Old's Maternal-Newborn Nursing and Women's Health, 11e (Davidson/London/Ladewig)

Chapter 32 Postpartum Adaptation and Nursing Assessment

1. The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?
2. Document the findings.
3. Catheterize the client.
4. Massage the uterine fundus until it is firm.
5. Call the physician immediately.

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Offer a warm water bottle for her abdomen.
2. Call the physician to report this finding.
3. Inform her that this is not normal, and she will need an oxytocic agent.
4. Administer a mild analgesic to help with breastfeeding.
5. Administer a mild analgesic at bedtime to ensure rest.

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?
2. Methylergonovine maleate (Methergine)
3. Rh immune globulin (R h o G A M)
4. Terbutaline (Brethine)
5. Docusate (Colace)

Page Ref: 870

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate?
2. Encourage sitz baths.
3. Position the client in the supine position.
4. Avoid stool softeners.
5. Decrease fluid intake.

Page Ref: 872

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | A A C N Essentials Competencies: Ⅸ. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?
2. Encourage the new mother, saying, "It will happen soon."
3. Instruct the client to eat a low-fiber diet.
4. Decrease fluid intake.
5. Obtain an order for a stool softener.

Page Ref: 859

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first?
2. Woman who is 2nd day post-cesarean, moderate lochia serosa
3. Woman day of delivery, fundus firm 2 c m above umbilicus
4. Woman who had a cesarean section, 1st postpartum day, 4 c m diastasis recti abdominis
5. Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants

Page Ref: 868

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse expects an initial weight loss for the average postpartum client to be which of the following?
2. 5 to 8 pounds
3. 10 to 12 pounds
4. 12 to 15 pounds
5. 15 to 20 pounds

Page Ref: 861

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅰ. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | N L N Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. To assess the healing of the uterus at the placental site, what does the nurse assess?
2. Lab values
3. Blood pressure
4. Uterine size
5. Type, amount, and consistency of lochia

Page Ref: 858

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?
2. "I should expect a lighter flow next week."
3. "The flow will increase if I am too active."
4. "My bleeding will remain red for about a month."
5. "I will be able to use a pantiliner in a day or two."

Page Ref: 858

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take?
2. Answer questions quickly and try to divert her attention to other subjects.
3. Review the documentation of the birth experience and discuss it with her.
4. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience.
5. Submit a referral to Social Services because of possible obsessive behavior.

Page Ref: 875

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: Q S E N Competencies: Ⅰ. B. 15. Communicate care provided and needed at each transition in care. | A A C N Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Which statement by a new mother 1 week postpartum indicates maternal role attainment?
2. "I don't think I'll ever know what I'm doing."
3. "This baby feels like a real stranger to me."
4. "It works better for me to undress the baby and to nurse in the chair rather than the bed."
5. "My sister took to mothering in no time. Why can't I?"

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis.

Learning Outcome: 2 Describe the psychologic adjustments that normally occur during the postpartum period.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following?
2. The taking-hold phase
3. Postpartum hemorrhage
4. The taking-in period
5. Epidural anesthesia

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?
2. "The en face position promotes bonding and attachment."
3. "Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed."
4. "In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous."
5. "The needs of the mother and of her infant are balanced during the phase of mutual regulation."

Page Ref: 865

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Make sure she gets a kosher diet.
2. Expect that most visitors will be women.
3. Uncover only the necessary skin when assessing.
4. The father will take an active role in infant care.
5. She will prefer a male physician.

Page Ref: 863

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

Standards: Q S E N Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | A A C N Essentials Competencies: Ⅶ. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | N L N Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following?
2. Help the new mother by allowing her to focus on resting and caring for the baby.
3. Teach her son-in-law the right way to be a father because this is his first child.
4. Make sure that her daughter does not become abusive towards the infant.
5. Pass on cultural values and beliefs to the newborn grandchild.

Page Ref: 875

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅶ. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | N L N Competencies: Relationship-Centered Care: Be open to others' ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. How does the nurse assess for Homans' sign?
2. Extending the foot and inquiring about calf pain.
3. Extending the leg and inquiring about foot pain.
4. Flexing the knee and inquiring about thigh pain.
5. Dorsiflexing the foot and inquiring about calf pain.

Page Ref: 874

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 16. Demonstrate the application of psychomotor skills for efficient, safe and compassionate delivery of patient care. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Which of the following symptoms would be an indication of postpartum blues?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Overeating
2. Anger
3. Mood swings
4. Constant sleepiness
5. Crying

Page Ref: 863

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | A A C N Essentials Competencies: Ⅸ. 16. Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Nursing interventions that foster the process of becoming a mother include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Encouraging detachment from the nurse-patient relationship
2. Promoting maternal-infant attachment
3. Building awareness of and responsiveness to infant interactive capabilities
4. Instruct about promoting newborn independence
5. Preparing the woman for the maternal social role

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?
2. Increased blood pressure
3. Hypoglycemia
4. Postpartum hemorrhage
5. Postpartum infection

Page Ref: 857

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?
2. Asking the client to void and donning clean gloves
3. Listening to bowel sounds and then asking when her last bowel movement occurred
4. Offering the patient pre-medication 2 hours before the assessment
5. Completing the assessment and explaining the results to the client

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | A A C N Essentials Competencies: Ⅸ. 4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network. | N L N Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an I V of lactated Ringer's solution running at 100 m L/h r. Her fundus is firm and to the right of midline. What is the best nursing action?
2. To massage the fundus vigorously
3. To assess the client's pain level
4. To increase the rate of the I V
5. To assist the client to the bathroom

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | N L N Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up?
2. Firm fundus
3. Fundus at the umbilical level
4. Moderate lochia rubra
5. Steady trickle of blood

Page Ref: 858

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Which of the following behaviors noted in the postpartum client would require the nurse to assess further?
2. Responds hesitantly to infant cries.
3. Expresses satisfaction about the sex of the baby.
4. Friends and family visit the client and give advice.
5. Talks to and cuddles with the infant frequently.

Page Ref: 864

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurse's best response?
2. "We see this from time to time. It's not a big deal."
3. "The gush is an indication that your fundus isn't contracting."
4. "Don't worry. I'll make sure everything is fine."
5. "Blood pooled in the vagina while you were in bed."

Page Ref: 868

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Which of the following conditions would predispose a client for thrombophlebitis?
2. Severe anemia
3. Cesarean delivery
4. Anorexia
5. Hypocoagulability

Page Ref: 874

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅴ. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?
2. "I am so happy and blessed to have my new baby."
3. "One minute I'm laughing and the next I'm crying."
4. "My husband is helping out by changing the baby at night."
5. "Breastfeeding is going quite well now that the engorgement is gone."

Page Ref: 863

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. B. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Threats to the integrity of relationships, and the potential for conflict and abuse. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The postpartum client is about to go home. The nurse includes which subject in the teaching plan?
2. Replacement of fluids
3. Striae
4. Diastasis of the recti muscles
5. R E E D A scale

Page Ref: 859

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Establish a therapeutic relationship with her physician
2. Adapt to altered lifestyles and family structure resulting from the addition of a new member
3. Restore her intellectual abilities
4. Restore physical condition
5. Develop competence in caring for and meeting the needs of her infant

Page Ref: 875

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation.

Learning Outcome: 5 Examine the physical and developmental tasks that the mother must accomplish during the postpartum period.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is beginning the postpartum teaching of a mother who has given birth to her first child. What aspect of teaching is most important?
2. Describe the likely reaction of siblings to the new baby.
3. Discuss adaptation to grandparenthood by her parents.
4. Determine whether father-infant attachment is taking place.
5. Assist the mother in identifying the baby's behavior cues.

Page Ref: 864

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn?
2. The client who is discussing how the baby looks like her father
3. The client who is singing softly to her baby
4. The client who continues to touch her baby with only her fingertips
5. The client who picks her baby up when the baby cries

Page Ref: 864

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: Q S E N Competencies: Ⅰ. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior?
2. The client is not attaching to her infant appropriately.
3. The client is not going to be a good mother, and the baby is at risk.
4. The client has no mother present to role-model behaviors.
5. The client is exhibiting normal behavior for her culture.

Page Ref: 875

Cognitive Level: Understanding

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅰ. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Relationship-Centered Care: Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make?
2. "I have a lot more time to myself than I thought I would have."
3. "My confidence level in my parenting is higher than I anticipated."
4. "I am constantly tired. I feel like I could sleep for a week."
5. "My baby likes everyone, and never fusses when she's held by a stranger."

Page Ref: 875

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is preparing a class for mothers who have just recently delivered and their partners. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. "We should avoid holding the baby too much."
2. "Looking directly into the baby's eyes might frighten him."
3. "Talking to the baby is good because he'll recognize our voices."
4. "Holding the baby so we have direct face-to-face contact is good."
5. "We should only touch the baby with our fingertips for the first month."

Page Ref: 878

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: Q S E N Competencies: Ⅰ. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | A A C N 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. | N L N Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation.

Learning Outcome: 7 Identify the factors that influence the development of parent-newborn attachment in the nursing assessment of early attachment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The home care nurse is assessing the level of a mother's fundus who delivered 3 days ago. Where should the fundus be located?

1. A
2. B
3. C
4. D

Page Ref: 857

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a woman's body returns to its pre-pregnant state.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. During a postpartum assessment, the nurse suspects the patient has a full bladder. Where is the fundus located for the nurse to make this clinical determination?

1. A
2. B
3. C
4. D

Page Ref: 858

Cognitive Level: Analyzing

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse performs the following while assessing a postpartum patient. For what is the nurse assessing?

1. Fundal height
2. Uterine bleeding
3. Bladder distention
4. Abdominal distention

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. The nurse is determining a postpartum patient's amount of lochia. For which observation should the nurse document a moderate amount?

Page Ref: 870

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Implementation: Communication and Documentation.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.

1. Put the following components specific to a postpartum examination in the proper sequential order:
2. L-lochia
3. E-emotional
4. H-Homans'/hemorrhoids
5. B-breasts
6. E-episiotomy/lacerations

Page Ref: 868

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance

Standards: Q S E N Competencies: Ⅰ. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | A A C N Essentials Competencies: Ⅸ. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | N L N Competencies: Context and Environment: Practice; conduct population-based transcultural health assessments and interventions. | Nursing/Integrated Concepts: Assessment: Nursing Process.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

M N L L O: Demonstrate ability to perform assessment and interpret data during the postpartum period.