NUR 113 Postpartum Quiz

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

• Notify the client’s provider.

• Increase the frequency of fundal massage.

• Document the findings and continue to monitor the client.

• Encourage the client to empty her bladder.

Answer explanation

These are expected findings in the client who is 1 hour postpartum. There is no need to notify the provider, increase the frequency of fundal massage, or encourage the client to empty her bladder. (ATI)

A nurse is caring for a client who experienced a vaginal delivery 12 hr ago. When palpating the client’s abdomen, at which of the following positions should the nurse expect to find the uterine fundus?

• At the level of the umbilicus

• 2 cm above the umbilicus

• One fingerbreadth above the symphysis pubis

• To the right of the umbilicus

Answer explanation

*Within 12 hr, the fundus should be palpable at the level of the umbilicus and then recede 1 to 2 cm each day. Correct

A nurse is caring for a client who is postpartum and finds the fundus slightly boggy and displaced to the right. Based on these findings, which of the following actions should the nurse take?

• Encourage the client to perform Kegel exercises.

• Encourage the client to move to the left lateral position.

• Ask the client to rate her pain.

• Assist the client to the bathroom to void.

Answer explanation

A full bladder causes the uterus to be displaced above the umbilicus and off to one side. This prevents the uterus from contracting normally and increases the risk of hemorrhage. (ATI)

A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9 lb 6 oz. (4252 g). The nurse should recognize that this client is at risk for which of the following postpartum complications?

• Puerperal infection

• Retained placental fragments

• Thrombophlebitis

• Uterine atony

Answer explanation

A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine atony.

A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?

• Assess client's blood pressure.

• Assess the bladder for distention.

• Massage the client's fundus.

• Prepare to administer a prescribed oxytocic preparation.

Answer explanation

The initial management of excessive uterine bleeding is firm massage of the uterine fundus. This action stimulates contraction of the uterine muscles, which constrict the maternal uterine blood vessels. (ATI and Saunders NCLEX)

A nurse is assessing a client for postpartum infection. Which of the following findings should indicate to the nurse that the client requires further evaluation for endometritis?

• Moderate amount of dark red lochia with a bloody odor

• A localized area of breast tenderness

• Pelvic pain

• Hematuria

Answer explanation

Indications of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

• Flex her knee while resting.

• Massage the area.

• Elevate her leg.

• Apply cold compresses.

Answer explanation

The client should elevate her leg to encourage venous return and to relieve pain.

A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should the nurse anticipate in the care of this client? (Select all that apply.)

• Document fundal height.

• Massage a boggy fundus

• Determine whether the fundus is midline

• Perform an in and out catheterization if the bladder becomes distended

Answer explanation

*Fundal height should be documented each time it is assessed.

*The initial nursing intervention when assessing a boggy uterus is uterine massage.

*The nurse should palpate the uterus for fundal height, tone and if midline with each fundal massage.

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)

• "I am likely to have a fever during the first week I am home."

• "I will resume taking my prenatal vitamins."

• "I will call my provider if I have discharge from my incision."

• "I should not have unrelieved pain in my abdomen."

• "I will rest in a recliner until my incision is healed."

Answer explanation

*Prenatal vitamins are often continued after birth for 6 weeks to ensure adequate vitamin intake and to promote healing.

*The client should report incisional discharge, redness, ecchymosis and/or edema, because it can be an indication of infection.

*A client will have abdominal pain and tenderness from the surgical procedure. Unrelieved pain can be an indication of infection.

*he postpartum client is at risk for thrombosis, especially following cesarean delivery. The nurse should encourage the client to ambulate and to avoid sitting for prolonged periods of time with legs crossed to reduce the risk for thrombophlebitis. Clients who have had a cesarean birth should wait until the 6-week follow-up visit before performing strenuous exercise, heavy lifting, or excessive stair climbing.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

• Evaluate the firmness of the uterus.

• Initiate oxygen therapy by nonrebreather mask.

• Administer oxytocin infusion.

• Obtain a type and crossmatch.

Answer explanation

A blood pressure of 60/50 mm Hg can indicate postpartum hemorrhage; therefore, the first action the nurse should take is to evaluate the firmness of the uterus to determine if there is uterine atony.