Chapter 21: Nursing Care of the Family During the Postpartum Period
MULTIPLE CHOICE
1. 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 three times daily,
and a stool softener. Which information regarding the client’s condition is most closely
correlated with these orders?
a. Woman is a gravida 2, para 2.
b. Woman had a vacuum-assisted birth.
c. Woman received epidural anesthesia.
d. Woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations,
and hemorrhoids. A multiparous classification is not an indication for these orders. A
vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate
these interventions. The use of an epidural anesthesia has no correlation with these orders.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status,
positive; rubella titer, 1:8 (eNnU
zyRmSeIim
NmGuTnBoa.ssCaO
yM[EIA] 0.8); hematocrit, 30%. How should
the nurse best interpret these data?
a. Rubella vaccine should be administered.
b. Blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of childbirth.
d. Kleihauer-Betke test should be performed.
ANS: A
This client’s rubella titer indicates that she is not immune and needs to receive a vaccine.
These data do not indicate that the client needs a blood transfusion. Rh immune globulin is
indicated only if the client has an Rh-negative status and the infant has an Rh-positive
status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is
suspected, especially if the mother is Rh negative. However, the data provided do not
indicate a need for performing this test.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
3. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on
palpation. Which guidance should the nurse provide to the client at this time?
a. Run warm water on her breasts during a shower.
b. Apply ice to the breasts for comfort.
, c. Express small amounts of milk from the breasts to relieve the pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate
intervention for treating engorgement in a mother who is bottle feeding. The ice packs
should be applied for 15 minutes on and 45 minutes off to avoid rebound engorgement. A
bottle-feeding mother should avoid any breast stimulation, including pumping or expressing
milk. A bottle-feeding mother should continuously wear a well-fitted support bra or breast
binder for at least the first 72 hours after giving birth. A loose-fitting bra will not aid
lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate
the nipples and thereby stimulate lactation.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
4. 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. What is
the nurse’s most appropriate response?
a. “Didn’t you like your lunch?”
b. “Does your health care provider 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 NURSINGTB.COM
Offering to warm the food shows cultural sensitivity to the dietary preferences of the woman
and is the most appropriate response. Cultural dietary preferences must be respected.
Women may request that family members bring favorite or culturally appropriate foods to
the hospital. Asking the woman to identify her food does not show cultural sensitivity. Both
remaining options demonstrate insensitivity.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
5. A primiparous woman is to be discharged from the hospital the following day with her
infant girl. Which behavior indicates a need for further intervention by the nurse before the
woman can be discharged?
a. The woman is weepy and asks to postpone learning about infant care.
b. The woman continues to hold and cuddle her infant after she has fed her.
c. The woman asks for several magazines to read while her infant sleeps.
d. The woman changes her infant’s diaper and then shows the nurse the contents of
the diaper.
ANS: A
, The client should be excited, happy, and interested or involved in infant care. A woman who
is sad, tearful, or disinterested in caring for her infant may be exhibiting signs of depression
or postpartum blues and may require further intervention. Holding and cuddling her infant
after feeding is an appropriate parent-infant interaction. Taking time for herself while the
infant is sleeping is an appropriate maternal action. Showing the nurse the contents of the
diaper is appropriate because the mother is seeking approval from the nurse and notifying
the nurse of the infant’s elimination patterns.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
6. The trend in the United States is for women to remain hospitalized no longer than 1 or 2
days after giving birth. Which scenario is not a contributor to this model of care?
a. Wellness orientation model of care rather than a sick-care model
b. Desire to reduce health care costs
c. Consumer demand for fewer medical interventions and more family-focused
experiences
d. Less need for nursing time as a result of more medical and technologic advances
and devices available at home that can provide information
ANS: D
Nursing time and care are in demand as much as ever; the nurse simply has to do things
more quickly. A wellness orientation model of care seems to focus on getting clients out the
door sooner. In most cases, less hospitalization results in lower costs. People believe that the
family gives more nurturing care than the institution.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
7. A hospital has several different perineal pads available for use. A nurse is observed soaking
several of them and writing down what is observed. What goal is the nurse attempting to
achieve by performing this practice?
a. To improve the accuracy of blood loss estimation, which usually is a subjective
assessment
b. To determine which pad is best
c. To demonstrate that other nurses usually underestimate blood loss
d. To reveal which brand of pad is more absorbent
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss; anything done to
help in the assessment is valuable. The nurse is noting the saturation volumes and soaking
appearances. Instead of determining which pad is best, the nurse is more likely noting
saturation volumes and soaking appearances to improve the accuracy of estimated blood
loss. Nurses usually overestimate blood loss.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
MULTIPLE CHOICE
1. 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 three times daily,
and a stool softener. Which information regarding the client’s condition is most closely
correlated with these orders?
a. Woman is a gravida 2, para 2.
b. Woman had a vacuum-assisted birth.
c. Woman received epidural anesthesia.
d. Woman has an episiotomy.
ANS: D
These orders are typical interventions for a woman who has had an episiotomy, lacerations,
and hemorrhoids. A multiparous classification is not an indication for these orders. A
vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate
these interventions. The use of an epidural anesthesia has no correlation with these orders.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status,
positive; rubella titer, 1:8 (eNnU
zyRmSeIim
NmGuTnBoa.ssCaO
yM[EIA] 0.8); hematocrit, 30%. How should
the nurse best interpret these data?
a. Rubella vaccine should be administered.
b. Blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of childbirth.
d. Kleihauer-Betke test should be performed.
ANS: A
This client’s rubella titer indicates that she is not immune and needs to receive a vaccine.
These data do not indicate that the client needs a blood transfusion. Rh immune globulin is
indicated only if the client has an Rh-negative status and the infant has an Rh-positive
status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is
suspected, especially if the mother is Rh negative. However, the data provided do not
indicate a need for performing this test.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
3. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed.
During the assessment, the nurse notices that both breasts are swollen, warm, and tender on
palpation. Which guidance should the nurse provide to the client at this time?
a. Run warm water on her breasts during a shower.
b. Apply ice to the breasts for comfort.
, c. Express small amounts of milk from the breasts to relieve the pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.
ANS: B
Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate
intervention for treating engorgement in a mother who is bottle feeding. The ice packs
should be applied for 15 minutes on and 45 minutes off to avoid rebound engorgement. A
bottle-feeding mother should avoid any breast stimulation, including pumping or expressing
milk. A bottle-feeding mother should continuously wear a well-fitted support bra or breast
binder for at least the first 72 hours after giving birth. A loose-fitting bra will not aid
lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate
the nipples and thereby stimulate lactation.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
4. 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. What is
the nurse’s most appropriate response?
a. “Didn’t you like your lunch?”
b. “Does your health care provider 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 NURSINGTB.COM
Offering to warm the food shows cultural sensitivity to the dietary preferences of the woman
and is the most appropriate response. Cultural dietary preferences must be respected.
Women may request that family members bring favorite or culturally appropriate foods to
the hospital. Asking the woman to identify her food does not show cultural sensitivity. Both
remaining options demonstrate insensitivity.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
5. A primiparous woman is to be discharged from the hospital the following day with her
infant girl. Which behavior indicates a need for further intervention by the nurse before the
woman can be discharged?
a. The woman is weepy and asks to postpone learning about infant care.
b. The woman continues to hold and cuddle her infant after she has fed her.
c. The woman asks for several magazines to read while her infant sleeps.
d. The woman changes her infant’s diaper and then shows the nurse the contents of
the diaper.
ANS: A
, The client should be excited, happy, and interested or involved in infant care. A woman who
is sad, tearful, or disinterested in caring for her infant may be exhibiting signs of depression
or postpartum blues and may require further intervention. Holding and cuddling her infant
after feeding is an appropriate parent-infant interaction. Taking time for herself while the
infant is sleeping is an appropriate maternal action. Showing the nurse the contents of the
diaper is appropriate because the mother is seeking approval from the nurse and notifying
the nurse of the infant’s elimination patterns.
PTS: 1 DIF: Cognitive Level: Analyzing
TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
6. The trend in the United States is for women to remain hospitalized no longer than 1 or 2
days after giving birth. Which scenario is not a contributor to this model of care?
a. Wellness orientation model of care rather than a sick-care model
b. Desire to reduce health care costs
c. Consumer demand for fewer medical interventions and more family-focused
experiences
d. Less need for nursing time as a result of more medical and technologic advances
and devices available at home that can provide information
ANS: D
Nursing time and care are in demand as much as ever; the nurse simply has to do things
more quickly. A wellness orientation model of care seems to focus on getting clients out the
door sooner. In most cases, less hospitalization results in lower costs. People believe that the
family gives more nurturing care than the institution.
NURSINGTB.COM
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
7. A hospital has several different perineal pads available for use. A nurse is observed soaking
several of them and writing down what is observed. What goal is the nurse attempting to
achieve by performing this practice?
a. To improve the accuracy of blood loss estimation, which usually is a subjective
assessment
b. To determine which pad is best
c. To demonstrate that other nurses usually underestimate blood loss
d. To reveal which brand of pad is more absorbent
ANS: A
Saturation of perineal pads is a critical indicator of excessive blood loss; anything done to
help in the assessment is valuable. The nurse is noting the saturation volumes and soaking
appearances. Instead of determining which pad is best, the nurse is more likely noting
saturation volumes and soaking appearances to improve the accuracy of estimated blood
loss. Nurses usually overestimate blood loss.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
