Chapter 15: Caring for the Postpartal Woman and Her Family Nursing School Test Banks

Chapter 15: Caring for the Postpartal Woman and Her Family

MULTIPLE CHOICE

1. The perinatal nurse demonstrates the correct technique of postpartum uterine palpation for a student nurse. The nurse explains that support for the lower uterine segment is critical, because without it there is an increased risk of which complication?
A. Incorrect measurement
B. Intensifying the patients pain
C. Uterine edema
D. Uterine inversion
ANS: D
The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

2. The perinatal nurse and student nurse are conducting an assessment on a postpartal woman. The nurse demonstrates percussion of the bladder. They hear a dull, thudding sound. How should the nurse document this information?
A. A bladder containing about 500 cc of urine
B. A full bladder
C. An empty bladder
D. An overdistended bladder
ANS: C
To percuss the bladder, the nurse places one finger flat on the patients abdomen over the bladder and taps it with the finger of the other hand. A full bladder produces a resonant sound. An empty bladder has a dull, thudding sound.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

3. The perinatal nurse describes the need for an assessment for deep vein thrombosis (DVT) in the postpartum patient. Which of the following is one test that can be used as a screening measure for DVT?
A. Chadwicks sign
B. Homans sign
C. Grey Turners sign
D. McBurneys sign
ANS: B
Homans sign is often used in the assessment for deep venous thrombosis (DVT) in the leg. To assess for Homans sign, the patients legs should be extended and relaxed, with the knees flexed. The examiner grasps the foot and sharply dorsiflexes it. No pain or discomfort should be present. The other leg is assessed in the same manner. If calf pain is elicited, a positive Homans sign is present. The pain occurs from inflammation of the blood vessel and is believed to be associated with the presence of a thrombosis. Pain on dorsiflexion is indicative of DVT in approximately 50% of patients. A negative Homans sign does not rule out DVT. Chadwicks sign is a bluish discoloration of the cervix that may indicate pregnancy. Grey Turners sign is a bruising or bluish discoloration of the flank, often seen in acute pancreatitis. McBurneys sign, an indicator of appendicitis, is a deep tenderness to palpation at McBurneys point.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

4. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping when she breastfeeds her infant. The perinatal nurse should document this condition as which of the following?
A. Afterpains
B. Bladder hypertonia
C. Rectus abdominis diastasis
D. Uterine hypertonia
ANS: A
Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced afterpains because both cause powerful uterine contractions. Patients often describe the sensation as a discomfort similar to menstrual cramps.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

5. A postpartum woman is Rho(D)-negative and needs an injection of Rho(D) immune globulin. Which of the following doses would the perinatal nurse expect to be ordered?
A. 120 g
B. 250 g
C. 300 g
D. 350 g
ANS: C
Nonsensitized women who are Rho(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 g of Rho(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations (e.g., hemorrhage, exchange of maternalfetal blood), a larger dose of RhoGAM may be indicated.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

6. The perinatal nurse listens as the patient describes her labor and emergency cesarean birth. Providing an opportunity to review this experience may assist the patient in doing which of the following?
A. Decreasing her ambivalence about her labor and birth
B. Developing more positive feelings about her labor and birth
C. Initiating her role development in the letting-go stage
D. Understanding the various demands associated with the maternal role
ANS: B
After a cesarean birth, especially when unplanned, nurses must be aware of the myriad of potential psychological issues that may arise. Research suggests that women may perceive cesarean birth to be a less positive experience than a vaginal birth, and for unplanned or emergent cesarean deliveries, the experience of cesarean birth may be associated with more negative perceptions of the birthing experience. Allowing the patient to talk about the experience can help her develop a more positive attitude about her own experience.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Easy

PTS: 1

7. The perinatal nurse is teaching the patient about breastfeeding and explains that which of the following is the most appropriate time to breastfeed?
A. Four to 5 hours after the last feeding
B. Only when her infant exhibits hunger-related crying
C. When her infant is in a quiet alert state
D. When her infant is in an active alert state
ANS: C
The optimal time to breastfeed is when the baby is in a quiet alert state. Crying is usually a late sign of hunger and achieving satisfactory latch-on at this time is difficult. Latch-on is proper attachment of the infant to the breast for feeding. The neonate is most alert during the first 1 to 2 hours after an unmedicated birth, and this is the ideal time to put the infant to the breast.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

8. The perinatal nurse observes the new mother watching her baby daughter closely, touching her face, and asking many questions about infant feeding. This is best described as which stage of mothering?
A. Taking charge
B. Taking hold
C. Taking in
D. Taking time
ANS: A
As the mothers physical condition improves, she begins to take charge and enters the taking-hold phase, in which she assumes care for herself and her infant. At this time, the mother eagerly wants information about infant care and shows signs of bonding with her infant. During this phase, the nurse should closely observe motherinfant interactions for signs of poor bonding and, if present, implement actions to facilitate attachment.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

9. A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. The most appropriate nursing action at this time is to do which of the following?
A. Ask any visitors to leave now or stay quiet.
B. Dim the lights in the patients room.
C. Notify the patients health-care provider.
D. Perform a comprehensive pain assessment.
ANS: D
The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort to provide interventions in a timely manner and to enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0-to-10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The other actions are not warranted at this time.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

10. A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best?
A. Assess if the pain is worse when she sits upright.
B. Call the provider and ask for stronger analgesics.
C. Document the findings in the patients chart.
D. Notify the health-care provider immediately.
ANS: A
Headache is not uncommon after childbirth. Patients who received epidural or spinal anesthesia may complain of headaches, especially on assuming an upright position. Because this patient had an epidural, the nurse should first assess for this situation. Asking for stronger pain medication should not be done unless the nurse has completed a comprehensive pain assessment. The health-care provider does not need to be notified right away unless the patient has other symptoms, such as blurred vision. Documentation should be thorough, but the nurse needs to take further action first.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

11. A new mother is accompanied by her mother during her hospital stay on the postpartum unit. The patients mother has made specific various requests of the nurses, including asking for a bottle so she can feed the baby after the new mother attempts to breastfeed for the first time. How would the perinatal nurse best respond to the patients mother in a culturally sensitive way?
A. Ask both the patient and her mother about the preferred infant feeding method and assess what they already know.
B. Ask the patients mother to leave for 30 minutes to allow for some alone time with the patient in order to explore her learning needs.
C. Ask the patient what she knows about breastfeeding and provide information to both women to support the patients decision.
D. Convey to the patient and her mother an understanding of the concepts of hot and cold within their belief system.
ANS: C
In certain multicultural populations such as India, Thailand, and China, the womans postpartum confinement lasts for 40 days. During this time, prolonged rest with restricted activity is believed to be essential. The postpartum period is an important time for ensuring future good health, and great emphasis is placed on allowing the mothers body to regain balance after the birth of a child. To provide sensitive, appropriate care, nurses need to adopt a flexible approach when caring for women who embrace non-Western health beliefs and practices. The nurse should advocate for the patient by inquiring about her feeding preferences and by providing information to the mother and her family to support her in her decision.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

12. A nurse has brought a newborn to his mothers room. What action by the nurse takes priority?
A. Asking the mother her full name and her birth date
B. Comparing the baby to a photograph on the mothers bedside table
C. Having the mother wash her hands before taking the baby
D. Matching the information on the mothers and babys wristbands
ANS: D
The safety and security of the infant must be maintained at all times. When bringing the baby to the mother, the nurse ensures proper identification by comparing and matching information on both the mothers and the babys identification band. Having the mother wash her hands before taking the baby is a good practice to reduce the risk of infection, but security takes priority.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

13. A nurse assesses a womans temperature 6 hours after a vaginal birth and finds it to be 100.4F (38C). What action by the nurse is best?
A. Encourage the woman to drink plenty of fluids.
B. Document the findings and notify the provider.
C. Have the woman cough and deep breathe.
D. Prepare to administer acetaminophen (Tylenol).
ANS: A
Dehydration and exertion often cause a transient increase in body temperature up to 100.4F (38C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. The findings should be documented, but the provider does not need to be notified. Coughing and deep breathing are good strategies to relieve atelectasis, but this is not the most common cause of elevated temperature after childbirth. The patient may or may not want acetaminophen, but drinking more fluids is the priority over giving an antipyretic medication.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

14. A nurse assessing a postpartum woman 12 hours after uncomplicated vaginal birth finds her pulse to be 110 beats/minute. What action by the nurse is best?
A. Assess the patient for causes of tachycardia.
B. Document the findings and notify the provider.
C. Facilitate a blood draw for laboratory studies.
D. Place the patient on a 1,000-mL fluid restriction.
ANS: A
Postpartum tachycardia can result from several causes, including complications, blood loss, prolonged labor, temperature elevation, and infection. The nurse should assess the patient thoroughly to determine the cause of the tachycardia prior to notifying the provider. A blood draw may or may not be necessary. A fluid restriction would not be helpful, as this would lead to a temperature elevation and further tachycardia.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

15. A nurse is assisting a postpartum woman to get up for the first time after an unmedicated vaginal birth. What action by the nurse is best?
A. Apply a properly fitting gait belt before assisting the woman.
B. Determine if the woman has normal sensation to her lower extremities.
C. Instruct the woman to sit on the edge of the bed prior to standing.
D. Take the patients blood pressure lying down and then in a standing position.
ANS: C
Orthostatic hypotension can occur in the postpartum woman. The nurse should instruct the woman to change positions slowly and sit on the edge of the bed prior to standing up. A gait belt is not necessary. Checking for lower extremity sensation would be important after spinal or epidural anesthetic. Obtaining orthostatic blood pressures is not necessary unless this is an ongoing problem.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

16. A woman has painful hemorrhoids after a vaginal birth. Her husband brings her a donut pillow to sit on. What response by the nurse is best?
A. A lot of women get good pain relief from these.
B. Donut pillows actually increase hemorrhoid pain.
C. I will have to get permission for her to use this.
D. That was nice of you, but these dont work well.
ANS: B
Soft surfaces and pillows such as donut rings should not be used by the woman with hemorrhoids, as they separate the buttocks when the woman sits down and decrease venous flow, which increases pain. The woman should be instructed to sit on hard surfaces and tighten the buttocks prior to sitting. The other responses do not give accurate information.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

17. A postpartum patient complains of severe perineal pain and a sensation of needing to defecate but cannot pass stool. What action by the nurse is best?
A. Administer a stool softener.
B. Document the findings in the chart.
C. Offer a warm sitz bath.
D. Palpate the perineal area.
ANS: D
A perineal hematoma can cause excessive pain and the sensation of needing to defecate. The nurse assesses for this condition by gently palpating the perineal area through sterile gloves while observing for the degree of sensitivity to this touch. If a hematoma is suspected, the provider needs to be notified immediately so that the bleeding can be identified and halted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

18. A patient is receiving methylergonovine (Methergine) after a vaginal birth. What assessment finding by the nurse warrants immediate intervention?
A. Headache
B. Nausea
C. Palpitations
D. Uterine cramping
ANS: C
Methergine can cause headache, dysrhythmias, nausea and vomiting, and other side effects. Palpitations can indicate a cardiac rhythm disturbance and should be reported immediately.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

19. Two days after an uncomplicated vaginal birth, the nurse notes that the patients hemoglobin is 13 mg/dL and the hematocrit is 48%. What does the nurse conclude about these values?
A. Patient is dehydrated
B. Needs further assessment
C. Normal for this situation
D. Serious anemia
ANS: C
After a vaginal birth, the hemoglobin can drop about 1 gram, or 2 grams following a cesarean birth (normal for women is 12.115.1 mg/dL). Due to diuresis, hemoconcentration can occur, resulting in a rise in the hematocrit (normal in women is 36.144.3%). Therefore, these findings are normal after an uncomplicated vaginal birth.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Reduction of Risk Potential
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

20. A diabetic patient is 1 day postpartum after an uncomplicated vaginal birth. She wants to know why her blood sugar levels are so much lower than usual. What explanation by the nurse is best?
A. Because you are dehydrated, your blood sugar decreases for a few days.
B. I will call the dietician to see if you are getting enough calories.
C. The levels of hormones that cause an anti-insulin effect are decreased.
D. The exertion from childbirth is like a massive workout for your body.
ANS: C
After childbirth, levels of hormones that exert an anti-insulin effect, such as estrogen, progesterone, human placental lactogen, cortisol, growth hormone, and insulinase, all decline. This leads to a drop in blood glucose in the few days following childbirth.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

21. A woman with a history of mild heart failure has just vaginally given birth to a healthy baby. What action by the nurse is most important?
A. Assess the woman for signs of heart failure.
B. Facilitate an EKG.
C. Insert a Foley catheter for hourly urine output assessments.
D. Auscultate the womans heart sounds.
ANS: A
Dramatic changes occur in the maternal hemodynamic system after the birth of the baby. This can lead to cardiac instability. In a woman with known heart failure, the nurse should be vigilant about assessing for signs of heart failure. Listening to heart sounds is part of the assessment, but is not sufficient. The woman may or may not need a catheter for hourly urine output assessments or an EKG.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

22. A woman is 10 hours postpartum after an uncomplicated vaginal birth. She has voided four times, and each time the volume is less than 100 mL. What action by the nurse is best?
A. Ask the woman to keep a voiding log for 24 hours.
B. Palpate the fundus and assess the amount of lochia present.
C. Request an order for a straight catheterization.
D. Run the water in the bathroom faucet during voiding attempts.
ANS: B
Women who have recently given birth are at risk for urinary stasis and retention, which can lead to a boggy uterus and increased lochia. Frequently voiding 150 mL or less is a sign of urinary stasis and retention. The nurse should assess these factors first. The woman may need assistance when ambulating to the bathroom, or the nurse may need to run the water in the bathroom faucet during voiding attempts. A last resort is straight catheterization for severe urinary retention. Because the woman should be on intake and output assessments, a voiding log will not be helpful.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

23. The nursing faculty member explains to a class of nursing students the correct way to assist with perineal care (peri-care) after childbirth. Which action by a student nurse would warrant intervention by the faculty member?
A. Has woman squirt warm water toward the front of the perineum
B. Instructs the woman to wash her hands prior to peri-care
C. Removes the peri-pad from back to front and appropriately disposes of it
D. Washes the hands before assisting woman with her peri-care
ANS: C
The peri-pad is removed from front to back to avoid contaminating the vagina with the part of the peri-pad that has come into contact with the rectal area. The other steps are appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

24. A woman complains of perineal pain. The nurse assesses swelling, but sees no other abnormalities. The woman does not wish pharmacological treatment. What suggestion by the nurse is most appropriate?
A. Applying a covered ice pack to the perineum every 2 to 4 hours for 20 minutes
B. Placing cool cabbage leaves on the womans peri-pad
C. Sitting on a donut-type pillow when out of bed
D. Immersing in a sitz bath with a water temperature of 120F (48.9C)
ANS: A
An ice pack, wrapped in cloth, can be applied to the perineum for 20 minutes every 2 to 4 hours for discomfort. Ice has vasoconstrictive and numbing effects. Cooled cabbage leaves can be placed against the womans breasts to help with engorgement. Donut pillows are not recommended because they spread the buttocks and increase pain, especially if the woman has hemorrhoids. Sitz bath water should be no higher than 105F (40.5C).

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

25. A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, which action by the nurse takes priority?
A. Assess sensation in the lower extremities.
B. Discontinue the patients intravenous line.
C. Encourage the patient to cough and deep breathe.
D. Have the patient sit on the edge of the bed.
ANS: A
After a cesarean birth with spinal or epidural anesthesia, the nurse must assess sensation in the womans legs. She will not be allowed out of bed until sensation returns. Discontinuing the IV line may or may not be appropriate. Coughing and deep breathing are always important for a postoperative patient, but this action is not related to ambulating for the first time. Sitting on the edge of the bed prior to getting up would only be done if the woman had full sensation in her legs.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

26. A woman is 1 day postcesarean birth. The nurse auscultates crackles in her lung bases. Which action by the nurse is best?
A. Call respiratory therapy for a breathing treatment.
B. Facilitate the woman having a chest x-ray.
C. Have the woman use her incentive spirometer.
D. Notify the provider and document the findings.
ANS: C
Rales are not uncommon postoperatively and indicate atelectasis. The nurse should have the woman use her spirometer, cough, and deep breathe. The other interventions are not warranted.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

27. A woman had a cesarean birth 2 hours ago. She now complains of being hungry and wants something to eat. What action by the nurse is best?
A. Assess for bowel sounds and ask if she is passing gas.
B. Inform the woman that she cant eat until her bowels move.
C. Order her a meal high in carbohydrates.
D. Provide her with a medical liquid diet.
ANS: A
Until bowel function returns following a cesarean birth, the patient should only be offered ice chips and small sips of water. The nurse assesses for return of bowel function by listening for bowel sounds and asking the woman if she is passing gas. The other actions are not appropriate.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

28. An infant was born weighing 6 lb (2.72 kg). At the end of 30 days, approximately how much should this infant weigh to demonstrate effective breastfeeding?
A. 6 lb, 4 oz to 7 lb (2.833.17 kg)
B. 7 to 9 lb (3.174 kg)
C. 9 to 11 lb (45 kg)
D. 10 to 12 lb, 6 oz (4.55.6 kg)
ANS: A
An infant usually loses 5% of body weight during the first few days of life, and then begins gaining weight at the rate of to 1 oz/day. That would result in an infant weighing 6 lb, 4 oz to 7 lb at the end of 30 days.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

29. A mother brings her 3-month-old baby to the clinic for a well-baby check. She appears exhausted and when the nurse questions her, the mother explains that she feels that she is the only person who can look after and care for her infant properly, so all of her time is devoted to this task. The nurse should document which of the following?
A. Difficulty with letting-go, as evidenced by excluding her partner from infant care
B. Poor bonding, as evidenced by resentment toward the baby and fatigue
C. Personal neglect, as evidenced by exhaustion and by not taking care of herself
D. Time management problems, as evidenced by needing the entire day to care for the baby
ANS: A
During the letting-go stage, the mother begins to see the baby as separate from herself. The mother should be able to leave the baby with a sitter, make time for herself, and reconnect with her partner. Overprotective mothers have difficulty with this stage due to trouble accepting help and excluding others, especially the partner. There is no evidence that this mother is resentful, is neglecting all of her personal needs, or has time management problems.

Cognitive Level: Evaluation/Evaluating
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Evaluation
Difficulty: Moderate

PTS: 1

30. A nurse manager has many at-risk mothers in the labor and birth unit. What policy can the manager adapt that would best facilitate motherbaby bonding?
A. Encourage attendance at a support group with other at-risk mothers.
B. Limit separation of mother and baby to exceptional circumstances only.
C. Offer the mother the services of a one-to-one mentor for 1 year.
D. Teach breastfeeding and promote its use exclusively for 1 full year.
ANS: B
The most critical action a nurse can take to enhance bonding is to minimize the time the mother and her baby are separated while in the hospital. This policy would be most beneficial to promote bonding. The other ideas are good ones that might be helpful to some new mothers, but the critical action is to minimize separation.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

31. An adolescent has vaginally given birth to a healthy baby. What action by the nurse would be most important in developing a plan to help this mother bond successfully?
A. Ask the mother about her expectations of the baby and their relationship.
B. Determine if the mother plans to keep the baby or give it up for adoption.
C. Inquire as to how many family members are available to help care for the baby.
D. Refer the mother and her baby to the social worker or to the visiting nurses.
ANS: A
Adolescent mothers may have difficulty with bonding and attachment because they have unrealistic ideas of the babys level of functioning and may not be aware of the babys level of vulnerability. Asking about the mothers expectations for the baby and their relationship is a good starting point to initiate a discussion about this topic. Plans for keeping or adopting the baby should have already been established. Family members can help give the mother a break from infant care, but the less the mother cares for the baby, the less bonding she will demonstrate. A referral may be needed, but this is not the first action.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

32. A new mother is concerned that her 3-year-old child is not adapting well to the birth of a new sibling 1 month ago. What suggestion can the nurse provide to best help this mother?
A. Explain to the child that she will always have a special bond with the new sibling.
B. Give the 3-year-old a special chore that only she does to help her mom.
C. Promise the 3-year-old that she can have a pet if she is good to her new sibling.
D. Tell the child she will need to get used to having a new baby in the house.
ANS: B
Often siblings have a rough time adapting to the arrival of a new sibling. Some suggestions for the parents are to talk to the child about her feelings, teach the child how to play with the baby, praise age-appropriate behaviors and do not criticize regressive behaviors (regression is common), set aside special time each day for the older child, and give the older child a special chore to be a big helper for Mommy. A special chore, such as bringing diapers when the baby needs changing, can help boost her self-esteem and make her feel important to the family.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

33. A husband calls the perinatal clinic because he is worried about his wifes emotional state after giving birth 2 weeks ago. Which question by the nurse would be most helpful?
A. Can you explain specifically what you are worried about?
B. How is your wifes appetite? Is she eating enough?
C. Is your wife still able to care for herself and the baby?
D. When did all the symptoms start, before or after the birth?
ANS: C
Emotional difficulties after birth include the baby blues, postpartum depression, and postpartum psychosis. The most important determinant rests with the knowledge that postpartum or baby blues do not interfere with the womans ability to care for herself and her family. This question effectively triages the situation. Can you is a yes-no question and is never a good type of question to use when assessing a situation. In both baby blues and depression, appetite may be diminished.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

MULTIPLE RESPONSE

1. The nurse is assessing a woman in the immediate postpartum period. The patients respiratory rate is 22 breaths/minute. The most important aspects of nursing care would be to do which of the following? (Select all that apply.)
A. Assess and provide pain management.
B. Assess the patients blood pressure and pulse.
C. Increase the patients fluid intake.
D. Notify the provider for continued tachypnea.
E. Provide ongoing physical assessment.
ANS: A, B, D, E
During the immediate postpartal period, the respiratory rate should remain within the normal range of 12 to 20 respirations per minute. However, slightly elevated respirations may occur due to pain, fear, excitement, exertion, or excessive blood loss. The nurse should assess and treat any pain. Taking the pulse and blood pressure can provide information on the patients hemodynamic status. If tachypnea continues despite appropriate interventions, the provider should be notified. Ongoing physical assessment is part of postpartum care.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

2. The perinatal nurse includes a pain assessment as part of the postpartum care provided to each patient. This action helps to do which of the following? (Select all that apply.)
A. Decrease the length of the hospital stay
B. Decrease the recovery time
C. Decrease the risk of depression
D. Help identify complications
E. Improve the patients coping ability
ANS: B, C, D, E
Routine, comprehensive pain assessments enable the nurse to provide interventions in a timely manner to enhance the effectiveness of medications; they also ensure early identification of complications resulting in painful stimuli. Information and patient involvement increase the patients perception of control and increase her personal satisfaction with postpartum pain management, thereby decreasing recovery time and the risk for depression. A pain-free patient can cope with the demands of a new baby better than a patient who is uncomfortable and dissatisfied with pain management.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

3. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after childbirth. Which hormones are responsible for the diuresis? (Select all that apply.)
A. Estrogen
B. Norepinephrine
C. Oxytocin
D. Prolactin
E. Progesterone
ANS: A, C
Maternal diuresis occurs almost immediately after birth, and urinary output reaches up to 3,000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the levels of oxytocin and estrogen naturally occurs and contributes to the diuresis.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

4. The perinatal nurse knows that breastfeeding is contraindicated if a mother has which of the following conditions? (Select all that apply.)
A. Active herpes lesion on her nipple
B. Active tuberculosis
C. Infant diagnosed with phenylketonuria
D. Small breasts
E. Taking venlafaxine (Effexor) for anxiety.
ANS: A, B
There are only a few situations in which breastfeeding is contraindicated: infants with galactosemia (due to an inability to digest the lactose in the milk), mothers with active tuberculosis or HIV infection, mothers with active herpes lesions on the nipples, mothers who are receiving certain medications such as lithium or methotrexate, and mothers who are exposed to radioactive isotopes (e.g., during diagnostic testing).

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

5. The postpartum nurse is aware that following childbirth there is an increased risk of maternal perineal infection related to which of the following factors? (Select all that apply.)
A. Drainage of blood and lochia
B. Impaired tissue integrity
C. The anatomical proximity to the anus
D. Urinary retention
E. Weakness and fatigue
ANS: A, B, C, D
The proximity of the perineum to the anus increases the risk of a laceration or surgical incision becoming contaminated with fecal material, and the continuous drainage of blood coupled with impaired tissue integrity creates a favorable medium for the proliferation of bacteria. Urinary stasis and retention can lead to urinary tract infections. Weakness and fatigue would not lead to an increased risk for infection.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

6. The perinatal nurse teaches the student nurse that deep breathing exercises following cesarean birth are critical to the prevention of what complications? (Select all that apply.)
A. Abdominal distension
B. Atelectasis
C. Increased tidal volume
D. Pneumonia
E. Pulmonary embolism
ANS: B, D
Incisional pain and abdominal distension often cause patients to adopt shallow breathing patterns that can lead to decreased gas exchange and a reduced tidal volume. To facilitate adequate lung functions, patients should be taught how to perform pulmonary exercises. Expectoration of secretions and deep breathing help prevent common complications, including atelectasis and pneumonia. Abdominal distension and gas pains are common after abdominal surgery and result from delayed peristalsis. Coughing and deep breathing wont prevent pulmonary embolism.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

7. The perinatal nurse is teaching the new mother who has chosen to formula-feed her infant. Which of the following are appropriate instructions to give the parents? (Select all that apply.)
A. Discard any unused formula in the bottle following use.
B. Mix the powdered formula with hot water only.
C. Only prepare enough formula to last for 24 hours.
D. Periodically check the nipple for slow flow.
E. Wipe off the top of the liquid formula can before opening it.
ANS: A, D
Parents should be advised to read and follow the manufacturers instructions explicitly when preparing the formula, as some require no water and some need to be diluted with water. Cold water should be used to mix the powder. Only the amount to be used for each feeding should be prepared, and any unused formula should be discarded. The nipples should be checked periodically during feedings for correct flow and should be replaced regularly. The cans of liquid formula should be shaken and washed before opening.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

8. The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include which of the following behaviors? (Select all that apply.)
A. Mouth movements
B. Moving the hand to the mouth
C. Sticking the tongue out
D. Vocalizations
E. Yawning
ANS: A, B, D
The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or the mothers neck or shoulder, makes movements of the mouth, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

9. A nurse uses the acronym REEDA to perform a perineal assessment on a postpartum woman. What are the components of this exam? (Select all that apply.)
A. Approximation of the episiotomy
B. Drainage or discharge
C. Ecchymosis
D. Estimated length of the episiotomy
E. Redness
ANS: A, B, C, E
REEDA stands for redness, edema, ecchymosis, drainage or discharge, and approximation of the episiotomy (if present).

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

10. A woman is considering abandoning breastfeeding attempts because of severe afterpains. What actions by the nurse are most helpful? (Select all that apply.)
A. Administer pain medication 30 minutes prior to breastfeeding.
B. Encourage ambulation.
C. Have the woman lie prone with a pillow under her stomach.
D. Offer the woman information on commercial baby formula.
E. Prepare a sitz bath for the woman after she has breastfed.
ANS: A, B, C, E
Because breast milk is the perfect food for baby, the nurse should support a womans decision to breastfeed and help remove any obstacles to this practice. Breastfeeding women should take pain medication 30 minutes prior to nursing to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk. Ambulation also helps to decrease afterpains. To ease discomfort, the woman can be assisted into a prone position and a small pillow can be placed under her abdomen. Initiating a sitz bath after breastfeeding may be helpful in decreasing discomfort. Switching to formula and bottle feeding should be a last resort after all other interventions have been tried.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

11. A nurse is observing a student nurse prepare a sitz bath. Which actions should be performed by the student? (Select all that apply.)
A. Confirm that the patient can ambulate to the bathroom.
B. Fill the water bag with water heated to 120F (48.9C).
C. Help the patient remove the peri-pad from front to back.
D. Ensure that the patient is covered enough to prevent chilling.
E. Place the sitz bath in the toilet with the overflow opening directed toward the front.
ANS: A, C, D
To properly prepare a sitz bath, first ensure that the patient is able to ambulate to the bathroom. The water should be heated to 105F (41C). Peri-pads are removed from front to back to prevent infection. The patient should be seated on the toilet where the sitz apparatus has been positioned so that the overflow opening is pointed toward the back of the toilet. The patient is covered to prevent chilling.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Nursing Process: Implementation
Integrated Process: Physiological Integrity: Basic Care and Comfort
Difficulty: Moderate

PTS: 1

12. A nurse is caring for a woman who just experienced a cesarean birth under epidural anesthesia. What interventions are important to include on this womans care plan? (Select all that apply.)
A. Apply compression stockings or sequential compression devices.
B. Encourage ankle exercises while the woman remains in bed.
C. Keep the woman NPO until she is allowed out of bed into a chair.
D. Maintain bedrest until sensation returns to the womans legs.
E. Only allow the woman to hold her infant with supervision while in bed.
ANS: A, B, D
Because epidural or spinal anesthesia causes loss of sensation in the legs, women are kept on bedrest after cesarean birth until the sensation returns (unless they had general anesthesia). This increases the risk of deep vein thrombosis, so compression stockings or sequential compression devices and ankle exercises are important. The woman does not need to be kept NPO until she is allowed out of bed, nor does she need supervision to hold her infant while in bed.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

13. A nursing faculty member is explaining to a class of students that women experiencing cesarean birth have more challenges than do women who give birth vaginally. The faculty member is referring to what challenges? (Select all that apply.)
A. Delayed motherinfant bonding
B. Difficulty in choosing an infant feeding method
C. Increased risk of deep vein thrombosis
D. Pain from the surgical incision and intestinal gas
E. Slower initiation and pace of ambulation
ANS: A, C, D, E
Women who have a cesarean birth face increased challenges, including delayed bonding, pain from surgical incisions and intestinal gas, an increased risk for deep vein thrombosis, and a slower start and pace of ambulation. Difficulty choosing an infant feeding method is not a typical challenge faced only by women who have experienced a cesarean birth.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

14. The perinatal nurse explains to students that certain groups of women are less likely to breastfeed. Which of the following women would the nurse identify as needing extra education, support, or encouragement to breastfeed? (Select all that apply.)
A. African American
B. Asian
C. Those with a college education
D. Those older than 25
E. Those who participate in federal nutrition programs
ANS: A, E
Women who are less likely to breastfeed include those who are younger than 25 years of age, those with a lower income, primiparas, African Americans, those who participate in federal nutrition programs, those with a high school education or less, and those who are employed full time outside the home.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

15. A visiting nurse is concerned that a mother has not properly bonded with her infant. The nurse should assess for what factors that could impact this process? (Select all that apply.)
A. Chaotic home life
B. Disappointment in her birth experience
C. Lack of family support
D. Poverty
E. Substance abuse
ANS: A, C, D, E
Many stressors can have a negative impact on the bonding process, including a chaotic home life, lack of family support, poverty, substance abuse, and concerns about child care if the mother must return to work. Disappointment in the birth experience may be an issue for some women with bonding difficulties, but it is not a typical cause of this problem.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

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