Maternity And Pediatric Nursing,
Second Edition: Chapter 15:
Postpartum Adaptations; Prepu Exam
With All Passed Answers Get A+
A woman who is breastfeeding her newborn reports that her breasts seem
quite full. Assessment reveals that her breasts are engorged. Which factor
would the nurse identify as the most likely cause for this development? -
Ans--inability of infant to empty breasts
For the breastfeeding mother, engorgement is often the result of vascular
congestion and milk stasis, primarily caused by the infant not fully emptying
the mother's breasts at each feeding. Cracking of the nipple could lead to
infection. Improper positioning may lead to nipple tenderness or pain.
Inadequate secretion of prolactin causes a decrease in the production of
milk.
The nurse is caring for a client in the postpartum period. The client has
difficulty in voiding and is catheterized. The nurse then would monitor the
client for which condition? - Ans--urinary tract infection
The nurse would need to monitor the client for signs and symptoms of a
urinary tract infection, a risk associated with catheterization. Stress
incontinence is caused due to loss of pelvic muscle tone after birth.
Increased urinary output is observed in diuresis. Catheterization does not
cause loss of pelvic muscle tone, increased urine output, or stress
incontinence.
A nurse is caring for a nonbreastfeeding client in the postpartum period. The
client reports engorgement. What suggestion should the nurse provide to
alleviate breast discomfort? - Ans--Wear a well-fitting bra.
The nurse should suggest the client wear a well-fitting bra to provide
support and help alleviate breast discomfort. Application of warm
,compresses and expressing milk frequently is suggested to alleviate breast
engorgement in breastfeeding clients. Hydrogel dressings are used
prophylactically in treating nipple pain.
A client in her sixth week postpartum reports general weakness. The client
has stopped taking iron supplements that were prescribed to her during
pregnancy. The nurse would assess the client for which condition? - Ans--
hypovolemia
The nurse should assess the client for hypovolemia as the client must have
had hemorrhage during birth and puerperium. Additionally, the client also
has discontinued iron supplements. Hyperglycemia can be considered if
the client has a history of diabetes. Hypertension and hyperthyroidism are
not related to discontinuation of iron supplements.
A concerned client tells the nurse that her husband, who was very excited
about the baby before its birth, is apparently happy but seems to be afraid of
caring for the baby. What suggestion should the nurse give to the client's
husband to resolve the issue? - Ans--Hold the baby frequently.
The nurse should suggest that the father care for the newborn by holding
and talking to the child. Reading up on parental care and speaking to his
friends or the primary care provider will not help the father resolve his fears
about caring for the child.
During a postpartum exam on the day of birth, the woman reports that she is
still so sore that she cannot sit comfortably. The nurse examines her
perineum and find the edges of the episiotomy approximated without signs
of a hematoma. Which intervention will be most beneficial at this point? -
Ans--Place an ice pack.
The labia and perineum may be edematous after birth and bruised; the use
of ice would assist in decreasing the pain and swelling. Applying a warm
washcloth would bring more blood as well as fluid to the sore area, thereby
increasing the edema and the soreness. Applying a witch hazel pad needs
the order of the primary care provider. Notifying a care provider is not
necessary at this time as this is considered a normal finding.
, A woman who gave birth to a healthy newborn 2 months ago comes to the
clinic and reports discomfort during sexual intercourse. Which suggestion
by the nurse would be most appropriate? - Ans--"You might try using a
water-soluble lubricant to ease the discomfort."
Coital discomfort and localized dryness usually plague most postpartum
women until menstruation returns. Water-soluble lubricants can reduce
discomfort during intercourse. Although it may take some time for the
woman's body to return to its prepregnant state, telling the woman this does
not address her concern. Telling her that dyspareunia is normal and that it
takes time to resolve also ignores her concern. Kegel exercises are helpful
for improving pelvic floor tone but would have no effect on vaginal dryness.
For the first hour after birth, the height of the fundus is at the umbilicus or
even slightly above it. - Ans--True
A client who gave birth about 12 hours ago informs the nurse that she has
been voiding small amounts of urine frequently. The nurse examines the
client and notes the displacement of the uterus from the midline to the right.
What intervention would the nurse perform next? - Ans--Perform urinary
catheterization.
Displacement of the uterus from the midline to the right and frequent voiding
of small amounts suggests urinary retention with overflow. Catheterization
may be necessary to empty the bladder to restore tone. An IV and oxytocin
are indicated if the client experiences hemorrhage due to uterine atony from
being displaced. The healthcare provider would be notified if no other
interventions help the client.
While caring for a client following a lengthy labor and birth, the nurse notes
that the client repeatedly reviews her labor and birth and is very dependent
on her family for care. The nurse is correct in identifying the client to be in
which phase of maternal role adjustment? - Ans--taking-in
The taking-in phase occurs during the first 24 to 48 hours following the birth
of the newborn and is characterized by the mother taking on a very passive
role in caring for herself, as well as recounting her labor experience. The
second maternal adjustment phase is the taking-hold phase and usually
Second Edition: Chapter 15:
Postpartum Adaptations; Prepu Exam
With All Passed Answers Get A+
A woman who is breastfeeding her newborn reports that her breasts seem
quite full. Assessment reveals that her breasts are engorged. Which factor
would the nurse identify as the most likely cause for this development? -
Ans--inability of infant to empty breasts
For the breastfeeding mother, engorgement is often the result of vascular
congestion and milk stasis, primarily caused by the infant not fully emptying
the mother's breasts at each feeding. Cracking of the nipple could lead to
infection. Improper positioning may lead to nipple tenderness or pain.
Inadequate secretion of prolactin causes a decrease in the production of
milk.
The nurse is caring for a client in the postpartum period. The client has
difficulty in voiding and is catheterized. The nurse then would monitor the
client for which condition? - Ans--urinary tract infection
The nurse would need to monitor the client for signs and symptoms of a
urinary tract infection, a risk associated with catheterization. Stress
incontinence is caused due to loss of pelvic muscle tone after birth.
Increased urinary output is observed in diuresis. Catheterization does not
cause loss of pelvic muscle tone, increased urine output, or stress
incontinence.
A nurse is caring for a nonbreastfeeding client in the postpartum period. The
client reports engorgement. What suggestion should the nurse provide to
alleviate breast discomfort? - Ans--Wear a well-fitting bra.
The nurse should suggest the client wear a well-fitting bra to provide
support and help alleviate breast discomfort. Application of warm
,compresses and expressing milk frequently is suggested to alleviate breast
engorgement in breastfeeding clients. Hydrogel dressings are used
prophylactically in treating nipple pain.
A client in her sixth week postpartum reports general weakness. The client
has stopped taking iron supplements that were prescribed to her during
pregnancy. The nurse would assess the client for which condition? - Ans--
hypovolemia
The nurse should assess the client for hypovolemia as the client must have
had hemorrhage during birth and puerperium. Additionally, the client also
has discontinued iron supplements. Hyperglycemia can be considered if
the client has a history of diabetes. Hypertension and hyperthyroidism are
not related to discontinuation of iron supplements.
A concerned client tells the nurse that her husband, who was very excited
about the baby before its birth, is apparently happy but seems to be afraid of
caring for the baby. What suggestion should the nurse give to the client's
husband to resolve the issue? - Ans--Hold the baby frequently.
The nurse should suggest that the father care for the newborn by holding
and talking to the child. Reading up on parental care and speaking to his
friends or the primary care provider will not help the father resolve his fears
about caring for the child.
During a postpartum exam on the day of birth, the woman reports that she is
still so sore that she cannot sit comfortably. The nurse examines her
perineum and find the edges of the episiotomy approximated without signs
of a hematoma. Which intervention will be most beneficial at this point? -
Ans--Place an ice pack.
The labia and perineum may be edematous after birth and bruised; the use
of ice would assist in decreasing the pain and swelling. Applying a warm
washcloth would bring more blood as well as fluid to the sore area, thereby
increasing the edema and the soreness. Applying a witch hazel pad needs
the order of the primary care provider. Notifying a care provider is not
necessary at this time as this is considered a normal finding.
, A woman who gave birth to a healthy newborn 2 months ago comes to the
clinic and reports discomfort during sexual intercourse. Which suggestion
by the nurse would be most appropriate? - Ans--"You might try using a
water-soluble lubricant to ease the discomfort."
Coital discomfort and localized dryness usually plague most postpartum
women until menstruation returns. Water-soluble lubricants can reduce
discomfort during intercourse. Although it may take some time for the
woman's body to return to its prepregnant state, telling the woman this does
not address her concern. Telling her that dyspareunia is normal and that it
takes time to resolve also ignores her concern. Kegel exercises are helpful
for improving pelvic floor tone but would have no effect on vaginal dryness.
For the first hour after birth, the height of the fundus is at the umbilicus or
even slightly above it. - Ans--True
A client who gave birth about 12 hours ago informs the nurse that she has
been voiding small amounts of urine frequently. The nurse examines the
client and notes the displacement of the uterus from the midline to the right.
What intervention would the nurse perform next? - Ans--Perform urinary
catheterization.
Displacement of the uterus from the midline to the right and frequent voiding
of small amounts suggests urinary retention with overflow. Catheterization
may be necessary to empty the bladder to restore tone. An IV and oxytocin
are indicated if the client experiences hemorrhage due to uterine atony from
being displaced. The healthcare provider would be notified if no other
interventions help the client.
While caring for a client following a lengthy labor and birth, the nurse notes
that the client repeatedly reviews her labor and birth and is very dependent
on her family for care. The nurse is correct in identifying the client to be in
which phase of maternal role adjustment? - Ans--taking-in
The taking-in phase occurs during the first 24 to 48 hours following the birth
of the newborn and is characterized by the mother taking on a very passive
role in caring for herself, as well as recounting her labor experience. The
second maternal adjustment phase is the taking-hold phase and usually
