3.
4. Within the fi rst 24 hours postpartum, the maternal temperature may increase to 100.4°F, a normal postpartum fi nding attributed to dehydra- tion. A temperature higher than 100.4°F after the fi rst 24 hours indicates a potential for infection.Hemoconcentration is a normal fi nding postpartum due to the remobilization and rapid loss of excess body fl uids. WBC count is normally elevated as a response to the infl ammation, pain, and stress of the birthing process. A pulse rate of 60 bpm is normal at this period and results from an increased cardiac output (mobilization of excess extracellular fl uid into the vascular bed, decreased pressure from the uterus on vessels, blood fl ow back to the heart from the uterus returning to the central circulation) and alteration in stroke volume.
CN: Physiological adaptation;
CL: Analyze
4.
4. Uterine massage enables immediate con- traction of the uterus to prevent bleeding. In-and-out catheterization relieves bladder distention, elimi- nates displacement, fi rms the uterus, and prevents uterine bleeding. A bladder scan is not necessary because the nurse is able to palpate the full bladder.The positioning of the uterus indicates a full blad- der. An indwelling urinary catheter is not necessary because most clients spontaneously void within 12 hours. The use of an NSAID will help reduce the infl ammation that may be present but its action is not immediate and the status of the fundus needs more immediate interventions because of the risk of postpartum hemorrhage associated with a full blad- der.
CN: Management of care; CL: Synthesize
5.
2. Pain medication is the fi rst strategy to initi- ate at this pain level. When trauma has occurred to any area, the usual intervention is ice for the fi rst 24 hours and heat after the fi rst 24 hours. Sitz baths are initiated at the conclusion of ice therapy. Ice has already been initiated and will prevent further edema to the rectal sphincter and perineum and continue to reduce some of the pain. Anesthetic sprays can also be utilized for the perineal area when pain is involved but would not lower the pain to a level that the client considers tolerable.CN: Physiological adaptation;
CL: Synthesize
6.
3. Stage four is the fi rst 2 to 4 hours postpar- tum. At this time, the nurse should frequently assess maternal vital signs, the fundus, bladder status, and lochia. The vital signs indicate the ability of the client to transition from pregnancy to postpartum and the physical status of the mother. The mater- nal fundus should remain fi rm, midline, and at the umbilicus or lower. A bladder that is distendedAnswers, Rationales, and Test Taking Strategies
The answers and rationales for each question follow below, along with keys ( ) to the client need (CN) and cognitive level (CL) for each question. Use these keys to further develop your test-taking skills.
For additional information about test-taking skills and strategies for answering questions, refer to pages 10–21, and pages 25–26 in Part 1 of this book.
The Postpartal Client with a
not be appropriate. Local law enforcement agencies would be contacted only if the mother initiates use of the drugs on hospital premises and such con- tact would be made through the hospital security system.
CN: Physiological adaptation;
CL: Synthesize
10.
4. Acetaminophen and hydrocodone (Vico- din) would be the drug of choice for this situation because the pain level is so high. Aspirin is not usually used because of the bleeding risk associated with its use. Although ibuprofen would typically be a good choice because it inhibits the prostaglan- din synthesis associated with a multiparous client breast-feeding, the pain level is too high for this drug to have an acceptable effect. Docusate (Colace) is used as a stool softener postpartum but does not provide pain relief.CN: Pharmacological and parenteral therapies; CL: Synthesize
11.
1. Immediately after delivery of the pla- centa, the nurse would expect to palpate the fundus halfway between the umbilicus and the symphy- sis pubis. Within 2 hours postpartum, the fundus should be palpated at the level of the umbilicus.The fundus remains at this level or may rise slightly above the umbilicus for approximately 12 hours.
After the fi rst 12 hours, the fundus should decrease one fi ngerbreadth (1 cm) per day in size. By the ninth or tenth day, the fundus usually is no longer palpable.
CN: Health promotion and maintenance;
CL: Apply
12.
2. The instillation of erythromycin into the neonate’s eyes provides prophylaxis for ophthalmia neonatorum, or neonatal blindness caused by gonor- rhea in the mother. Erythromycin is also effective in the prevention of infection and conjunctivitis from Chlamydia trachomatis. The medication may result in redness of the neonate’s eyes, but this redness will eventually disappear. Erythromycin ointment is not effective in treating neonatal chorioretinitis from cytomegalovirus. No effective treatment is available for a mother with cytomegalovirus. Erythromycin ointment is not effective in preventing cataracts.Additionally, neonatal infection with beta-hemolytic streptococcus results in pneumonia, bacterial men- ingitis, or death. Cataracts in the neonate may be congenital or may result from maternal exposure to rubella. Erythromycin ointment is also not effec- tive for preventing and treating strabismus (crossed eyes). Infants may exhibit intermittent strabismus until 6 months of age.
CN: Pharmacological and parenteral therapies; CL: Apply
may displace the normally fi rm uterus and cause hemorrhage. The lochia is assessed for color, odor, and amount postpartum. Assessment of the mother’s ability to push, hydration, emotional stability, con- traction patterns, and fetal heart tones is important in stages one and two. Maternal vital signs will be assessed during all stages of labor. Maternal emo- tional status and infant bonding and feeding prefer- ences are lower priorities than the physical well- being of the mother.
CN: Reduction of risk potential;
CL: Analyze
7.
2. Educating the client about caring for herself and her infant are the two highest priority goals. Following delivery, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specifi c needs of each client. Bonding is signifi cant, but is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.CN: Management of care; CL: Create
8.
3. The client is in the taking hold phase with a demonstrated focus on the neonate and learning about and fulfi lling infant care and needs. The tak- ing in phase is the fi rst period after delivery where there is emphasis on reviewing and reliving the labor and delivery process, concern with self and needing to be mothered. Eating and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individu- als assume care of the infant and begins the separa- tion process.CN: Psychosocial adaptation;
CL: Analyze
9.
1. A urine toxicology screening will be col- lected to document that the infant has been exposed to illegal drug use. This documentation will be the basis for legal action for the protection of this infant.If the infant tests positive for cocaine, the legal sys- tem will be activated to provide and ensure protec- tive custody for this child. Hospital security would not become involved unless the mother is obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any hospital- ized clients unless the safety of the infant is jeop- ardized, thus limiting contact with visitors would
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bladder emptying. A prolonged fi rst stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a urinary tract infection, she would exhibit symptoms such as dysuria and a burn- ing sensation. After delivery, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on the bladder occurs during labor.
CN: Health promotion and maintenance;
CL: Analyze
17.
2. For clients who are bottle-feeding, the menstrual fl ow should return in 6 to 10 weeks, after a rise in the production of follicle-stimulating hormone by the pituitary gland. Nonlactating moth- ers rarely ovulate before 4 to 6 weeks postpartum.Therefore, 3 to 4 weeks is too early for the menstrual cycle to resume. For women who are breast-feeding, the menstrual fl ow may not return for 3 to 4 months (12 to 16 weeks) or, in some women, for the entire period of lactation, because ovulation is suppressed.
CN: Health promotion and maintenance;
CL: Apply
18.
4. The client’s dizziness is most likely caused by orthostatic hypotension secondary to the decreased volume of blood in the vascular system resulting from the physiologic changes occurring in the mother after delivery. The client is experienc- ing dizziness because not enough blood volume is available to perfuse the brain. The nurse should fi rst allow the client to “dangle” on the side of the bed for a few minutes before attempting to ambulate.By 6 hours postpartum, the effects of the anesthesia should be worn off completely. Typically, the effects of epidural anesthesia wear off by 1 to 2 hours post- partum, and the effects of local anesthesia usually disappear by 1 hour. The client scenario provides no information to indicate that the client experienced any postpartum hemorrhage. Normal blood loss dur- ing delivery should not exceed 500 mL.
CN: Health promotion and maintenance;
CL: Apply
19.
4. Because the diet of Hispanic Americans from Mexico and Central America commonly includes beans, corn products, tomatoes, chili pep- pers, potatoes, milk, cheeses, and eggs, the nurse needs to encourage an intake of meats, dark green leafy vegetables, and other high-protein products that are rich in iron. Doing so helps to compensate for the signifi cant blood loss and subsequent iron loss that occurs during the postpartum period. Addi- tionally, fresh fruits, meats, and green leafy vegeta- bles may be scarce, possibly resulting in defi ciencies of vitamin A, vitamin D, and iron. Tomatoes are high in vitamin C, potatoes are good sources of carbohy- drates and vitamin C, and corn products are high in thiamine, but these are not rich sources of iron.CN: Health promotion and maintenance;
CL: Create
13.
3. Phytonadione (vitamin K or AquaMEPHY- TON) acts as a preventive measure against neonatal hemorrhagic disease. At birth, the neonate does not have the intestinal fl ora to produce vitamin K, which is necessary for coagulation. Hypoglycemia is pre- vented and treated by feeding the infant. Hyperbili- rubinemia severity can be decreased by early feeding and passage of meconium to excrete the bilirubin.Hyperbilirubinemia is treated with phototherapy.
Polycythemia may occur in neonates who are large for gestational age or post-term. Clamping of the umbilical cord before pulsations cease reduces the incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe.
CN: Pharmacological and parenteral therapies; CL: Apply
14.
3. The fi rst 12 hours after delivery are part of the taking-in phase of maternal postpartum adjustment, which typically lasts from 1 to 3 days.During the taking-in phase, the client is primar- ily concerned with her own needs. After the fi rst 1 to 3 days postpartum, the client is in the taking- hold phase and can focus more on the needs of the neonate. Although the family is an important unit of care and the signifi cant other is important for the mother’s emotional support, during the taking-in phase the mother is focused on herself.
CN: Health promotion and maintenance;
CL: Analyze
15.
1. The client has a hematoma. During the fi rst 24 hours postpartum, ice packs can be applied to the perineal area to reduce swelling and discomfort.Ice packs usually are not effective after the fi rst 24 hours. Although vital signs, including temperature, are important assessments, taking the client’s tem- perature is unrelated to the hematoma and would provide no additional information about swelling.
After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat is an effec- tive way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve with- out further treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide a baseline for subsequent measurements and should notify the physician of its presence. An antibiotic is not warranted at this point because the client is not exhibiting any signs or symptoms of infection.
CN: Health promotion and maintenance;
CL: Synthesize
16.
4. Urinary retention soon after delivery is usually caused by edema and trauma of the lower urinary tract; this commonly results in diffi culty with initiating voiding. Hyperemia of the bladder mucosa also commonly occurs. The combination of hyper- emia and edema predisposes to decreased sensation to void, overdistention of the bladder, and incompleteBillings_Part 2_Chap 1_Test 4.indd 135
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24.
3. After an uncomplicated delivery, postpar- tum exercises may begin on the fi rst postpartum day with exercises to strengthen the abdominal muscles.These are done in the supine position with the knees fl exed, inhaling deeply while allowing the abdo- men to expand and then exhaling while contracting the abdominal muscles. Exercises such as sit-ups (sitting, then lying back, and returning to a sitting position) and push-ups or exercises involving reach- ing for the knees are ordinarily too strenuous for the fi rst postpartum day. Sit-ups may be done later in the postpartum period, after approximately 3 to 6 weeks.
CN: Health promotion and maintenance;
CL: Apply
25.
2. Lochia can be expected to increase when the client fi rst ambulates. Lochia tends to pool in the uterus and vagina when the client is recumbent and fl ows out when the client arises. If the client had reported that her lochia was bright red, the nurse would suspect bleeding. In this situation, the client would be put back in bed and the physician would be notifi ed. Early postpartum hemorrhage occurs during the fi rst 24 hours, but typically the fundus is soft or “boggy.” The client’s fundus here is fi rm and midline. Late postpartal hemorrhage, occurring after the fi rst 24 hours, is usually caused by retained placental fragments or abnormal involution of the placental site.CN: Health promotion and maintenance;
CL: Synthesize
26.
4. After delivery, the nurse should plan to measure the client’s fi rst two voidings and record the amount to make sure that the client is emptying the bladder. Frequent voidings of less than 150 mL suggest that the client is experiencing urinary reten- tion. In addition, if urinary retention is occurring, the bladder may be palpable and the fundus may be displaced from midline. The client does not need to be catheterized unless there is evidence of urinary retention. Palpation of the bladder before voiding is unnecessary. However, if the client has diffi culty voiding or exhibits signs of urinary retention, then bladder palpation is indicated. The fundus can be displaced by a full bladder and should be assessed after the client voids.CN: Health promotion and maintenance;
CL: Synthesize
27.
2. Clients sometimes feel faint or dizzy when taking a shower for the fi rst time after delivery because of the sudden change in blood volume in the body. Primarily for this reason, the nurse remains nearby while the client takes her fi rst shower after delivery. If the client becomes dizzy or expresses symptoms of feeling faint, the nurse should get the client back to bed as soon as possible. If the client20.
4. A small, constant trickle of blood and a fi rm fundus are usually indicative of a vaginal tear or cervical laceration. If the client had retained pla- cental tissue, the fundus would fail to contract fully (uterine atony), exhibiting as a soft or boggy fundus.Also, vaginal bleeding would be evident. Uterine inversion occurs when the uterus is displaced outside of the vagina and is obvious on inspec- tion. Bladder distention may result in uterine atony because the pressure of the bladder displaces the fundus, preventing it from fully contracting. In this case the fundus would be soft, possibly boggy, and displaced from midline.
CN: Reduction of risk potential;
CL: Analyze
21.
4. On about the eleventh postpartum day, the lochia should be lochia alba, clear or white in color.Lochia rubra, which is dark red to red, may persist for the fi rst 2 to 3 days postpartum. From day 3 to about day 10, lochia serosa, which is pink or brown, is normal.
CN: Health promotion and maintenance;
CL: Evaluate
22.
2. The nurse should instruct the client to cleanse the perineal area with warm water and to wipe from front to back with a blotting motion.Warm water is soothing to the tender tissue, and wiping from front to back reduces the risk of contamination. Hot, sudsy water may increase the client’s discomfort and may even burn the client in a very tender area. After the fi rst 24 hours, warm water sitz baths taken three or four times a day for 20 minutes can help increase circulation to the area. Ice packs are helpful for the fi rst 24 hours.
CN: Health promotion and maintenance;
CL: Evaluate
23.
3. After explaining the procedure to the client, the nurse should wash hands and don clean gloves for the procedure. Washing the hands prevents the spread of infection. Standard precau- tions are necessary to protect both the client and the nurse. The temperature of the water should be between 100° and 105° F (37.4° and 40° C) to prevent burns. Spraying the perineal area with the ordered analgesic spray is done after the sitz bath to provide the greatest pain relief. Assessing the client’s perineum for swelling and redness is part of the nursing assessment and needs to be done after hand washing and donning clean gloves. Also, the assessment would be done before the nurse explains the procedure.CN: Safety and infection control;
CL: Synthesize
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31.
2. According to Erikson, infants are in the trust versus mistrust stage. Holding, talking to, sing- ing to, and patting neonates helps them develop trust in caregivers. Tactile stimulation is important and should be encouraged. Holding neonates often is unlikely to spoil them because they are totally dependent on other human beings to meet their needs. Being held makes infants feel loved and cared for and should be encouraged. The mother can hold the neonate as often as she wants, not just when the baby is crying or fussy. Overstimulation typically does not result from holding an infant.CN: Health promotion and maintenance;
CL: Synthesize
32.
4. Excessive perspiration and diuresis is common during the puerperium as the body attempts to return to its prepregnant state. The most appropriate nursing diagnosis is Excess fl uid volume related to normal postpartal diuresis. A temperature of 99° F (37.2° C) is normal during the fi rst 24 hours postpartum. Foul-smelling lochia and a tempera- ture higher than 100.4° F (38° C) would suggest an infection. Although hormonal shifts occur during the postpartum period, the client’s diaphoresis is related to diuresis, not to a problem with thermoreg- ulation caused by hormonal changes. No evidence is presented to suggest altered renal tissue perfusion related to the client’s multiparity status. Clients with renal disease or renal failure may exhibit painful urination, fl ank pain, or lack of urinary output.CN: Health promotion and maintenance;
CL: Analyze
33.
4. If the client continues to complain of perineal pain after an analgesic medication has been given, the nurse should inspect the client’s perineum for a hematoma, because this is the usual cause of such discomfort. Ibuprofen is a nonsteroi- dal anti-infl ammatory medication used to relieve mild pain. Pain from a perineal hematoma can be moderate to severe, possibly requiring a stronger analgesic, such as acetaminophen with codeine (Tylenol with Codeine). Ice applied to the perineum during the fi rst 24 hours postpartum may decrease the severity of hematoma formation. Application of warm heat, such as a sitz bath three times daily for 20 minutes, also can help to relieve the discomfort when implemented after the fi rst 24 hours. Typically hematomas resolve themselves within 6 weeks.A puerperal infection would be indicated if the cli- ent’s temperature were 100.4° F (41° C) or higher.
Also, lochia most likely would be foul smelling.
A continuous trickle of lochia rubra would suggest a possible vaginal laceration. No evidence is pre- sented to suggest a history of drug abuse.
CN: Reduction of risk potential;
CL: Analyze faints while in the shower, the nurse should cover
the client to protect her privacy, stay with the client, and call for assistance. Fatigue postpartum is com- mon and will precede taking a shower. Diuresis is a normal physiologic response during the postpartum period and not associated with showering. Hygiene needs also precede the shower.
CN: Safety and infection control;
CL: Analyze
28.
2. The nurse should instruct the client to squeeze or contract the muscles of the buttocks together before sitting down in the chair; this contracts the pelvic fl oor muscles, which reduces the tension on the tender perineal area. Then the client should put her full weight slowly down on the chair. Pain medication may only be ordered for every 3 to 4 hours, so the client may not be able to receive pain medication every time she desires to sit in the chair. The episiotomy pain usually fades by the fi fth or sixth postpartum day. Maintaining a relaxed posture before sitting does not contract the pelvic fl oor muscles. Most physicians order an analgesic cream or spray when a client has an epi- siotomy, but they provide only temporary relief.CN: Health promotion and maintenance;
CL: Synthesize
29.
1. Neonates like to look at eyes, and eye- to-eye contact is a highly effective way to provide visual stimulation. The parent’s eyes are circular, move from side to side, and become larger and smaller. Neonates have been observed to fi x on them. In general, neonates prefer circular objects of darkness against a white background. Sharp black and white images of geometric fi gures are appropri- ate. Use of bright colors on the walls and moving a colorful rattle do not provide as much visual stimu- lation as eye-to-eye contact with talking. Brightly colored animals and cartoon fi gures are more appro- priate at approximately 1 year of age.CN: Health promotion and maintenance;
CL: Create
30.
2. The father is praying to Allah because of the Muslim belief that the fi rst sounds a child hears should be from the Koran in praise of and supplication to Allah. Although male children are revered in this culture, this practice is performed by Muslims whether the child is male or female. The father’s actions are unrelated to his wife and son’s being healthy. The nurse should allow the practice because doing so demonstrates cultural sensitivity and builds a trusting relationship with the fam- ily. The Muslim faith does not have a baptism rite whereby the child becomes a member of the faith.CN: Health promotion and maintenance;
CL: Analyze
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