postpartum day 3. • C. Fundus palpable in the abdomen at 2 weeks postpartum. • D. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2. Incorrect Correct Answer: A. Fundus 1 cm above the umbilicus 1 hour postpartum. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. Immediately postpartum, the uterine fundus is palpable at or near the level of the maternal umbilicus. If the fundus is found above the navel, the mother probably needs to pass urine. Call a midwife if the uterus feels soft or is not descending. • Option B: The fundus should be below the umbilicus by PP day 3. By approximately one-hour post-delivery, the fundus is firm and at the level of the umbilicus. The fundus continues to descend into the pelvis at the rate of approximately 1 cm or finger-breadth per day and should be nonpalpable by 14 days postpartum. • Option C: The fundus shouldn’t be palpated in the abdomen after day 10. Thereafter, most of the reduction in size and weight occurs in the first 2 weeks, at which time the uterus has shrunk enough to return to the true pelvis. Over the next several weeks, the uterus slowly returns to its nonpregnant state, although the overall uterine size remains larger than prior to gestation. • Option D: The uterus should feel firm and should feel about the size of a grapefruit for the first few days. The fundus (top portion of the uterus) should be felt at the level of the belly button or lower. The mother can attempt to feel her fundus by gently pressing on her abdomen. The uterus shrinks at about the rate of one cm. per day. By day 10 it can no longer be felt above the pubic bone. 29. 29. Question A client is complaining of painful contractions, or after pains, on postpartum day 2. Which of the following conditions would increase the severity of afterpains? • A. Bottle-feeding • B. Diabetes • C. Multiple gestation • D. Primiparity Incorrect Correct Answer: C. Multiple gestation Multiple gestation, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains. Afterpain is a common phenomenon after vaginal delivery. Any factor that causes a delay in the process of uterus sub involution and consequently returning its size to pre-pregnancy status could affect the severity of afterpain. • Option A: There was a positive correlation between the number of pregnancies and the duration of breastfeeding with mean score of afterpain. Also, the length of ambulation decreased the afterpain intensity. However, the intensity of afterpain had no significant relationship with stimulation with oxytocin in labor, prescription of methylergonovine, and also oxytocin after delivery. Considering that a longer duration of breastfeeding and ambulation in the early postpartum period could decrease afterpain, it is suggested to encourage postpartum mothers to begin breastfeeding and ambulation as soon as possible after birth. • Option B: Diabetes has no correlation with afterpains. Afterpains (cramping) are the contractions of the uterus occurring in the days following childbirth. They are normal but can be uncomfortable. Afterpains are usually strongest on the second and third days following delivery, when the mother is breastfeeding or after she takes a uterus-contracting medication prescribed by her physician or midwife. Cramping is most noticeable after the birth of a second or third baby. • Option D: After-pains are contractions that occur after labor and delivery. These contractions signal the process of involution, the process of the uterus shrinking back down to its pre-pregnancy size and shape. While after-pains are not a reason to worry, they can cause discomfort and even pain. After-pains can vary significantly from person to person. If this is not the first baby, the pain may be worse than experienced during previous pregnancies. For pain, the mother can use comfort measures like warm packs, massage of the fundus through the abdomen, and certain medications (with a practitioner’s approval). Over-the-counter medication works well for most women. 30. 30. Question On which of the postpartum days can the client expect lochia serosa? • A. Days 3 and 4 PP • B. Days 3 to 10 PP • C. Days 10-14 PP • D. Days 14 to 42 PP Incorrect Correct Answer: B. Days 3 to 10 PP. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. The mother might notice increased lochia when she gets up in the morning when she is physically active, or while breastfeeding. Moms who have cesarean sections may have less lochia after 24 hours than moms who had vaginal deliveries. The bleeding generally stops within 4 to 6 weeks after delivery. The mother should wear pads, not tampons, as nothing should go in the vagina for six weeks. • Option A: The lochia is the vaginal discharge that originates from the uterus, cervix, and vagina. The lochia is initially red and comprises blood and fragments of decidua, endometrial tissues, and mucus and lasts 1 to 4 days. Lochia rubra usually lasts for the first 3 to 4 days PP. • Option C: The lochia then changes color to yellowish or pale brown, lasting 5 to 9 days, and is composed mainly of blood, mucus, and leukocytes. Lochia alba, which contains leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP. • Option D: Finally, the lochia is white and contains mostly mucus, lasting up to 10 to 14 days. The lochia can persist up to 5 weeks postpartum. The persistence of red lochia beyond one week might be an indicator of uterine subinvolution. The presence of an offensive odor or large pieces of tissue or blood clots in lochia or the absence of lochia might be a sign of infection. 31. 31. Question Which of the following behaviors characterizes the PP mother in the taking in phase? • A. Passive and dependent • B. Striving for independence and autonomy • C. Curious and interested in care of the baby • D. Exhibiting maximum readiness for new learning Incorrect Correct Answer: A. Passive and dependent During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate’s needs. The woman becomes dependent on her healthcare provider or support person with some of the daily tasks and decision-making. This dependence is mainly due to her physical discomfort from hemorrhoids or the after pains, from the uncertainty of how she could care for the newborn, and also from the extreme tiredness she feels that follows childbirth. • Option B: The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy. The woman starts to initiate actions on her own and makes decisions without relying on others. She starts to focus on the newborn instead of herself and begins to actively participate in newborn care. The woman still needs positive reinforcements despite the independence that she is already showing because she might still feel insecure about the care of her child. • Option C: During the taking hold phase, demonstrate newborn care to the mother and watch her do a return demonstration of every procedure. Allow the woman to settle in gradually into her new role while still at the hospital or healthcare facility because making decisions about the child’s welfare is a difficult part of motherhood. • Option D: She also is most ready to learn. She is concerned about her ability to take care of her newborn. This phase is associated with a great deal of anxiety (especially by a new mother). She may have several mood swings. The mother might be involved in a lot of activity trying to accomplish tasks. 32. 32. Question Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? • A. Uterine atony • B. Cervical laceration • C. Urinary tract infection • D. Retained placental fragments Incorrect Correct Answer: B. Cervical laceration Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Cervical lacerations (CL) are a known cause of postpartum hemorrhage. Although CL occurs in more than half of vaginal deliveries,1 they are less than 0.5 cm in length and rarely require repair. • Option A: Uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. Atony of the uterus, also called uterine atony, is a serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage. • Option C: UTI won’t cause vaginal bleeding, although hematuria may be present. Urinary tract infection (UTI) is a common postpartum infection occurring in 2%–4% of all deliveries. Although postpartum UTI is usually a mild infection, it is associated with discomfort, prolonged hospital stay and readmission and has been associated with an increased risk of discontinued breastfeeding. • Option D: Postpartum retained placental fragments (RPF) are most often clinically manifested as delayed postpartum hemorrhage or prolonged postpartum spotting. This is a rare complication of labor, yet can potentially cause severe morbidity and discomfort. 33. 33. Question What type of milk is present in the breasts 7 to 10 days PP? • A. Colostrum • B. Transitional milk • C. Mature milk • D. Hind milk Incorrect Correct Answer: B. Transitional milk Transitional milk comes after colostrum and usually lasts until 2 weeks PP. When breastfeeding mothers talk about their milk coming in, they are referring to the onset of production of transitional milk, the creamy milk that immediately follows colostrum. Transitional milk is produced anywhere from about two to five days after birth until ten to fourteen days after birth. • Option A: Alv