A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus, expecting it to be at which location? A) Two fingerbreadths above the umbilicus B) At the level of the umbilicus C) Two fingerbreadths below the umbilicus D) Four fingerbreadths b...
Maternity and Pediatric Nursing 4th
Edition
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse
palpates the client's fundus, expecting it to be at which location?
A) Two fingerbreadths above the umbilicus
B) At the level of the umbilicus
C) Two fingerbreadths below the umbilicus
D) Four fingerbreadths below the umbilicus - C
During the first few days after birth, the uterus typically descends downward from the
level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is
about 2 fingerbreadths below the umbilicus.
When caring for a mother who has had a cesarean birth, the nurse would expect the
client's lochia to be:
A) Greater than after a vaginal delivery
B) About the same as after a vaginal delivery
C) Less than after a vaginal delivery
D) Saturated with clots and mucus - C
Women who have had cesarean births tend to have less flow because the uterine
debris is removed manually along with delivery of the placenta.
A client who is breastfeeding her newborn tells the nurse, I notice that when I feed him, I
feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?
Which response by the nurse would be most appropriate?
A) Your uterus is still shrinking in size; that's why you're feeling this pain.
B) Let me check your vaginal discharge just to make sure everything is fine.
C) Your body is responding to the events of labor, just like after a tough workout.
D) The baby's sucking releases a hormone that causes the uterus to contract - D
The woman is describing afterpains, which are usually stronger during breast-feeding
because oxytocin released by the sucking reflex strengthens uterine contractions.
Afterpains are associated with uterine involution, but the woman's description strongly
correlates with the hormonal events of breast-feeding. All women experience afterpains,
but they are more acute in multiparous women secondary to repeated stretching of the
uterine muscles.
The nurse interprets which of the following as evidence that a client is in the
taking-in phase?
A) Client states, He has my eyes and nose.
B) Client shows interest in caring for the newborn.
C) Client performs self-care independently.
D) Client confidently cares for the newborn - A
During the taking-in phase, new mothers when interacting with their newborns spend
time claiming the newborn and touching him or her, commonly identifying specific
, features in the newborn such as "he has my nose" or "his fingers are long like his
father's." Independence in self-care and interest in caring for the newborn are typical of
the taking-hold phase. Confidence in caring for the newborn is demonstrated during the
letting-go phase.
A postpartum client is experiencing subinvolution. When reviewing the woman's labor
and birth history, which of the following would the nurse identify as being least
significant to this condition?
A) Early ambulation
B) Prolonged labor
C) Large fetus
D) Pulse rate of 60 beats/minute - A
Factors that inhibit involution include prolonged labor and difficult birth, incomplete
expulsion of amniotic membranes and placenta, uterine infection, overdistention of
uterine muscles (such as by multiple gestation, hydramnios, or large singleton fetus),
full bladder (which displaces the uterus and interferes with contractions),
anesthesia(which relaxes uterine muscles), and close childbirth spacing. Factors that
facilitate uterine involution include complete expulsion of amniotic membranes and
placenta at birth, complication-free labor and birth process, breast-feeding, and early
ambulation.
A woman who gave birth 24 hours ago tells the nurse, I've been urinating so much over
the past several hours. Which response by the nurse would be most appropriate?
A) You must have an infection, so let me get a urine specimen.
B) Your body is undergoing many changes that cause your bladder to fill quickly.
C) Your uterus is not contracting as quickly as it should.
D) The anesthesia that you received is wearing off and your bladder is working
again. - B
Postpartum diuresis occurs as a result of several mechanisms: the large amounts of IV
fluids given during labor, a decreasing antidiuretic effect of oxytocin as its level declines,
the buildup and retention of extra fluids during pregnancy, and a decreasing production
of aldosterone—the hormone that decreases sodium retention and increases urine
production. All these factors contribute to rapid filling of the bladder within 12 hours of
birth. Diuresis begins within 12 hours after childbirth and continues throughout the first
week postpartum. Rapid bladder filling, possible infection, or effects of anesthesia are
not involved.
A group of students are reviewing the process of breast milk production. The
students demonstrate understanding when they identify which hormone as
responsible for milk let-down?
A) Prolactin
B) Estrogen
C) Progesterone
D) Oxytocin - D
Don't let this confuse you! Milk let-down/stimulation vs milk production (prolactin)
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