Question 1

The nurse is assessing the abdomen of a client who delivered an infant 1 hour ago. On the diagram, where should the nurse assess the client's uterine level?

Accepted Answer

The answer of The nurse is assessing the abdomen of...

Question 2

The nurse is assessing the episiotomy of a client who is 2 days postpartum. In which order should the nurse complete this assessment? 
A. Edema
B. Redness
C. Ecchymosis
D. Approximation
E. Discharge/drainage

Accepted Answer

The correct order for assessing an episiotomy is Redness, Edema, Ecchymosis, Discharge/drainage, and Approximation (REEDA).

Question 3

What amount of weight loss, in pounds, should the nurse expect in an average postpartum client?

Accepted Answer

The average weight loss immediately after delivery is approximately 10 to 12 pounds. This accounts for the weight of the baby, placenta, and amniotic fluid. Additional weight loss occurs over the next several weeks as the body sheds excess fluid.

Question 4

The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene?

Accepted Answer

The answer of The nurse is observing a graduate nurse's...

Question 5

A postpartum client is not going to breastfeed her newborn. What should the nurse include when teaching this client about breast care?

Accepted Answer

The nurse should include teaching on lactation suppression to help reduce discomfort and engorgement. The other options are not applicable to a client who is not breastfeeding.

Question 6

The nurse is preparing material to instruct a client who has given birth to her first child. What aspect of teaching is most important?

Accepted Answer

Assisting the mother in identifying behavior cues of the baby is the most important aspect of teaching for a new mother. Understanding the baby's behavior cues will help the mother respond appropriately to the baby's needs and facilitate bonding between mother and baby. The other options are also important in the postpartum period, but they are not the most critical aspect of teaching for a new mother.

Question 7

A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient?

Accepted Answer

The appropriate intervention is to teach the mother how to interact with her infant, as this can help improve bonding and ensure the infant's needs are met.

Question 8

A postpartum client weighing 165 lb is prescribed to take 12 mg/kg/day of lysine to help with afterpains. If the client ingests 375 mg of lysine in food, how many additional milligrams of the supplement should the client take? (Calculate to the nearest whole number.)

Accepted Answer

The answer of A postpartum client weighing 165 lb is...

Question 9

The nurse decides that a family with a newborn would benefit from a Social Services consultation. What statements were made by family members that caused the nurse to make this decision? Select all that apply.

Accepted Answer

These statements indicate potential issues within the family dynamics or support system that may benefit from social services intervention. Statement B reflects body image concerns that could affect postpartum health. Statement C suggests a lack of family support. Statement D indicates financial or employment stress. Statement E implies feelings of being overwhelmed or unsupported.

Question 10

The nurse is making a visit to the home of a new mother. Which observation indicates that the mother and infant are in the phase of mutual regulation?

Accepted Answer

Mutual regulation involves both the mother and infant adjusting to each other's needs and signals. The mother's vocalization of frustration indicates an awareness and adjustment to the infant's behavior, which is part of mutual regulation.

Question 11

What should the nurse assess to determine healing of the uterus at the placental site?

Accepted Answer

The type, amount, and consistency of lochia can indicate the healing of the uterus at the placental site. Specifically, a decrease in the amount of lochia and a change in consistency from lochia rubra (bright red) to lochia serosa (pinkish-brown) and then to lochia alba (cream-colored) suggest that the uterus is healing. Laboratory values and blood pressure can provide information about the mother's overall health, but do not directly indicate healing of the placental site. Uterine size may also provide some information, but is less reliable than lochia assessment.

Question 12

In which order should the nurse conduct the examination of a postpartum client? 
A)L-lochia
B) B-bowel
C) B-breast
D) U-uterus
E) B-bladder
F) E-emotional
G) H-Homans/hemorrhoids
H) E-episiotomy/laceration/edema

Accepted Answer

The answer of In which order should the nurse conduct...

Question 13

Every time the nurse enters the client's room, the client, who delivered 3 hours ago, asks the nurse something else about the birth experience. What action should the nurse take?

Accepted Answer

The nurse should take the time to review the documentation of the birth experience and discuss it with the client. This can help the client process their experience and alleviate anxiety or concerns they may have. It is important for the nurse to prioritize the client's needs and provide support, rather than trying to quickly divert attention or jump to conclusions about changes in behavior. Referring to Social Services or healthcare providers should only be done if there are significant concerns for the client's safety or well-being.

Question 14

On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse?

Accepted Answer

The taking-in phase is a period of time after giving birth during which the new mother is focused on her own needs, such as resting and processing the birth experience. During this phase, the mother may have difficulty retaining new information or focusing on external events. This is likely the reason for the mother's memory lapse regarding the breastfeeding teaching.

Question 15

During a home visit the nurse is concerned that a new mother is experiencing postpartum blues. What did the nurse assess to make this clinical determination? Select all that apply.

Accepted Answer

The answer of During a home visit the nurse is...

Question 16

The nurse is performing an assessment of early attachment. Which action indicates that the client is pleased with the baby's appearance and sex?

Accepted Answer

Pointing out family traits in the newborn indicates that the mother is pleased with the baby's appearance.

Question 17

A client weighing 80 kg lost 5 kg of body weight immediately after delivery. In 2 days, another 3 kg has been lost. During a 6-week postpartum examination the client was pleased to learn of returning to her prepregnancy weight of 143 lb. How many kilograms of weight did the client lose during the 6 weeks postpartum? (Calculate to the nearest whole number.)

Accepted Answer

The answer of A client weighing 80 kg lost 5...

Question 18

The nurse is preparing to assess assigned clients on a postpartum unit. Which client should be seen first?

Accepted Answer

This client has a fundus that is higher than expected, indicating possible uterine atony and increased risk for postpartum hemorrhage. This requires immediate assessment and intervention. The other clients have less urgent assessment needs.

Question 19

A postpartum client becomes concerned when a gush of blood occurs during the fundal assessment. What should the nurse explain about this occurrence?

Accepted Answer

The gush of blood during a fundal assessment often occurs because blood has pooled in the vagina while the woman was lying down. When the uterus is massaged or the position is changed, this pooled blood can be expelled.

Quiz 28: Postpartum Adaptation and Nursing Assessment