Chapter 30
1) The nurse has received an end of shift report on the postpartum unit. Which patient should
she see first?
1. Multip, second day post-cesarean, moderate lochia serosa
2. Primip, day of delivery, fundus firm 2 cm above umbilicus
3. Multip, first postpartum day, 4 cm diastasis recti abdominis
4. Primip, first postpartum day, hypoactive bowel sounds all quadrants
Answer: 2
Rationale 1:
This patient is not experiencing any unexpected findings.
Rationale 2:
This patient is the top priority. The fundus should not be positioned above the umbilicus after
delivery. This high location could indicate an overdistended bladder or uterine atony and
excessive bleeding.
Rationale 3:
This finding is normal, especially in a multiparous patient.
Rationale 4:
Bowel sounds are often decreased after delivery.
2) The nurse expects an initial weight loss for the average postpartum patient to be:
1. 5–8 pounds.
2. 10–12 pounds.
3. 12-15 pounds.
4. 15–20 pounds.
Answer: 2
Rationale 1:
5–8 pounds might be the loss after a preterm birth.
Rationale 2:
10–12 pounds is the usual initial weight loss. This weight is lost with the birth of the infant
and the expulsion of the placenta and the amniotic fluid.
Rationale 3:
12–15 pounds is close, but it does not match the usual weight of placenta, amniotic fluid, and
full-term infant weight.
Rationale 4:
15–20 pounds might be the loss from a multiple birth.
3) To assess healing of the uterus at the placental site, the nurse assesses:
1. Lab values.
2. Blood pressure.
3. Uterine size.
4. Type, amount, and consistency of lochia.
Answer: 4
Rationale 1:
Lab values is incomplete as an answer because it does not indicate which lab values are in
question.
Rationale 2:
Blood pressure varies slightly in the normal postpartum woman and would not affect the
placental site.
Rationale 3:
Uterine size alone is not enough to assess the placenta site.
Rationale 4:
Type, amount, and consistency of lochia determine the stage of healing of the placenta site,
which occurs by a process of exfoliation.
4) A Jewish patient delivers a healthy baby boy on Thursday afternoon, and she is set to be
discharged on Saturday morning. Why might this present a problem for the patient?
1. Jewish custom is to have the infant circumcised two days after birth.
2. The woman will expect to be in the hospital at least seven days after delivery.
3. Saturday is considered the Sabbath and she will not be able to leave the hospital that day.
4. The husband cannot touch his wife while she is experiencing vaginal discharge, so he will
not be able to assist his wife to and from the vehicle.
Answer: 3
Rationale 1:
Jewish custom is to have the infant circumcised eight days after birth, not two days after
birth. Jewish couples will need to return to the hospital for circumcision of the infant after
discharge.
Rationale 2:
The woman will expect to be cared for by her family for the first seven days after delivery.
This does not need to take place in the hospital and should not interfere with discharge from
the hospital.
Rationale 3:
The Sabbath is sacred for Jews, and Jewish custom prohibits travel, writing, and the use of
electricity on the Sabbath. Therefore, the woman will not travel home or sign any discharge
forms until after the Sabbath.
Rationale 4:
If the patient had a normal delivery and healthy baby, she will be able to walk on her own.
Therefore, this would not interfere with the woman’s discharge from the hospital.
5) On the first postpartum day, the nurse teaches the patient about breastfeeding. Two hours
later, the mother seems to remember very little of the teaching. The nurse understands this
memory lapse to be due to:
1. The taking-hold phase.
2. Postpartum hemorrhage.
3. The taking-in phase.
4. Epidural anesthesia
Answer: 3
Rationale 1:
The taking-hold phase occurs by the second or third day, when the mother is ready to resume
control of life and is open to teaching.
Rationale 2:
Postpartum hemorrhage is a serious complication and will need medical intervention.
Rationale 3:
The taking-in phase, which occurs during the first day or two following birth, is characterized
by a passive and dependent affect. The mother also might be in need of food and rest.
Rationale 4:
Epidural anesthesia is a pharmacological approach to pain control.
6) The nurse is working with a new mother who follows Muslim traditions. Which
expectations and actions are appropriate for this patient?
1. Be sure she gets a kosher diet.
2. Expect that most visitors will be women.
3. Uncover only the necessary skin when assessing.
4. The patient will avoid cold air and water after birth.
5. She will prefer a male physician.
Answer: 2,3
Rationale 1:
A kosher diet is appropriate for Jewish women, not Muslims. Although many of the dietary
laws are similar, kosher is not appropriate for a Muslim patient.
Rationale 2:
This is true because women are not in the company of men to whom they are not married
whenever possible.
Rationale 3:
Modesty is very important to Muslims. Use the bed covers to drape the patient while
performing the postpartum assessment.
Rationale 4:
Hispanic, African, and Asian women are likely to avoid cold air and water after delivery, but
Muslim women do not follow this same belief.
Rationale 5:
Because of modesty and the restrictions against touching and being touched by males who are
not the spouse, most Muslim women highly prefer female care providers.
7) The nurse is observing a new graduate’s assessment of a postpartum patient. Which action
by the student nurse should prompt a corrective intervention by the preceptor nurse?
1. Ask the patient to void, and don clean gloves.
2. Discussing the effectiveness of patient comfort measures while performing the perineal
assessment.
3. Instructing the patient’s visitors to leave the room prior to beginning the assessment.
4. Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal
assessment.
Answer:
Rationale 1:
Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body
fluids.
Rationale 2:
The assessment provides an excellent opportunity for teaching about good healthcare
practices in both the short and long term, including comfort measures.
Rationale 3:
The nurse should allow the patient to choose whether visitors leave or remain in the room
during the assessment.
Rationale 4:
The supine position prevents a falsely high assessment of fundal height.
8) Put the following components specific to postpartum examination of a patient in the proper
sequential order.
Choice 1. L-lochia
Choice 2. E-emotional
Choice 3. H-Homans’/hemorrhoids
Choice 4. B-breast
Choice 5. E-episiotomy/laceration/edema
Choice 6. U-uterus
Choice 7. B-bowel
Choice 8. B-bladder
Answer: 4,6,8,7,1,5,3,2
Rationale 1:
Breast (Choice 4) assessment should be performed first during the postpartum examination.
This includes assessing breast engorgement, tenderness, and the mother's breastfeeding
experience.
Rationale 2:
Uterus (Choice 6) assessment follows breast examination. The healthcare provider should
assess the fundal height, location, and firmness of the uterus to monitor for uterine involution
and potential complications such as uterine atony or retained placental fragments.
Rationale 3:
Bladder (Choice 8) assessment is the next step in the postpartum examination sequence.
Checking for bladder distention, urinary frequency, and any difficulty with urination is
important to prevent urinary retention or urinary tract infections.
Rationale 4:
Bowel (Choice 7) assessment comes after bladder assessment. It involves evaluating bowel
function, including bowel sounds, presence of gas or stool, and any signs of constipation or
bowel obstruction.
Rationale 5:
Lochia (Choice 1) assessment follows bowel assessment. This involves evaluating the
amount, color, and odor of vaginal discharge to monitor for normal postpartum bleeding or
signs of complications such as hemorrhage or infection.
Rationale 6:
Episiotomy/laceration/edema (Choice 5) assessment should be performed next. This includes
inspecting the perineum for any lacerations, episiotomy healing, or signs of infection. Edema
in the perineal area should also be assessed.
Rationale 7:
Homans’/hemorrhoids (Choice 3) assessment is the last step in the postpartum examination
sequence. This involves evaluating for the presence of hemorrhoids, which may develop or
worsen during pregnancy and childbirth. Additionally, checking for signs of deep vein
thrombosis using Homans' sign may be included in this assessment.
Rationale 8:
Emotional (Choice 2) assessment is an ongoing process throughout the postpartum period but
may be considered the last step in the examination sequence. It involves assessing the
mother's emotional well-being, bonding with the baby, and any signs of postpartum
depression or anxiety.
9) The nurse is performing a postpartum assessment on a newly delivered patient. When
checking the fundus, there is a gush of blood. The patient asks why that is happening. The
best response is:
1. “We see this from time to time. It’s not a big deal.”
2. “The gush is an indication that your fundus isn’t contracting.”
3. “Don’t worry. I’ll make sure everything is fine.”
4. “Blood has pooled in the vagina while you were in bed.”
Answer: 4
Rationale 1:
Although a gush of blood during fundus assessment is fairly common, this response is not
therapeutic because it does not answer the patient’s question.
Rationale 2:
The fundus might be contracting well. The gush is from pooled lochia in the vagina.
Rationale 3:
This response is not therapeutic because it focuses on the nurse and has a “don’t worry”
aspect that most patients find demeaning.
Rationale 4:
Because of the angle of the vagina, lochia pools in the vagina while a woman is lying or
semi-sitting in bed, which leads to a gush when fundal massage is undertaken.
10) The postpartum nurse is caring for a first-time mother who is unable to breastfeed her
baby. While assessing the patient’s breasts the day after birth, which teaching point should
the nurse include?
1. The let-down reflex
2. Lactation suppression
3. The purpose of fundal massage
4. The cause of afterpains
Answer: 2
Rationale 1:
The let-down reflex is an important teaching point for breastfeeding patients.
Rationale 2:
It is important to teach non-breastfeeding patients about lactation suppression after delivery
but before discharge.
Rationale 3:
The purpose of fundal massage should be addressed when assessing the uterus and fundus,
not when assessing the breasts.
Rationale 4:
Afterpains can be stimulated by breastfeeding, and they are more common in multiparas.
Therefore, the nurse will likely not need to teach a non-breastfeeding primipara about
afterpains.
LO05 - Describe the normal characteristics and common concerns of the mother considered
in a postpartum assessment.
11) Every time the nurse enters the room of a postpartum patient who gave birth three hours
ago, the patient asks something else about her birth experience. The nurse would:
1. Answer questions quickly and try to divert her attention to other subjects.
2. Review documentation of the birth experience and discuss it with her.
3. Contact the physician to warn him the patient might want to file a lawsuit due to her
preoccupation with her birth experience.
4. Submit a referral to Social Services because you are concerned about obsessive behavior.
Answer: 2
Rationale 1:
Answering questions quickly and trying to divert her attention to other subjects trivializes her
questions and does not allow her to sort out the reality from her subjective experience.
Rationale 2:
Review documentation of the birth experience and discuss it with her so the patient can
integrate the experience. Three hours after birth, the mother needs to talk about her
perceptions of her labor and delivery.
Rationale 3:
Contacting the physician to warn him that the patient might want to file a lawsuit due to her
preoccupation with her birth experiences is not warranted.
Rationale 4:
Submitting a referral to Social Services because you are concerned about obsessive behavior
is an incorrect action because this behavior is normal.
12) During her interactions with a primipara mother, the nurse notices that the mother rarely
interacts with the infant unless the infant begins to cry vigorously. She appears relieved when
a nurse comes to check on the infant. What is the appropriate nursing intervention for this
patient?
1. Ask the mother if she has previous experience caring for babies, and then teach her how to
interact appropriately with her infant.
2. Contact Social Services with concerns of neglect.
3. Provide the care the infant needs while continuing to evaluate the mother’s actions.
4. Take the infant to the nursery so it can receive more consistent care.
Answer: 1
Rationale 1:
Many primipara mothers will be hesitant to care for the infant because they feel inadequate.
Taking time to talk to the mother and teach her how to care for her baby is the proper nursing
intervention.
Rationale 2:
The mother may only need some education on how to care for her infant. If the nurse
consistently teaches the mother and encourages mother-infant interaction and the mother
continues to ignore the child, then it may be appropriate to contact Social Services in extreme
circumstances.
Rationale 3:
While this action does provide for the needs of the child while he or she is in the hospital, it
does not help the mother know how to care for her child once she returns home.
Rationale 4:
Instead of encouraging mother-infant bonding, this action may emotionally distance the
mother from her child even more. It may also confirm the mother’s feelings of inadequacy.
13) During the first several months after birth, the mother and infant begin to know each
other. This relationship progresses through several phases. Which of the following actions are
to be expected in the phase of mutual regulation?
1. The infant grasps his or her mother’s finger while nursing.
2. The infant begins to seek out the mother over other individuals.
3. The mother spends more time making eye-to-eye contact with the infant.
4. The mother vocalizes feelings of frustration with her infant.
Answer: 4
Rationale 1:
Actions that make the infant more attractive to the mother, such as grasping a finger, usually
occurs during the acquaintance phase.
Rationale 2:
When the relationship between mother and infant reaches reciprocity, the infant will seek to
interact with the mother more.
Rationale 3:
Holding the infant in the en face position is likely to occur most often in the acquaintance
phase.
Rationale 4:
The mother is most likely to vocalize her negative maternal feelings during the phase of
mutual regulation, when both the mother and infant are determining the amount of control
each partner will have in the relationship.
14) The nurse is to begin the postpartum teaching of a mother who has given birth to her first
child. What aspect of teaching is most important?
1. Describe the likely reaction of siblings to the new baby.
2. Discuss adaptation to grandparenthood by her parents.
3. Determine if father–infant attachment is taking place.
4. Assist the mother in identifying behavior cues of the baby.
Answer: 4
Rationale 1:
This is not appropriate because the baby has no siblings.
Rationale 2:
Adaptation to grandparenthood is a task for her parents and not a high priority for teaching to
the new mother.
Rationale 3:
Although father–infant attachment is important, the mother is the main patient, and teaching
her directly is a higher priority.
Rationale 4:
Helping the mother to identify her baby’s behavior cues facilitates the acquaintance phase of
maternal–infant attachment.
15) The nurse is performing an assessment of early attachment. During the assessment, the
nurse needs to answer the question “Does the mother seem pleased with her baby’s
appearance and sex?” Which action of the mother might help answer this question?
1. The mother enfolds the infant in her arms.
2. The mother feeds the infant every 2-3 hours as instructed.
3. The mother points out family traits she sees in the newborn.
4. The mother asks questions about how to properly bathe her infant.
Answer: 3
Rationale 1:
This action can be used to assess if the mother is attracted to her newborn and is forming
emotional attachments with the newborn.
Rationale 2:
This action can be used to assess the ability of the mother to care for the infant’s needs as
they arise.
Rationale 3:
This action will help determine if the mother is pleased with her baby’s appearance. She may
point out both positive and negative traits.
Rationale 4:
This action helps assess the mother’s willingness to learn how to care for her infant.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
