The Postpartal Client Who Bottle-Feeds - LIPPINCOTT'S Q & A Review for NCLEX-RN

79.

1. By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a non- pregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).

CN: Physiological adaptation;

CL: Analyze

80.

4. The use of a breast pump to remove milk is contraindicated in bottle-feeding mothers. Nipple and breast stimulation and emptying of the breasts produce milk, rather than eliminate milk production. The bottle-feeding client is discouraged from stimulating the breasts in any way. A sports bra that is well fi tting provides support and decreases stimulation. (Binders are not suggested.) Having the water in a shower land on the shoulders of the mother rather than the breasts also decreases stimulation.

Only water is necessary to clean nipples when breast or bottle-feeding.

CN: Basic care and comfort; CL: Evaluate

81.

4. The bottle- or breast-feeding preference is the least important information to be reported to the oncoming shift. The bottle- or breast-feeding plans will be important after delivery as many mothers breast-feed within an hour after delivery. The client’s obstetrical history is a higher priority because it provides information about previous birthing experience. Information on cervical effacement, dilation, and station indicates the current state of labor and is essential for planning continuity of care for this client. Nurses on the incoming shift should also know the extent of support the client will need and who is currently providing that support.

CN: Physiological adaptation; CL: Create

82.

3. As a general rule, most neonates require 50 to 55 calories per pound of body weight, or about 117 calories per kilogram of weight, each day. If the neonate receives less than this amount, malnutrition may occur. More than this amount can lead to obesity.

CN: Basic care and comfort; CL: Apply

Billings_Part 2_Chap 1_Test 4.indd 144

Billings_Part 2_Chap 1_Test 4.indd 144 8/7/2010 9:43:07 AM8/7/2010 9:43:07 AM

to monitor the client’s input and output should be done after the physician is contacted. Palpating the fundus every 15 minutes is not necessary unless the client’s fundus becomes soft or “boggy.” Assess- ment of the retention catheter is a normal part of the elimination assessment by the nurse, but displace- ment is not the cause of the red-tinged urine.

CN: Reduction of risk potential;

CL: Synthesize

92.

3. The most appropriate response would be to explain that the vaginal spotting in female neonates is associated with hormones received from the mother. Estrogen is believed to cause slight vaginal bleeding or spotting in the female neonate. The con- dition disappears spontaneously, so there is no need for concern. Telling the mother that it is of no concern does not allay the mother’s worry. The vaginal spotting is related to hormones received from the mother, not to swallowing blood during the delivery or hemorrhagic disease of the neonate. Anemia is associated with hemorrhagic disease.

CN: Health promotion and maintenance;

CL: Synthesize

93.

1. VBAC can be attempted if the client has not had a classic uterine incision. This type of incision carries a danger of uterine rupture. A physician must be available, and a cesarean delivery must be possible within 30 minutes. A history of rapid labor is not a criterion for VBAC. A low transverse incision is not a contraindication for VBAC. A classic (vertical) incision is a contraindication because the client has a greater possibility for uterine rupture. Estimated fetal weight greater than 4,000 g by itself is not a contraindication if the mother is not diabetic.

CN: Health promotion and maintenance;

CL: Apply

94.

4. Abdominal distention, a major source of discomfort for the postoperative client, is best relieved by having the client ambulate more fre- quently. Ambulation stimulates circulation and peristalsis, thereby promoting the passage of fl atus.

Carbonated beverages contribute to additional gas formation, as can drinking through a straw, and should be avoided. The client can progress from full liquids to soft foods and then to a regular diet, once bowel sounds are present. The client does not need to limit her diet to soft foods, but she may wish to avoid foods that increase intestinal gas, such as beans or brussel sprouts.

CN: Basic care and comfort;

CL: Synthesize

95.

3. For maximum effectiveness, RhoGAM should be administered within 72 hours postpartum. Most Rh-negative clients also receive RhoGAM during the prenatal period at 28 weeks’ gestation

88.

2. Bottle “propping” is not recommended because it can lead to aspiration, delayed bonding, feelings of mistrust (Erikson), and possible otitis media. The neonate will not be overfed during bottle propping but may suck too quickly, possibly resulting in aspiration of the formula. Putting the neonate to bed with a bottle can lead to tooth decay later in the formative years, but an infant cannot hold the bottle. The cause of SIDS has not been determined.

However, it is associated with placing the infant in a prone position after eating.

CN: Reduction of risk potential;

CL: Synthesize

The Postpartal Client with a Cesarean Birth

89.

3. The client should have more active bowel sounds by this time postpartum. Ambulation will encourage passing fl atus and begin peristaltic action in the gastrointestinal track. Medicating the client should be evaluated prior to ambulating but it is probably too soon because the last dose was 3 hours ago and her pain assessment rating is fairly low. Pain medications should not have codeine as a component as it decreases peristaltic activity. Incen- tive spirometry or asking the client to turn, cough and deep breathe are appropriate to encourage good oxygen exchange in the lungs prior to ambulation, and walking can be used concurrently with these intervention. Participating in infant care is another way to encourage the mother to move about but the primary goal would be to have her walk on the unit, a more purposeful activity.

CN: Physiological adaptation;

CL: Synthesize

90.

2. Hemabate is an oxytocic prostaglandin that causes uterine contraction in women who are bleeding heavily. Nausea, vomiting, diarrhea, and fever are common adverse effects of prostaglandin administration. Vertigo and confusion are not associated with this drug. Vaginal bleeding may occur with inadequate amounts of Hemabate if the client continues to bleed. Restlessness may result if inadequate amounts of Hemabate are used and the woman continues to bleed and goes into shock. If too large a dose is given, the client may experience headache and hypertension because Hemabate does contract smooth muscles.

CN: Pharmacological and parenteral therapies; CL: Evaluate

91.

4. Slightly red-tinged urine may indicate that the bladder was accidentally cut during the cesarean delivery. The nurse should notify the physician as soon as possible about the urine color. Continuing

Billings_Part 2_Chap 1_Test 4.indd 145

Billings_Part 2_Chap 1_Test 4.indd 145 8/7/2010 9:43:08 AM8/7/2010 9:43:08 AM

thrombophlebitis. Other signs include edema and redness at the site and may be more reliable as an indicator of thrombophlebitis. The nurse should notify the physician immediately and ask the client to remain in bed to minimize the risk for pulmonary embolus, a serious consequence of thrombophlebitis should a clot dislodge. The Homan sign is observed on the client’s legs, so placing an ice pack on the perineal area is inappropriate.

However, ice to the perineum would be useful for episiotomy pain and swelling. The client does not need to be positioned in a semi-Fowler’s position but should remain on bed rest to prevent dislodge- ment of a potential clot.

CN: Reduction of risk potential;

CL: Synthesize

99.

4. Heparin therapy is ordered to prevent further clot formation by inhibiting further thrombus and clot formation. Heparin, an anticoagulant, does not make blood clots thinner. An adverse effect of heparin therapy during the puerperium is increased lochia fl ow, so the nurse must be observant for symptoms of hemorrhage, such as heavy lochial fl ow. Heparin does not increase diaphoresis, which is normal for the postpartum client.

CN: Pharmacological and parenteral therapies; CL: Evaluate

100.

2. A major complication of deep vein thrombosis is pulmonary embolism. Signs and symptoms, which may occur suddenly and require immedi- ate treatment, include dyspnea, severe chest pain, apprehension, cough (possibly accompanied by hemoptysis), tachycardia, fever, hypotension, diaphoresis, pallor, shortness of breath, and friction rub. Pain in the calf is common with a diagnosis of deep vein thrombosis. Hypotension, not hypertension, would suggest a possible pulmonary embolism. It also could suggest possible hemorrhage secondary to intravenous heparin therapy. Bradycar- dia for the fi rst 7 days in the postpartum period is normal.

CN: Reduction of risk potential;

CL: Synthesize

101.

3. A slow pulse (bradycardia) is normal for the fi rst 7 days postpartum as the body begins to adjust to the decrease in blood volume and return to the prepregnant state. Adverse effects of heparin therapy suggesting prolonged bleeding include hematuria, epistaxis, increased lochial fl ow, and bleeding gums. Typically, tachycardia, not bradycardia, would be associated with hemorrhage. Pete- chiae indicate bleeding under the skin or in subcu- taneous tissue.

CN: Reduction of risk potential;

CL: Evaluate and then again after delivery. The drug is given to

Rh-negative mothers who have a negative Coombs test and deliver Rh-positive neonates. If there is doubt about the fetus’s blood type after pregnancy is terminated, the mother should receive the medication.

CN: Pharmacological and parenteral therapies; CL: Apply

96.

1. After a cesarean delivery, most mothers have the greatest comfort when the neonate is positioned in the football hold with the mother in a semi-Fowler position, supporting the neonate’s head in her hand and resting the neonate’s body on pillows alongside her hip. This position prevents pressure on the uterine incision yet allows the neonate easy access to the mother’s breast. The scissors hold, where the mother places her hand well back on the breast to prevent touching the areola and interfering with the neonate’s mouth placement, is used by the mother to hold the breast and support it during breast-feeding. The cross-cradle hold is done when the mother holds the neonate’s head in the hand opposite from the breast on which the neonate will feed and the mother’s arm supports the neonate’s body across her lap. This position can be uncomfortable because of the pressure placed on the client’s incision line. For the cradle hold, the mother cradles the infant alongside the arm at the breast on which the neonate will feed. This position also can be uncomfortable because of the pressure placed on the incision line.

CN: Basic care and comfort;

CL: Synthesize

The Postpartal Client with Complications

97.

2. The separation of the abdominal muscles is a frequent occurrence during pregnancy and postpartum, caused by the size of the fetus and infl uenced by maternal hormones. The nurse should discuss the separation with the client and assure her that there are no further actions indicated. Exercises involving the head and shoulders may be initiated after the 6-week checkup to improve the muscle tone of the abdomen but exercise will not repair the separation. A referral to a surgeon for surgical repair is a personal choice of the client but would not be medically indicated for the separation.

CN: Physiological adaptation;

CL: Synthesize

98.

3. A positive Homan’s sign, discomfort behind the knee or in the upper calf area on dorsifl exion of the foot, may be indicative of

Billings_Part 2_Chap 1_Test 4.indd 146

Billings_Part 2_Chap 1_Test 4.indd 146 8/7/2010 9:43:08 AM8/7/2010 9:43:08 AM

106.

2. The client diagnosed with cystitis needs to void every 2 to 4 hours while awake to keep her bladder empty. In addition, she should maintain adequate fl uid intake; 3,000 mL per day is recommended. Intake of acidic fruit juices (e.g., cranberry, apricot) is recommended because of their association with reducing the risk for infection. The client should wear cotton underwear and avoid tight-fi tting slacks. She does not need to wash with povidone iodine (Betadine) after void- ing. Plain warm water is suffi cient to keep the perineal area clean.

CN: Basic care and comfort; CL: Create

107.

1. The client can continue to breast-feed as often as she desires. Continuation of breast-feeding is limited only by the client’s discomfort or malaise.

Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk.

Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breast- feeding mothers. Manual pumping of the breasts is not necessary.

CN: Health promotion and maintenance;

CL: Apply

108.

1. Methylergonovine maleate (Methergine) can cause hypertension, so the nurse should assess the client’s blood pressure before and after administration. This drug should not be administered to clients who are hypertensive. Assessing pulse, respiration, and temperature is important for all postpartum clients to provide evidence of possible complications, such as infection. Tachycardia and diminished breath sounds are associated with pulmonary embolism, but these signs are not specifi c to methylergonovine (Methergine) administration.

Assessing breath sounds would be important for a client who has had pregnancy-induced hypertension and received magnesium sulfate before delivery.

However, by the fourth postpartum day, the effects of magnesium sulfate should have disappeared.

Bowel sounds should be assessed after an operative delivery to determine whether peristalsis has begun so that the client can begin to drink clear liquids or eat soft foods.

CN: Pharmacological and parenteral therapies; CL: Analyze

109.

1. The client is exhibiting signs of early postpartal hemorrhage, defi ned as blood loss greater than 500 mL in the fi rst 24 hours postpartum. Rapid intravenous oxytocin infusion of 40 to 80 units in 1,000 mL of normal saline, oxygen therapy, and gentle fundal massage to contract the uterus are usually effective. If bleeding persists, the nurse should inspect the cervix and vagina for lacerations. Intramuscular or intravenous

102.

3. Successful teaching is demonstrated when the client says, “I should use a soft toothbrush to brush my teeth.” Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-infl ammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabo- lism of oral anticoagulants and should be avoided.

CN: Pharmacological and parenteral therapies; CL: Evaluate

103.

4. Frequent hand washing is the most important aspect of infection control.. The nurse can emphasize, monitor, and ensure this strategy for all who come in contact with this client. The use of gowns and gloves are appropriate when there is blood and stool. Barrier isolation and individual client care equipment are not needed in this situation.

CN: Reduction of risk potential;

CL: Evaluate

104.

1. Before administering ampicillin sodium (Polycillin) intravenously, the nurse must ask the client if she has any drug allergies, especially to penicillin. Antibiotic therapy can cause adverse effects, such as rash or even anaphylaxis. If the client is allergic to penicillin, the physician should be notifi ed and ampicillin should not be given. Check- ing the client’s pulse rate or placing her in a side- lying position and are not necessary. Assessing the amount of lochia by checking the perineal pad is important for all postpartum clients but is not necessary before antibiotic therapy.

CN: Pharmacological and parenteral therapies; CL: Apply

105.

3. The nurse should encourage the client to maintain Fowler’s position, which promotes comfort and facilitates drainage. Endometritis can make the client feel extremely uncomfortable and fatigued, so ambulation during intravenous therapy is not as important at this time. The client does not need to discontinue breast-feeding, although she may become quite fatigued and need assistance in caring for the neonate. Typically, breast-feeding would be discontinued only if the mother lacks the necessary energy. The institution’s policy regarding visitors is to be followed. However, visitors do not need to be restricted to prevent contamination because the client is not considered to be contagious. The nurse should maintain the client’s need for privacy and rest and should respect the client’s wishes related to visitors.

CN: Reduction of risk potential;

CL: Synthesize

Billings_Part 2_Chap 1_Test 4.indd 147

Billings_Part 2_Chap 1_Test 4.indd 147 8/7/2010 9:43:09 AM8/7/2010 9:43:09 AM

112.

4. The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a dilatation and curettage to remove remaining placental fragments.

Uterine atony, cervical lacerations, and vaginal lacerations are commonly associated with early, not late, postpartum hemorrhage.

CN: Health promotion and maintenance;

CL: Apply

113.

1. The client being treated for infectious mastitis should continue to breast-feed often, or at least every 2 to 3 hours. Treatment also includes bed rest, increased fl uid intake, local heat application, analgesics, and antibiotic therapy. Continually emptying the breasts decreases the risk of engorgement or breast abscess. The client should not discontinue breast-feeding unless she chooses to do so. The client may continue breast-feeding while receiving antibiotic therapy. Generally, the breast milk is not contaminated by the offending organism and is safe for the neonate.

CN: Physiological adaptation;

CL: Synthesize

114.

1. Down syndrome is a genetic abnormality that is caused by an extra chromosome that results in mental retardation. The degree of mental retardation is diffi cult to predict in a neonate, although most children born with Down syndrome have some degree of mental retardation. Various meth- ods can be used to determine whether a neonate has Down syndrome, which is commonly mani- fested by hypotonia, poor Moro refl ex, fl at facial profi le, upslanting palpebral fi ssures, epicanthal folds, and hyperfl exible joints. Genetic studies can be indicative of this disorder. Mothers older than 35 years of age are at a higher risk for having a child with Down syndrome. However, chromo- somal abnormalities can occur regardless of the mother’s age.

CN: Reduction of risk potential;

CL: Evaluate

115.

1. After birth, the client should make the decision about how much she would like to partici- pate in the neonate’s care. Seeing and caring for the neonate commonly facilitates the grief process. The nurse should be nonjudgmental and should allow the client any opportunity to see, hold, and care for the neonate. The physician does not need to be contacted about the client’s desire to see the baby, which is a normal reaction. The social worker and the adoptive parents do not need to give the client permission to feed the baby.

CN: Health promotion and maintenance;

CL: Synthesize methylergonovine may be administered, but this

drug elevates the blood pressure. Other phar- macologic interventions include prostaglandin (Hemabate, Prostin, PGF_2α) I.M. and misoprostol (Cytotec) rectally or vaginally. Severe uncontrolled hemorrhage may require bimanual uterine com- pression, a dilation and curettage to remove any retained placental tissue, or a hysterectomy to prevent maternal death from hemorrhage. The client should be placed in the supine position to allow evaluation of the fundus. The side-lying position is not helpful in controlling postpartum hemorrhage.

Vigorous fundal massage every 5 minutes is unnec- essary. In addition, it can be very painful for the mother. Rather, gentle massage along with oxytocin administration is used to stimulate the uterus to contract. A hysteromyomectomy is used to remove fi broid tumors. With massive hemorrhage, a hysterectomy (removal of the uterus) may be necessary to control the bleeding.

CN: Health promotion and maintenance;

CL: Create

110.

4. The most likely cause of this client’s uterine atony is overdistention of the uterus caused by the hydramnios. As a result, the stretched uterine musculature contracts less vigorously. Besides hydramnios, a large infant, bleeding from abruptio placentae or placenta previa, and rapid labor and delivery can also contribute to uterine atony during the postpartum period. Trauma during labor and delivery is not a likely cause. In addition, no evidence of excessive trauma was described in the scenario. Moderate fundal massage helps to contract the uterus, not contribute to uterine atony. Although a lengthy or prolonged labor can contribute to uterine atony, this client had a cesarean delivery for breech presentation. Therefore, it is unlikely that she had a long labor.

CN: Physiological adaptation; CL: Apply

111.

4. Scant and odorless vaginal discharge is associated with endometritis due to b-hemolytic streptococcus. The client also will exhibit “saw- tooth” temperature spikes between 101° and 104° F (38.3° to 40° C), tachycardia, and chills. The classic symptom of foul-smelling lochia is not associated with this type of endometritis. Profuse and foul-smelling lochia is associated with classic endometritis from pathogens such as chlamydia or staphylococcus, not group B hemolytic streptococcus. Abdominal distention is associated with parametritis as the pelvic cellulitis advances and spreads, causing severe pain and distention. Nausea and vomiting are associated with parametritis resulting from an abscess and advancing pelvic cellulitis.

CN: Reduction of risk potential;

CL: Analyze

Billings_Part 2_Chap 1_Test 4.indd 148

Billings_Part 2_Chap 1_Test 4.indd 148 8/7/2010 9:43:10 AM8/7/2010 9:43:10 AM

Dalam dokumen LIPPINCOTT'S Q & A Review for NCLEX-RN (Halaman 160-166)