McKinney Ch 20 Postpartum Adaptations Questions and Answers graded A+

1. A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage." ANS: C Feedback A Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. B Deep tendon reflexes should be 1+ to 2+. C Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein thrombosis. D A "fleshy" odor, not a foul odor, is within normal limits. 2. Which woman is most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit ANS: A Feedback A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. B Afterpains are particularly severe during breastfeeding, not bottle-feeding. C The uterus of a primipara tends to remain contracted. D The nonnursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse. 3. Which maternal event is abnormal in the early postpartum period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba ANS: D Feedback A The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after delivery and is facilitated by hormonal changes in the mother. B Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. C The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. 4. Which finding 12 hours after birth requires further assessment? a. The fundus is palpable two fingerbreadths above the umbilicus. b. The fundus is palpable at the level of the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus. ANS: A Feedback A The fundus rises to the umbilicus after delivery and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. B This is an appropriate assessment finding for 12 hours postpartum. C This is an appropriate assessment finding for 12 hours postpartum. D This is an unusual finding for 12 hours postpartum, but still appropriate. 5. If the patient's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, the nurse should a. Tell the physician immediately. b. Have the laboratory draw blood for reanalysis. c. Recognize that this is an acceptable range at this point postpartum. d. Begin antibiotic therapy immediately. ANS: C Feedback A Since this is a normal finding there is no reason to alert the physician. B There is no need for reassessment since it is expected for the WBCs to be elevated. C Marked leucocytosis occurs with WBC counts increasing to as high as 30,000/mm3during labor and the immediate postpartum period. The WBC falls to normal within 6 days postpartum. D Antibiotics are not needed because the elevated WBCs are due to stress of labor and not an infectious process. 6. Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Postpartum hemorrhage and eclampsia b. Fever and increased blood pressure c. Postpartum hemorrhage and urinary tract infection d. Urinary tract infection and uterine rupture ANS: C Feedback A There is no correlation between bladder distention and eclampsia. B There is no correlation between bladder distention and blood pressure or fevers. C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. D The risk of uterine rupture decreases after the birth. 7. A postpartum patient asks, "Will these stretch marks go away?" The nurse's best response is a. "They will continue to fade and should be gone by your 6-week checkup." b. "No, never." c. "Yes, eventually." d. "They will fade to silvery lines but won't disappear completely." ANS: D Feedback A Stretch marks do not disappear. B This is true, but more information can be added, such as the changes that will occur with the stretch marks. C This is not a true statement; they will not disappear. D Stretch marks never disappear altogether, but they gradually fade to silvery lines. 8. A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will decrease after delivery because of a. Increased estrogen b. Increased progesterone c. Decreased melanocyte-stimulating hormone d. Decreased human placental lactogen ANS: C Feedback A Estrogen levels decrease after delivery. B Progesterone levels decrease after delivery. C Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after delivery. D Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation. 9. If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the patient has a. Been lying on her right side too long b. A distended bladder c. Stretched ligaments that are unable to support the uterus d. A normal involution ANS: B Feedback A Position of the patient should not alter uterine position. B The presence of a full bladder will displace the uterus. C The problem is a full bladder displacing the uterus. D This is not an expected finding. 10. A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a. The woman is a gravida 2, para 2. b. The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy. ANS: D Feedback A A multiparous classification is not an indication for these orders. B A vacuum-assisted birth may be used in conjunction with an episiotomy, which indicates these interventions. C Use of epidural anesthesia has no correlation with these orders. D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. 11. Rho immune globulin will be ordered postpartum if which situation occurs? a. Mother Rh-, baby Rh+ b. Mother Rh-, baby Rh- c. Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh- ANS: A Feedback A An Rh- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. B The blood types are alike, so no antibody formation would be anticipated. C The blood types are alike, so no antibody formation would be anticipated. D If the Rh+ blood of the mother comes in contact with the Rh- blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's. 12. If rubella vaccine is indicated for a postpartum patient, instructions to the patient should include a. Drinking plenty of fluids to prevent fever b. No specific instructions c. Recommending that she stop breastfeeding for 24 hours after injection d. Explaining the risks of becoming pregnant within 1 month after injection ANS: D Feedback A The mother should be afebrile before the vaccine. B The mother does need to understand potential side effects, and that pregnancy is discouraged for at least 28 days after receiving the vaccine. C Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding. D Potential risks to the fetus can occur if pregnancy results within 28 days after rubella vaccine administration. Upgrade to remove ads Only $35.99/year 13. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a. Notify the physician of an impending hemorrhage. b. Assess the blood pressure and pulse. c. Evaluate the lochia. d. Assist the patient in emptying her bladder. ANS: D Feedback A Nursing actions need to be implemented before notifying the physician. B This is an important assessment if the bleeding continues. However, the focus should be on controlling the bleeding. C The focus needs to be on controlling the bleeding. D Urinary retention can cause overdistention of the urinary bladder, which lifts and displaces the uterus. 14. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a. Rectal suppositories b. Early and frequent ambulation c. Tightening and relaxing abdominal muscles d. Carbonated beverages ANS: B Feedback A Rectal suppositories can be helpful after distention occurs, but do not prevent it. B Activity can aid the movement of accumulated gas in the gastrointestinal tract. C Ambulation is the best prevention. D Carbonated beverages may increase distention. 15. What documentation on a woman's chart on postpartum day 14 indicates a normal involution process? a. Moderate bright red lochial flow b. Breasts firm and tender c. Fundus below the symphysis and not palpable d. Episiotomy slightly red and puffy ANS: C Feedback A The lochia should be changed by this day to serosa. B Breasts are not part of the involution process. C The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. D The episiotomy should not be red or puffy at this stage. 16. To assess fundal contraction 6 hours after cesarean delivery, the nurse should a. Palpate forcefully through the abdominal dressing. b. Gently palpate, applying the same technique used for vaginal deliveries. c. Place hands on both sides of the abdomen and press downward. d. Rely on assessment of lochial flow rather than palpating the fundus. ANS: B Feedback A Forceful palpation should never be used. B Assessment of the fundus is the same for both vaginal and cesarean deliveries; however, palpation should be gentle due to increased discomfort caused by the uterine incision. C The top of the fundus, not the sides, should be palpated and massaged. D The fundus should be palpated and massaged to prevent bleeding. 17. The mother-baby nurse is able to recognize reciprocal attachment behavior. This refers to a. The positive feedback an infant exhibits toward parents during the attachment process b. Behavior during the sensitive period when the infant is in the quiet alert stage c. Unidirectional behavior exhibited by the infant, initiated and enhanced by eye contact d. Behavior by the infant during the sensitive period to elicit feelings of "falling in love" from the parents ANS: A Feedback A In this definition, reciprocal refers to the feedback from the infant during the attachment process. B This is a good time for bonding, but it does not define reciprocal attachment. C Reciprocal attachment is not unidirectional. D Reciprocal attachment deals with feedback behavior and is not unidirectional. 18. The postpartum woman who continually repeats the story of her labor, delivery, and recovery experiences is a. Providing others with her knowledge of events b. Making the birth experience "real" c. Taking hold of the events leading to her labor and delivery d. Accepting her response to labor and delivery ANS: B A This is to satisfy her needs, not others. B Reliving the birth experience makes the event real and helps the mother realize that the pregnancy is over and that the infant is born and is now a separate individual. C She is in the taking-in phase, trying to make the birth experience seem real. D She is trying to make the event real and is trying to separate the infant from herself. 19. During which stage of role attainment do the parents become acquainted with their baby and combine parenting activities with cues from the infant? a. Anticipatory b. Formal c. Informal d. Personal ANS: B A The anticipatory stage begins during the pregnancy when the parents choose a physician and attend childbirth classes. B A major task of the formal stage of role attainment is getting acquainted with the infant. C The informal stage begins once the parents have learned appropriate responses to their infant's cues. D The personal stage is attained when parents feel a sense of harmony in their role. 20. On observing a woman on her first postpartum day sitting in bed while her newborn lies awake in the bassinet, the nurse should a. Realize that this situation is perfectly acceptable. b. Offer to hand the baby to the woman. c. Hand the baby to the woman. d. Explain "taking in" to the woman. ANS: C A This is expected behavior during the taking-in phase. However, interventions can facilitate infant bonding. B The woman is dependent and passive at this stage and may have difficulty making a decision. C During the "taking-in" phase of maternal adaptation, in which the mother may be passive and dependent, the nurse should encourage bonding when the infant is in the quiet alert stage. This is done best by simply giving the baby to the mother. D She learns best during the taking-hold phase. 21. A nurse is observing a family. The mother is holding the baby she delivered less than 24 hours ago. Her husband is watching his wife and asking questions about newborn care. The 4-year-old brother is punching his mother on the back. The nurse should a. Report the incident to the social services department. b. Advise the parents that the toddler needs to be reprimanded. c. Report to oncoming staff that the mother is probably not a good disciplinarian. d. Realize that this is a normal family adjusting to family change. ANS: D A There is no need to report this one incident. B Giving advice at this point would make the parents feel inadequate as parents. C This is normal for an adjusting family. D The observed behaviors are normal variations of families adjusting to change. 22. The best way for the nurse to promote and support the maternal-infant bonding process is to a. Help the mother identify her positive feelings toward the newborn. b. Encourage the mother to provide all newborn care. c. Assist the family with rooming-in. d. Return the newborn to the nursery during sleep periods. ANS: C A Having the mother express her feelings is important, but it is not the best way to promote bonding. B The mother needs time to rest and recuperate; she should not be expected to do all of the care. C Close and frequent interaction between mother and infant, which is facilitated by rooming-in, is important in the bonding process. This is often referred to as the mother-baby care or couplet care. D The mother needs to observe the infant during all stages so she will be aware of what to expect when they go home. 23. During which phase of maternal adjustment will the mother relinquish the baby of her fantasies and accept the real baby? a. Letting go b. Taking hold c. Taking in d. Taking on ANS: A A Accepting the real infant and relinquishing the fantasy infant occurs during the letting-go phase of maternal adjustment. B During the taking-hold phase the mother assumes responsibility for her own care and shifts her attention to the infant. C In the taking-in phase the mother is primarily focused on her own needs. D There is no taking-on phase of maternal adjustment. 24. A 25-year-old gravida 1 para 1 who had an emergency cesarean birth 3 days ago is scheduled for discharge. As you prepare her for discharge, she begins to cry. Your initial action should be to a. Assess her for pain. b. Point out how lucky she is to have a healthy baby. c. Explain that she is experiencing postpartum blues. d. Allow her time to express her feelings. ANS: D A This is an assumption. There is no evidence that she is in pain. B This is blocking communication. C She needs the opportunity to express her feelings first. Later, patient teaching can occur. D Although many women experience transient postpartum blues, they need assistance in expressing their feelings. This condition affects 70-80% of new mothers. 25. A man calls the nurse's station stating that his wife, who delivered 2 days ago, is happy one minute and crying the next. The man says, "She was never like this before the baby was born." The nurse's initial response should be to a. Tell him to ignore the mood swings, as they will go away. b. Reassure him that this behavior is normal. c. Advise him to get immediate psychological help for her. d. Instruct him in the signs, symptoms, and duration of postpartum blues. ANS: B A This blocks communication and may belittle the husband's concerns. B Before providing further instructions, inform family members of the fact that postpartum blues are a normal process to allay anxieties and increase receptiveness to learning. C Postpartum blues are a normal process that is short lived; no medical intervention is needed. D Client teaching is important; however, his anxieties need to be allayed before he will be receptive to teaching. 26. To promote bonding and attachment immediately after delivery, the nurse should a. Allow the mother quiet time with her infant. b. Assist the mother in assuming an en face position with her newborn. c. Teach the mother about the concepts of bonding and attachment. d. Assist the mother in feeding her baby. ANS: B A The mother should be given as much privacy as possible; however, nursing assessments must still be continued during this critical time. B Assisting the mother in assuming an en face position with her newborn will support the bonding process. C The mother has just delivered and is more focused on the infant; she will not be receptive to teaching at this time. D This is a good time to initiate breastfeeding, but first the mother needs time to explore the new infant and begin the bonding process. 27. In providing support to a new mother who must return to full-time employment 6 weeks after a vaginal delivery, the nurse should a. Allow her to express her positive and negative feelings freely. b. Reassure her that she'll get used to leaving her baby. c. Discuss child care arrangements with her. d. Allow her to solve the problem on her own. ANS: A A Allowing the patient to express feelings will provide positive support in her process of maternal adjustment. B This blocks communication and belittles the patient's feelings. C This is an important step in anticipatory guidance, but is not the best way to offer support. D She should be instrumental in solving the problem; however, allowing her time to express her feelings and talk the problem over will assist her in making this decision. 28. A new father states, "I know nothing about babies," but he seems to be interested in learning. The nurse should a. Continue to observe his interaction with the newborn. b. Tell him when he does something wrong. c. Show no concern, as he will learn on his own. d. Include him in teaching sessions. ANS: D Feedback A It is important to note the bonding process of the mother and the father, but that does not satisfy the expressed needs of the father. B He should be encouraged by pointing out the correct procedures he does. Criticizing him will discourage him. C This is not a nursing role. Nurses need to be sensitive to patients' needs. D The nurse must be sensitive to the father's needs and include him whenever possible. As fathers take on care new role, the nurse should praise every attempt even if his early care is awkward. 29. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you." ANS: D Feedback A Cultural dietary preferences must be respected. B Women may request that family members bring favorite or culturally appropriated foods to the hospital. C Cultural dietary preferences must be respected. A statement such as this does not show cultural sensitivity. D This statement shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. 30. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is a. Pouring water from a squeeze bottle over the woman's perineum b. Providing hot tea c. Asking the physician to prescribe analgesics d. Inserting a sterile catheter ANS: D Feedback A Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early on. B Hot tea or other fluids ad lib is an easy, noninvasive strategy, that should be tried early on. C If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter. D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills). 31. The nurse caring for the postpartum woman understands that breast engorgement is caused by a. Overproduction of colostrum b. Accumulation of milk in the lactiferous ducts and glands c. Hyperplasia of mammary tissue d. Congestion of veins and lymphatics ANS: D Feedback A Breast engorgement is not the result of overproduction of colostrum. B Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. C Hyperplasia of mammary tissue does not cause breast engorgement. D Breast engorgement is caused by the temporary congestion of veins and lymphatics. 32. Which hormone remains elevated in the immediate postpartum period of the breastfeeding woman? a. Estrogen b. Progesterone c. Prolactin d. Human placental lactogen ANS: C Feedback A Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. B Estrogen and progesterone levels decrease markedly after expulsion of the placenta, reaching their lowest levels 1 week into the postpartum period. C Prolactin levels in the blood increase progressively throughout pregnancy. In women who breastfeed, prolactin levels remain elevated into the sixth week after birth. D Human placental lactogen levels dramatically decrease after expulsion of the placenta. 33. Two days ago, a woman gave birth to a full-term infant. Last night, she awakened several times to urinate and noted that her gown and bedding were wet from profuse diaphoresis. One mechanism for the diaphoresis and diuresis that this woman is experiencing during the early postpartum period is a. Elevated temperature caused by postpartum infection b. Increased basal metabolic rate after giving birth c. Loss of increased blood volume associated with pregnancy d. Increased venous pressure in the lower extremities ANS: C Feedback A An elevated temperature causes chills and may cause dehydration, not diaphoresis and diuresis. B Diaphoresis and diuresis sometimes are referred to as reversal of the water metabolism of pregnancy, not as the basal metabolic rate. C Within 12 hours of birth, women begin to lose the excess tissue fluid that has accumulated during pregnancy. One mechanism for reducing these retained fluids is the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days after childbirth. Postpartal diuresis is another mechanism by which the body rids itself of excess fluid. D Postpartal diuresis may be caused by the removal of increased venous pressure in the lower extremities. 34. Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium? a. Varicosities of the legs b. Carpal tunnel syndrome c. Periodic numbness and tingling of the fingers d. Headaches ANS: D Feedback A Total or nearly total regression of varicosities is expected after childbirth. However, headaches might deserve attention. B Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Headaches, however, might deserve attention. C Periodic numbness of the fingers usually disappears after birth unless carrying the baby aggravates the condition. Headaches, however, might deserve attention. D Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. 35. Childbirth may result in injuries to the vagina and uterus. Pelvic floor exercises also known as Kegel exercises will help to strengthen the perineal muscles and encourage healing. The nurse knows that the patient understands the correct process for completing these conditioning exercises when she reports a. "I contract my thighs, buttocks, and abdomen." b. "I do 10 of these exercises every day." c. "I stand while practicing this new exercise routine." d. "I pretend that I am trying to stop the flow of urine midstream." ANS: D Feedback A Each contraction should be as intense as possible without contracting the abdomen, buttocks, or thighs. B Guidelines suggest that these exercises should be done 24 to 100 times per day. Positive results are shown with a minimum of 24 to 45 repetitions per day. C The best position to learn Kegel exercises is to lie supine with knees bent. A secondary position is on the hands and knees. D The woman can pretend that she is attempting to stop the passing of gas, or the flow of urine midstream. This will replicate the sensation of the muscles drawing upward and inward. 1. Nurses must be aware of the conditions that increase the risk of hemorrhage, one of the most common complications of the puerperium. What are the conditions? Select all that apply. a. Primipara b. Rapid or prolonged labor c. Overdistention of the uterus d. Uterine fibroids e. Preeclampsia ANS: B, C, D, E Feedback Correct Rapid or prolonged labor, overdistention of the uterus, uterine fibroids, and preeclampsia are all risk factors for postpartum hemorrhage. Incorrect Grand multiparity (5 or more pregnancies) is a risk factor for postpartum hemorrhage. Other risk factors include retained placenta, placenta previa, previous postpartum hemorrhage or placenta accreta, drugs (magnesium sulfate, tocolytics, oxytocin), and operative procedures. 2. Many women given up smoking during pregnancy to protect the health of the fetus. The majority of women resumed smoking within the first 6 months postpartum. Factors that increase the likelihood of relapse include (select all that apply) a. Living with a smoker b. Returning to work c. Weight concerns d. Successful breastfeeding e. Failure to breastfeed ANS: A, C, E Feedback Correct Other factors include intending to quit for pregnancy only, depression, and stress. Incorrect Successful breastfeeding is likely to inhibit smoking. Returning to work, although stressful, does not necessarily increase a return to smoking. 1. The acronym ________ is used as a reminder that the site of an episiotomy or perineal laceration should be assessed for five physical signs. ANS: REEDA The acronym REEDA indicates redness, edema, ecchymosis or bruising, discharge, and approximation (the edges of the wound should be close). If redness is accompanied by pain or tenderness, this may indicate infection. Edema may illustrate soft tissue damage and delay wound healing. There should be no discharge. The edges of the wound should be closely approximated as if held together by glue. 2. The process in which the uterus returns to a non-pregnant state after birth is known as __________. ANS: involution This process begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle. 1. The nurse evaluating the amount of lochia on a newly delivered patient knows that a moderate amount of flow constitutes a 4- to 6-inch stain on the peripad. Is this statement true or false? ANS: T Since estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: Scant—less than a 1-inch stain on the peripad Light—a 1- to 4-inch stain Moderate—a 4- to 6-inch stain Heavy—saturated peripad Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth since some of the endometrial lining is removed during surgery. 2. Clotting factors and fibrinogen levels normally are decreased during pregnancy and remain low in the immediate puerperium. This hypocoagulable state increases the risk of thromboembolism, especially after cesarean birth. Is this statement true or false? ANS: F Clotting factors and fibrinogen normally are increased during pregnancy and remain elevated in the immediate puerperium. This hypercoagulable state increases the risk of thromboembolism, especially after cesarean bir