Ricci, Kyle & Carman: Maternity and Pediatric
Nursing, Second Edition: Chapter 15: Postpartum
Adaptations; PrepU Q/A
A woman who is breastfeeding her newborn reports that her breasts
seem quite full. Assessment reveals that her breasts are engorged. Which
factor would the nurse identify as the most likely cause for this
development? Correct Answer-inability of infant to empty breasts
For the breastfeeding mother, engorgement is often the result of vascular
congestion and milk stasis, primarily caused by the infant not fully
emptying the mother's breasts at each feeding. Cracking of the nipple
could lead to infection. Improper positioning may lead to nipple
tenderness or pain. Inadequate secretion of prolactin causes a decrease in
the production of milk.
The nurse is caring for a client in the postpartum period. The client has
difficulty in voiding and is catheterized. The nurse then would monitor
the client for which condition? Correct Answer-urinary tract infection
The nurse would need to monitor the client for signs and symptoms of a
urinary tract infection, a risk associated with catheterization. Stress
incontinence is caused due to loss of pelvic muscle tone after birth.
Increased urinary output is observed in diuresis. Catheterization does not
cause loss of pelvic muscle tone, increased urine output, or stress
incontinence.
A nurse is caring for a nonbreastfeeding client in the postpartum period.
The client reports engorgement. What suggestion should the nurse
,provide to alleviate breast discomfort? Correct Answer-Wear a well-
fitting bra.
The nurse should suggest the client wear a well-fitting bra to provide
support and help alleviate breast discomfort. Application of warm
compresses and expressing milk frequently is suggested to alleviate
breast engorgement in breastfeeding clients. Hydrogel dressings are used
prophylactically in treating nipple pain.
A client in her sixth week postpartum reports general weakness. The
client has stopped taking iron supplements that were prescribed to her
during pregnancy. The nurse would assess the client for which
condition? Correct Answer-hypovolemia
The nurse should assess the client for hypovolemia as the client must
have had hemorrhage during birth and puerperium. Additionally, the
client also has discontinued iron supplements. Hyperglycemia can be
considered if the client has a history of diabetes. Hypertension and
hyperthyroidism are not related to discontinuation of iron supplements.
A concerned client tells the nurse that her husband, who was very
excited about the baby before its birth, is apparently happy but seems to
be afraid of caring for the baby. What suggestion should the nurse give
to the client's husband to resolve the issue? Correct Answer-Hold the
baby frequently.
The nurse should suggest that the father care for the newborn by holding
and talking to the child. Reading up on parental care and speaking to his
,friends or the primary care provider will not help the father resolve his
fears about caring for the child.
During a postpartum exam on the day of birth, the woman reports that
she is still so sore that she cannot sit comfortably. The nurse examines
her perineum and find the edges of the episiotomy approximated without
signs of a hematoma. Which intervention will be most beneficial at this
point? Correct Answer-Place an ice pack.
The labia and perineum may be edematous after birth and bruised; the
use of ice would assist in decreasing the pain and swelling. Applying a
warm washcloth would bring more blood as well as fluid to the sore
area, thereby increasing the edema and the soreness. Applying a witch
hazel pad needs the order of the primary care provider. Notifying a care
provider is not necessary at this time as this is considered a normal
finding.
A woman who gave birth to a healthy newborn 2 months ago comes to
the clinic and reports discomfort during sexual intercourse. Which
suggestion by the nurse would be most appropriate? Correct
Answer-"You might try using a water-soluble lubricant to ease the
discomfort."
Coital discomfort and localized dryness usually plague most postpartum
women until menstruation returns. Water-soluble lubricants can reduce
discomfort during intercourse. Although it may take some time for the
woman's body to return to its prepregnant state, telling the woman this
does not address her concern. Telling her that dyspareunia is normal and
that it takes time to resolve also ignores her concern. Kegel exercises are
, helpful for improving pelvic floor tone but would have no effect on
vaginal dryness.
For the first hour after birth, the height of the fundus is at the umbilicus
or even slightly above it. Correct Answer-True
A client who gave birth about 12 hours ago informs the nurse that she
has been voiding small amounts of urine frequently. The nurse examines
the client and notes the displacement of the uterus from the midline to
the right. What intervention would the nurse perform next? Correct
Answer-Perform urinary catheterization.
Displacement of the uterus from the midline to the right and frequent
voiding of small amounts suggests urinary retention with overflow.
Catheterization may be necessary to empty the bladder to restore tone.
An IV and oxytocin are indicated if the client experiences hemorrhage
due to uterine atony from being displaced. The healthcare provider
would be notified if no other interventions help the client.
While caring for a client following a lengthy labor and birth, the nurse
notes that the client repeatedly reviews her labor and birth and is very
dependent on her family for care. The nurse is correct in identifying the
client to be in which phase of maternal role adjustment? Correct
Answer-taking-in
The taking-in phase occurs during the first 24 to 48 hours following the
birth of the newborn and is characterized by the mother taking on a very
passive role in caring for herself, as well as recounting her labor
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