Chapter 14 High-Risk Postpartum Nursing Care

Chapter 14  High-Risk Postpartum Nursing Care

Complete Chapter Questions And Answers
 

Sample Questions

Multiple Choice

1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform?
a. Supervise all infant care.
b. Maintain client on strict bed rest.
c. Restrict visitation to her partner.
d. Carefully monitor toileting.

ANS: a

Feedback
a.
It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant.
b.
There is no need for a client with PP psychosis to be on strict bed rest.
c.
Visitation is not usually restricted to the woman’s partner.
d.
There is no need to monitor the client’s toileting.

KEY: Integrated Process: Nursing Process: Implementation | Cognitive Level: Application | Content Area: Postpartum Care; Psychopathology | Client Need: Health Promotion and Maintenance; Psychosocial Integrity | Difficulty Level: Difficult

2. Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery?
a. Nipples
b. Fundus
c. Lungs
d. Rectum

ANS: b

Feedback
a.
Her nipples should be assessed, but this is not the priority assessment.
b.
This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully.
c.
Her lungs should be assessed bilaterally, but this is not the priority assessment.
d.
Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

KEY: Integrated Process: Nursing Process: Assessment | Cognitive Level: Application | Content Area: Postpartum Care | Client Need: Health Promotion and Maintenance | Difficulty Level: Moderate

3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother?
a. Risk for altered parenting
b. Risk for imbalanced nutrition: less than body requirements
c. Risk for ineffective individual coping
d. Risk for fluid volume deficit

ANS: d

Feedback
a.
Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting.
b.
This woman’s baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements.
c.
There is no evidence that this mother is high risk for altered coping.
d.
This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

KEY: Integrated Process: Nursing Process: Analysis | Cognitive Level: Application | Content Area: Physiological Adaptation: Fluid and Electrolyte Imbalances; Postpartum Care; Reduction of Risk Potential: Potential for Alterations in Body Systems | Client Need: Health Promotion and Maintenance; Physiological Adaptation; Physiological Integrity: Reduction of Risk Potential | Difficulty Level: Difficult

4. The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by:
a. 5%
b. 8%
c. 10%
d. 15%

ANS: c
Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

5. The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and:
a. Breast engorgement
b. Uterine tenderness
c. Diarrhea
d. Emotional lability

ANS: b
During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

KEY: Integrated Process: Teaching and Learning | Cognitive Level: Knowledge | Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy