Chapter 33 The Postpartum Family: Needs and Care
1) The nurse assesses the postpartum client to have moderate lochia rubra
with clots. Which nursing intervention would be appropriate?
1. Assess fundus and bladder status.
2. Catheterize the client.
3. Administer Methergine IM per order.
4. Contact the physician immediately.
Answer: 1
Explanation: 1. The amount, consistency, color, and odor of the lochia are
monitored on an ongoing basis. Increased bleeding is most often related to
uterine atony and responds to fundal massage, expression of any clots, and
emptying the bladder. Page Ref: 891
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 7. 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: 2 Discuss appropriate nursing interventions to promote
maternal comfort and well-being.
MNL LO: 5.1.1 Examine the components of a postpartum assessment.
2) The nurse is providing education to the new family. Which question by the
nurse is best?
1. Do you know how to give the baby a bath?
2. You have diapers and supplies at home, right?
3. How have your breastfeedings been going?
4. How much formal education do you have?
Answer: 3
Explanation: 3. This is an open-ended question about an important
physiologic issue. A discussion that includes both partners can facilitate an open
dialog between them and can provide an opportunity for questions and answers.
,Page Ref: 887
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
,appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care; Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation
1
Copyright 2016 Pearson Education, Inc.
Learning Outcome: 4 Identify patient teaching topics for promoting postpartum
family wellness.
MNL LO: 5.4.1 Develop a discharge teaching plan for the postpartum
patient.
3) The postpartum nurse provides anticipatory guidance for the new mother
as well as teaching on self-care and infant care before discharge. Which
topics should be included?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Role changes brought on by the addition to the family unit
2. The realities of having a new baby, and how it affects previous lifestyle
3. Potential complications such as infant colic and postpartum issues
4. Sexuality and contraception
5. Toilet-training and preschool options
Answer: 1, 2, 3, 4
Explanation: 1. It is helpful for the nurse to advise parents that they may
experience feelings of uncertainty as they grow into the parental role and alter
their family processes to accommodate the new family member.
2. Guidance is essential in assisting the family to cope with role changes and
the realities of a new baby.
3. Guidance is essential in assisting the family to cope with potential
complications such as infant colic and postpartum health issues.
4. It is important for the nurse to present information about changes that may
, affect sexual activity and to discuss the importance of contraception during
the early postpartum period.
Page Ref: 887, 888
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care: Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate nursing responsibilities for patient teaching
during the early postpartum period.
MNL LO: 5.4.1 Develop a discharge teaching plan for the postpartum
patient.
2
Copyright 2016 Pearson Education, Inc.
4) A client is preparing to take a sitz bath for the first time. What will the
nurse do?
1. Allow the client privacy during the sitz bath.
2. Place a call bell well within reach and check on the client frequently.
3. Discourage the client from taking a sitz bath.
4. Check on the client after the sitz bath.
Answer: 2
Explanation: 2. The nurse should explain the purpose and use of the sitz bath,
anticipated effects, benefits, possible problems, and safety measures to
prevent slipping or an injury from hot water. A call bell would be a safety
measure.
1) The nurse assesses the postpartum client to have moderate lochia rubra
with clots. Which nursing intervention would be appropriate?
1. Assess fundus and bladder status.
2. Catheterize the client.
3. Administer Methergine IM per order.
4. Contact the physician immediately.
Answer: 1
Explanation: 1. The amount, consistency, color, and odor of the lochia are
monitored on an ongoing basis. Increased bleeding is most often related to
uterine atony and responds to fundal massage, expression of any clots, and
emptying the bladder. Page Ref: 891
Cognitive Level: Applying
Client Need/Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of
technology and standardized practices that support safety and quality. |
AACN Essentials Competencies: IX. 7. 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: 2 Discuss appropriate nursing interventions to promote
maternal comfort and well-being.
MNL LO: 5.1.1 Examine the components of a postpartum assessment.
2) The nurse is providing education to the new family. Which question by the
nurse is best?
1. Do you know how to give the baby a bath?
2. You have diapers and supplies at home, right?
3. How have your breastfeedings been going?
4. How much formal education do you have?
Answer: 3
Explanation: 3. This is an open-ended question about an important
physiologic issue. A discussion that includes both partners can facilitate an open
dialog between them and can provide an opportunity for questions and answers.
,Page Ref: 887
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
,appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care; Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation
1
Copyright 2016 Pearson Education, Inc.
Learning Outcome: 4 Identify patient teaching topics for promoting postpartum
family wellness.
MNL LO: 5.4.1 Develop a discharge teaching plan for the postpartum
patient.
3) The postpartum nurse provides anticipatory guidance for the new mother
as well as teaching on self-care and infant care before discharge. Which
topics should be included?
Note: Credit will be given only if all correct choices and no incorrect choices
are selected.
Select all that apply.
1. Role changes brought on by the addition to the family unit
2. The realities of having a new baby, and how it affects previous lifestyle
3. Potential complications such as infant colic and postpartum issues
4. Sexuality and contraception
5. Toilet-training and preschool options
Answer: 1, 2, 3, 4
Explanation: 1. It is helpful for the nurse to advise parents that they may
experience feelings of uncertainty as they grow into the parental role and alter
their family processes to accommodate the new family member.
2. Guidance is essential in assisting the family to cope with role changes and
the realities of a new baby.
3. Guidance is essential in assisting the family to cope with potential
complications such as infant colic and postpartum health issues.
4. It is important for the nurse to present information about changes that may
, affect sexual activity and to discuss the importance of contraception during
the early postpartum period.
Page Ref: 887, 888
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum
and Newborn Care
Standards: QSEN Competencies: I. B. 10. Engage patients or designated
surrogates in active partnerships that promote health, safety and well-being, and
self-care management. | AACN Essentials Competencies: IX. 7. Provide
appropriate patient teaching that reflects developmental stage, age, culture,
spirituality, patient preferences, and health literacy considerations to foster
patient engagement in their care. | NLN Competencies: Relationship-
Centered Care: Communicate information effectively; listen openly and
cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1 Delineate nursing responsibilities for patient teaching
during the early postpartum period.
MNL LO: 5.4.1 Develop a discharge teaching plan for the postpartum
patient.
2
Copyright 2016 Pearson Education, Inc.
4) A client is preparing to take a sitz bath for the first time. What will the
nurse do?
1. Allow the client privacy during the sitz bath.
2. Place a call bell well within reach and check on the client frequently.
3. Discourage the client from taking a sitz bath.
4. Check on the client after the sitz bath.
Answer: 2
Explanation: 2. The nurse should explain the purpose and use of the sitz bath,
anticipated effects, benefits, possible problems, and safety measures to
prevent slipping or an injury from hot water. A call bell would be a safety
measure.
