The nurse performs discharge teaching for a client who delivered an infant 2 days ago. The client asks the nurse to describe how the lochia will appear in 5 days. Which response by the nurse is best?

• "It will continue to be bloody like it is now."

• "It will be pink in color."

• "It will be yellow/white in color."

• "You will not have any lochia in 5 days."

The nurse palpates a client‘s fundus two hours after a vaginal delivery. The fundus is firm, shifted to the right, and is located two fingers above the umbilicus. Which statement does the nurse use to describe the finding to a colleague?

• “The fundus feels displaced due to a distended bladder.”

• “ The fundal assessment is within normal perimeters since the recent delivery.”

• “ I’m concerned about impending bleeding with the firmness I felt."

• “There may be retained placental tissue that has not been dispelled yet.”

A nurse is assessing a postpartum mother 12 hours after delivery. Which physical change should the nurse expect to find at this time?

• The fundus is palpable two fingerbreadths above the umbilicus.

• The fundus is firm and at the level of the umbilicus.

• Lochia rubra has completely stopped.

• The fundus is palpable two fingerbreadths below the umbilicus.

The nurse notes that a client two days postpartum has an oral temperature of 102°F (39.0°C) and yellow-brown foul-smelling lochia. The nurse immediately takes which action?

• Call the health care provider

• Assess the client for pelvic tenderness

• Increase the client's fluid intake

• Begin cooling measures

The nurse finds a postpartum client sitting in a pool of blood. The client is 6 hours post vaginal delivery. The client’s skin is cool and clammy with vital signs of BP 88/55 mm Hg, P 120 beats/minute, and R 40 breaths/minute. Which action does the nurse take first?

• Run to the nurses station to get help and notify the health care provider.

• Insert an indwelling urinary catheter and increase the client’s IV fluid rate.

• Place the client in high Fowler position and apply oxygen by nasal cannula.

• Gently massage the client’s uterus with two hands and verbally call for help.

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NGSS.HS-LS1-3

A client who delivered a neonate 2 days ago states to the nurse “I have terrible pain at my bottom all the time since the baby came.” Which question is important for the nurse to ask to determine the plan of care? (Select all that apply.)

• “Did you have an episiotomy during the delivery?”

• “Are you feeding the baby on a schedule?”

• “How often are you changing your peri pads?"

• “Do you understand how to use a sitz bath?”

• “What do you use for cleaning your bottom area?”

A nurse observes a 3-day postpartum mother who is attempting to change her infant’s diaper but becomes frustrated and asks for help. She expresses concern about “doing everything wrong.” Which nursing action is most appropriate?

• Explain that this behavior is characteristic of the letting-go phase

• Suggest she rest and allow staff to provide infant care.

• Take over the task to reduce her anxiety.

• Reassure her that she will soon adapt and encourage her to try again.

A new mother expresses concern about her emotional health, stating she feels sad and overwhelmed. Which response by the nurse is most appropriate?

• "You should not feel this way after having a baby."

• "Many new mothers experience mood changes; let's talk about your feelings."

• "You need to see a psychiatrist immediately."

• "Ignore these feelings; they will go away on their own."

A postpartum client tells the nurse, “I don’t want to breastfeed. I just want my milk to dry up. Can you give me something for that?”
Which nursing action is most appropriate at this time?

• Explain the benefits of breastfeeding and encourage her to reconsider.

• Encourage the client to express small amounts of milk to prevent discomfort.

• Teach the client to wear a tight-fitting bra, avoid breast stimulation, and use ice packs.

• Notify the health care provider to prescribe a dopamine agonist such as bromocriptine.

The nurse is providing discharge teaching to the parents of a healthy newborn about ways to reduce the risk of sudden infant death syndrome (SIDS). Which of the following statements by the parents indicate effective understanding of the teaching?
(Select all that apply.)

• “We’ll use a firm, flat mattress with a fitted sheet.”

• Our baby can sleep in our bed if we keep the blankets low.”

• “We’ll keep the crib free of pillows, toys, and loose blankets.”

• “We’ll always place our baby on the back to sleep.”

• “We’ll place the baby on the tummy for naps to help prevent a flat head.”