Chapter 32 Postpartum Family Adaptation and Nursing Assessment
1) The nurse determines the fundus of a postpartum client to be boggy.
Initially, what should the nurse do?
1. Document the findings.
2. Catheterize the client.
3. Massage the uterine fundus until it is firm.
4. Call the physician immediately.
Answer: 3
Explanation: 3. The nurse would massage the uterine fundus until it is firm
by keeping one hand in position and stabilizing the lower portion of the
uterus. With one hand used to massage the fundus, the nurse would put
steady pressure on the top of the now-firm fundus and to see if she was able
to express any clots.
Page Ref: 874
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of
strategies to reduce risk of harm to self or others. | AACN Essentials
Competencies: IX. 8. Implement evidence-based nursing interventions as
appropriate for managing the acute and chronic care of patients and
promoting health across the lifespan. | NLN Competencies: Quality and Safety:
Communicate potential risk factors and actual errors. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
1
Copyright 2016 Pearson Education, Inc.
2) The nurse is caring for a postpartum client who is experiencing afterpains
following the birth of her third child. Which comfort measure should the
nurse implement to decrease her pain?
,Note: Credit will be given only if all correct choices and no incorrect choices
are selected. Select all that apply.
1. Offer a warm water bottle for her abdomen.
2. Call the physician to report this finding.
3. Inform her that this is not normal, and she will need an oxytocic agent.
4. Administer a mild analgesic to help with breastfeeding.
5. Administer a mild analgesic at bedtime to ensure rest.
Answer: 1, 4, 5
Explanation: 1. A warm water bottle placed against the low abdomen may
reduce the discomfort of afterpains.
4. The breastfeeding mother may find it helpful to take a mild analgesic agent
approximately 1 hour before feeding her infant.
5. An analgesic agent such as ibuprofen is also helpful at bedtime if the
afterpains interfere with the mothers rest.
Page Ref: 867
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
2
Copyright 2016 Pearson Education, Inc.
3) The nurse would expect a physician to prescribe which medication to a
,postpartum client with heavy bleeding and a boggy uterus?
1. Methylergonovine maleate (Methergine)
2. Rh immune globulin (RhoGAM)
3. Terbutaline (Brethine)
4. Docusate (Colace)
Answer: 1
Explanation: 1. Methylergonovine maleate is the drug used for the prevention
and control of postpartum hemorrhage.
Page Ref: 875
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral
Therapies
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8.
Implement evidence-based nursing interventions as appropriate for managing
the acute and chronic care of patients and promoting health across the
lifespan. | NLN Competencies: Knowledge and Science: Value evidence- based
approaches to yield best practices for nursing. | Nursing/Integrated Concepts:
Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.3.2 Compare the various etiologies and management of
postpartum hemorrhage.
4) A postpartum client has inflamed hemorrhoids. Which nursing
intervention would be appropriate?
1. Encourage sitz baths.
2. Position the client in the supine position.
3. Avoid stool softeners.
4. Decrease fluid intake.
Answer: 1
Explanation: 1. Encouraging sitz baths is the correct approach because moist
, heat decreases inflammation and provides for comfort.
Page Ref: 882
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
3
Copyright 2016 Pearson Education, Inc.
5) The nurse assesses the postpartum client who has not had a bowel movement
by the third postpartum day. Which nursing intervention would be appropriate?
1. Encourage the new mother, saying, It will happen soon.
2. Instruct the client to eat a low-fiber diet.
3. Decrease fluid intake.
4. Obtain an order for a stool softener.
Answer: 4
Explanation: 4. Obtaining an order for a stool softener is the correct intervention
by the third day. In resisting or delaying the bowel movement, the woman
may cause increased constipation and more pain when elimination
finally occurs.
Page Ref: 879
Cognitive Level: Applying
1) The nurse determines the fundus of a postpartum client to be boggy.
Initially, what should the nurse do?
1. Document the findings.
2. Catheterize the client.
3. Massage the uterine fundus until it is firm.
4. Call the physician immediately.
Answer: 3
Explanation: 3. The nurse would massage the uterine fundus until it is firm
by keeping one hand in position and stabilizing the lower portion of the
uterus. With one hand used to massage the fundus, the nurse would put
steady pressure on the top of the now-firm fundus and to see if she was able
to express any clots.
Page Ref: 874
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of
strategies to reduce risk of harm to self or others. | AACN Essentials
Competencies: IX. 8. Implement evidence-based nursing interventions as
appropriate for managing the acute and chronic care of patients and
promoting health across the lifespan. | NLN Competencies: Quality and Safety:
Communicate potential risk factors and actual errors. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
1
Copyright 2016 Pearson Education, Inc.
2) The nurse is caring for a postpartum client who is experiencing afterpains
following the birth of her third child. Which comfort measure should the
nurse implement to decrease her pain?
,Note: Credit will be given only if all correct choices and no incorrect choices
are selected. Select all that apply.
1. Offer a warm water bottle for her abdomen.
2. Call the physician to report this finding.
3. Inform her that this is not normal, and she will need an oxytocic agent.
4. Administer a mild analgesic to help with breastfeeding.
5. Administer a mild analgesic at bedtime to ensure rest.
Answer: 1, 4, 5
Explanation: 1. A warm water bottle placed against the low abdomen may
reduce the discomfort of afterpains.
4. The breastfeeding mother may find it helpful to take a mild analgesic agent
approximately 1 hour before feeding her infant.
5. An analgesic agent such as ibuprofen is also helpful at bedtime if the
afterpains interfere with the mothers rest.
Page Ref: 867
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
2
Copyright 2016 Pearson Education, Inc.
3) The nurse would expect a physician to prescribe which medication to a
,postpartum client with heavy bleeding and a boggy uterus?
1. Methylergonovine maleate (Methergine)
2. Rh immune globulin (RhoGAM)
3. Terbutaline (Brethine)
4. Docusate (Colace)
Answer: 1
Explanation: 1. Methylergonovine maleate is the drug used for the prevention
and control of postpartum hemorrhage.
Page Ref: 875
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral
Therapies
Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple
dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8.
Implement evidence-based nursing interventions as appropriate for managing
the acute and chronic care of patients and promoting health across the
lifespan. | NLN Competencies: Knowledge and Science: Value evidence- based
approaches to yield best practices for nursing. | Nursing/Integrated Concepts:
Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.3.2 Compare the various etiologies and management of
postpartum hemorrhage.
4) A postpartum client has inflamed hemorrhoids. Which nursing
intervention would be appropriate?
1. Encourage sitz baths.
2. Position the client in the supine position.
3. Avoid stool softeners.
4. Decrease fluid intake.
Answer: 1
Explanation: 1. Encouraging sitz baths is the correct approach because moist
, heat decreases inflammation and provides for comfort.
Page Ref: 882
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to
relieve pain and suffering in light of patient values, preferences, and
expressed needs. | AACN Essentials Competencies: IX. 5. Deliver
compassionate, patient-centered, evidence-based care that respects patient
and family preferences. | NLN Competencies: Relationship-Centered Care:
Promote and accept the patients emotions; accept and respond to distress in
patient and self; facilitate hope, trust, and faith. | Nursing/Integrated
Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate the basic physiologic changes that occur in
the postpartum period as a womans body returns to its pre-pregnant state.
MNL LO: 5.2.1 Determine nursing interventions that promote maternal
comfort during the postpartum period.
3
Copyright 2016 Pearson Education, Inc.
5) The nurse assesses the postpartum client who has not had a bowel movement
by the third postpartum day. Which nursing intervention would be appropriate?
1. Encourage the new mother, saying, It will happen soon.
2. Instruct the client to eat a low-fiber diet.
3. Decrease fluid intake.
4. Obtain an order for a stool softener.
Answer: 4
Explanation: 4. Obtaining an order for a stool softener is the correct intervention
by the third day. In resisting or delaying the bowel movement, the woman
may cause increased constipation and more pain when elimination
finally occurs.
Page Ref: 879
Cognitive Level: Applying
