1. The perinatal nurse and student nurse are conducting an assessment on a postpartal
woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding
sound. How should the nurse document this information?
a. A bladder containing about 500 cc of urine
b. A full bladder
c. An empty bladder
d. A hard bladder
ANS: C
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 376-377
Heading: Bladder
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. A bladder containing about 500 cc of urine is full. A full bladder produces a
resonant sound.
B. A full bladder produces a resonant sound upon percussion.
C. To percuss the bladder, the nurse places one finger flat on the patient’s
abdomen over the bladder and taps it with the finger of the other hand. An
empty bladder has a dull, thudding sound.
D. The hardness of the bladder does not relate to the sound on percussion.
2. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping
when she breastfeeds her infant. The perinatal nurse should document this condition as
which of the following?
a. Afterpains
b. Bladder hypotonia
c. Diastasis recti abdominis
d. Uterine hemorrhage
, ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman. Page: 373
Heading: Pain
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Afterpains (afterbirth pains) are intermittent uterine contractions that occur
during the process of involution. Afterpains are more pronounced in patients
with decreased uterine tone due to overdistension, which is associated with
multiparity and macrosomia. Breastfeeding and the administration of
exogenous oxytocin usually produce pronounced afterpains because both cause
powerful uterine contractions. Patients often describe the sensation as a
discomfort like menstrual cramps.
B. Bladder hypotonia would cause issues with urinary retention. Cramping when
breastfeeding is not a sign of bladder hypotonia.
C. Diastasis recti abdominis is the separation between abdominal muscles that can
occur during pregnancy. It is signaled by soft and weak abdomen muscles after
birth, not severe cramping.
D. Uterine hemorrhage would be signaled by decreased blood pressure, swelling
and bruising of the vagina and labia, and uncontrolled bleeding.
3. A postpartum woman is complaining of a headache that is worsening despite having
taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural
anesthesia. What action by the nurse is best?
a. Assess if the pain is worse when she sits upright.
b. Call the provider and ask for stronger analgesics.
c. Document the findings in the patient’s chart.
d. Notify the health-care provider immediately.
ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 381-382
Heading: Neurological System
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
, Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Headache is not uncommon after childbirth. Patients who received epidural or
spinal anesthesia may complain of headaches, especially on assuming an
upright position. Because this patient had an epidural, the nurse should first
assess for this situation.
B. The nurse should complete a comprehensive pain assessment before requesting
stronger pain medication.
C. Documentation should be thorough, but the nurse needs to take further action
first.
D. The health-care provider does not need to be notified right away unless the
patient has other symptoms, such as blurred vision.
4. A new mother of multicultural ethnicity is accompanied by her mother during her hospital
stay on the postpartum unit. The patient’s mother has made specific various requests of
the nurses, including asking for a bottle so she can feed the baby after the new mother
attempts to breastfeed for the first time. How would the perinatal nurse best respond to
the patient’s mother in a culturally sensitive way?
a. Ask both the patient and her mother about the preferred infant feeding method and
assess what they already know.
b. Ask the patient’s mother to leave for 30 minutes to allow for some alone time with
the patient to explore her learning needs.
c. Ask the patient what she knows about breastfeeding and provide information to
both women to support the patient’s decision.
d. Convey to the patient and her mother an understanding of the concepts of “hot”
and “cold” within their belief system.
ANS: C
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 383
Heading: Developing Cultural Sensitivity
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. The nurse should advocate for the patient by inquiring about her feeding
preferences and by providing information to the mother and her family to
, support her in her decision.
B. The nurse should consult with the patient first, as the patient may wish for the
mother to stay.
C. Multicultural populations have a varied approach to childbirth/childrearing
practices and beliefs. The postpartum period is an important time for ensuring
future good health, and great emphasis is placed on allowing the mother’s body
to regain balance after the birth of a child. To provide sensitive, appropriate
care, nurses need to adopt a flexible approach when caring for women who
embrace multi-cultural health beliefs and practices. The nurse should advocate
for the patient by inquiring about her feeding preferences and by providing
information to the mother and her family to support her in her decision.
D. The nurse should not attempt to explain concepts about the family's culture but
rather be open to listening.
5. A nurse assesses a woman’s temperature 6 hours after a vaginal birth and finds it to be
100.4°F (38°C). What action by the nurse is best?
a. Encourage the woman to drink plenty of fluids.
b. Document the findings and notify the provider.
c. Have the woman cough and deep breathe.
d. Prepare to administer acetaminophen (Tylenol).
ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 373
Heading: Temperature
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Dehydration and exertion often cause a transient increase in body temperature
up to 100.4°F (38°C) during the first 24 hours after birth. Increased fluids
usually help restore normothermia. The nurse should first encourage the
woman to drink increased fluids.
B. The findings should be documented, but the provider does not need to be
notified.
C. Coughing and deep breathing are good strategies to relieve atelectasis, but this
is not the most common cause of elevated temperature after childbirth.
D. The patient may or may not want acetaminophen, but drinking more fluids is
the priority over giving an antipyretic medication.
woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding
sound. How should the nurse document this information?
a. A bladder containing about 500 cc of urine
b. A full bladder
c. An empty bladder
d. A hard bladder
ANS: C
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 376-377
Heading: Bladder
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. A bladder containing about 500 cc of urine is full. A full bladder produces a
resonant sound.
B. A full bladder produces a resonant sound upon percussion.
C. To percuss the bladder, the nurse places one finger flat on the patient’s
abdomen over the bladder and taps it with the finger of the other hand. An
empty bladder has a dull, thudding sound.
D. The hardness of the bladder does not relate to the sound on percussion.
2. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping
when she breastfeeds her infant. The perinatal nurse should document this condition as
which of the following?
a. Afterpains
b. Bladder hypotonia
c. Diastasis recti abdominis
d. Uterine hemorrhage
, ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman. Page: 373
Heading: Pain
Integrated Processes: Communication and Documentation
Client Need: Safe and Effective Care Environment: Management of Care
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Afterpains (afterbirth pains) are intermittent uterine contractions that occur
during the process of involution. Afterpains are more pronounced in patients
with decreased uterine tone due to overdistension, which is associated with
multiparity and macrosomia. Breastfeeding and the administration of
exogenous oxytocin usually produce pronounced afterpains because both cause
powerful uterine contractions. Patients often describe the sensation as a
discomfort like menstrual cramps.
B. Bladder hypotonia would cause issues with urinary retention. Cramping when
breastfeeding is not a sign of bladder hypotonia.
C. Diastasis recti abdominis is the separation between abdominal muscles that can
occur during pregnancy. It is signaled by soft and weak abdomen muscles after
birth, not severe cramping.
D. Uterine hemorrhage would be signaled by decreased blood pressure, swelling
and bruising of the vagina and labia, and uncontrolled bleeding.
3. A postpartum woman is complaining of a headache that is worsening despite having
taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural
anesthesia. What action by the nurse is best?
a. Assess if the pain is worse when she sits upright.
b. Call the provider and ask for stronger analgesics.
c. Document the findings in the patient’s chart.
d. Notify the health-care provider immediately.
ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 381-382
Heading: Neurological System
Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
Cognitive Level: Application [Applying]
, Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Headache is not uncommon after childbirth. Patients who received epidural or
spinal anesthesia may complain of headaches, especially on assuming an
upright position. Because this patient had an epidural, the nurse should first
assess for this situation.
B. The nurse should complete a comprehensive pain assessment before requesting
stronger pain medication.
C. Documentation should be thorough, but the nurse needs to take further action
first.
D. The health-care provider does not need to be notified right away unless the
patient has other symptoms, such as blurred vision.
4. A new mother of multicultural ethnicity is accompanied by her mother during her hospital
stay on the postpartum unit. The patient’s mother has made specific various requests of
the nurses, including asking for a bottle so she can feed the baby after the new mother
attempts to breastfeed for the first time. How would the perinatal nurse best respond to
the patient’s mother in a culturally sensitive way?
a. Ask both the patient and her mother about the preferred infant feeding method and
assess what they already know.
b. Ask the patient’s mother to leave for 30 minutes to allow for some alone time with
the patient to explore her learning needs.
c. Ask the patient what she knows about breastfeeding and provide information to
both women to support the patient’s decision.
d. Convey to the patient and her mother an understanding of the concepts of “hot”
and “cold” within their belief system.
ANS: C
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 383
Heading: Developing Cultural Sensitivity
Integrated Processes: Nursing Process: Assessment
Client Need: Psychosocial Integrity
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. The nurse should advocate for the patient by inquiring about her feeding
preferences and by providing information to the mother and her family to
, support her in her decision.
B. The nurse should consult with the patient first, as the patient may wish for the
mother to stay.
C. Multicultural populations have a varied approach to childbirth/childrearing
practices and beliefs. The postpartum period is an important time for ensuring
future good health, and great emphasis is placed on allowing the mother’s body
to regain balance after the birth of a child. To provide sensitive, appropriate
care, nurses need to adopt a flexible approach when caring for women who
embrace multi-cultural health beliefs and practices. The nurse should advocate
for the patient by inquiring about her feeding preferences and by providing
information to the mother and her family to support her in her decision.
D. The nurse should not attempt to explain concepts about the family's culture but
rather be open to listening.
5. A nurse assesses a woman’s temperature 6 hours after a vaginal birth and finds it to be
100.4°F (38°C). What action by the nurse is best?
a. Encourage the woman to drink plenty of fluids.
b. Document the findings and notify the provider.
c. Have the woman cough and deep breathe.
d. Prepare to administer acetaminophen (Tylenol).
ANS: A
Chapter: Chapter 11 – Caring for the Postpartal Woman and Her Family
Objective: #1. Assess the physiological and psychosocial status of the postpartal
woman.
Page: 373
Heading: Temperature
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Adaptation
Cognitive Level: Application [Applying]
Concept: Pregnancy
Difficulty: Moderate
Feedback
A. Dehydration and exertion often cause a transient increase in body temperature
up to 100.4°F (38°C) during the first 24 hours after birth. Increased fluids
usually help restore normothermia. The nurse should first encourage the
woman to drink increased fluids.
B. The findings should be documented, but the provider does not need to be
notified.
C. Coughing and deep breathing are good strategies to relieve atelectasis, but this
is not the most common cause of elevated temperature after childbirth.
D. The patient may or may not want acetaminophen, but drinking more fluids is
the priority over giving an antipyretic medication.
