Exam (elaborations)
20 Postpartum Adaptations
- Course
- Nursing
- Institution
- University At Buffalo
Chapter 20 Postpartum Adaptations
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Chapter 20: Postpartum AdaptationsTest Bank
MULTIPLE CHOICE
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.
PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 443
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
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.
PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 434
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
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.
PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 434
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
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.
PTS: 1 DIF: Cognitive Level: Application REF: p. 434
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
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/mm3 during 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.
PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 436
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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.
PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 437
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
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.
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