Preview Extract
Chapter 31
1) The nurse had completed a postpartum assessment on a patient who gave birth to her first
child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was
boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum
ecchymotic and edematous, and pain rating 6 on scale of 1–10. Her partner is present and
supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the
highest priority for this patient?
1. Acute pain related to perineal trauma
2. Risk for deficient fluid volume related to uterine bleeding and nausea
3. Readiness for enhanced family coping
4. Knowledge deficit related to newborn care
Answer: 2
Rationale 1:
Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid
volume deficit.
Rationale 2:
Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority
nursing diagnosis.
Rationale 3:
Although this nursing diagnosis may be applicable, family coping is a lower priority than is
risk for fluid volume deficit.
Rationale 4:
Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial
issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.
2) During a home care visit, the new mother complains of breast engorgement. Which
intervention is most appropriate for recommendation by the home care nurse?
1. “Apply an ice compress to your breast before nursing.”
2. “Encourage your baby to suckle for an average of 5 minutes per feeding.”
3. “Apply warm compresses to your breast after you finish feeding your baby.”
4. “When you aren’t nursing, wear a well-fitted nursing bra at all times, even when you
sleep.”
Answer: 4
Rationale 1:
Warm compresses before nursing stimulate let-down and soften the breast so that the infant
can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the
breasts and provide comfort to the mother.
Rationale 2:
For women with breast engorgement, the infant should suckle for an average of 15 minutes
per feeding and should feed at least 8 to 12 times in 24 hours.
Rationale 3:
Warm compresses before nursing stimulate let-down and soften the breast so that the infant
can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the
breasts and provide comfort to the mother.
Rationale 4:
The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and
prevent discomfort from tension.
3) The postpartum patient delivered 4 hours ago. She has a mediolateral episiotomy and large
hemorrhoids. She is rating her pain at 7 on a scale of 1–10. She has a history of anaphylactic
reaction to Tylenol (acetaminophen). Which nursing action would be best?
1. Offer the patient 800 mg Advil (ibuprofen) orally with food.
2. Provide two Percocet (oxycodone with acetaminophen) by mouth.
3. Encourage use of Dermoplast topical anesthetic spray.
4. Run very warm water into the tub and assist her into the bath.
Answer: 1
Rationale 1:
This is the best option, because the patient is experiencing moderately severe pain with
inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces
inflammation and provides pain relief.
Rationale 2:
This medication is contraindicated because of the patient’s allergic reaction to
acetaminophen.
Rationale 3:
Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a
patient has moderately severe pain.
Rationale 4:
Ice packs would be better at this stage, because they will cause vasoconstriction to reduce
edema and pain relief.
4) On the second day postpartum, the patient experiences engorgement. To relieve her
discomfort, the nurse should encourage the patient to:
1. Remove her bra.
2. Apply heat to her breasts.
3. Apply ice packs to her breasts.
4. Limit breastfeeding to twice daily.
Answer: 3
Rationale 1:
Removing her bra will only serve to increase breast milk production.
Rationale 2:
Applying heat will promote breast milk production.
Rationale 3:
Applying ice packs to the breasts relieves discomfort through the numbing effect of ice.
Rationale 4:
Limiting breastfeeding to b.i.d. actually would decrease the flow of breast milk eventually,
and would not serve to decrease the discomfort of mother or infant.
5) The nurse is caring for a patient who had a cesarean birth 4 hours ago. Which of the
following interventions would the nurse implement at this time?
1. Administer analgesics as needed.
2. Encourage the patient to ambulate to the bathroom to void.
3. Encourage leg exercises every 2 hours.
4. Encourage the patient to cough and deep-breathe every 2–4 hours.
5. Encourage the use of breathing, relaxation, and distraction.
Answer: 1,3,4,5
Rationale 1:
Administering analgesics as needed, encouraging leg exercises every 2 hours, encouraging
the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing,
relaxation, and distraction all address the patient’s nursing care needs, which are similar to
those of other surgical patients.
Rationale 2:
Encouraging her to ambulate to the bathroom to void might be an intervention done on the
first or second day postpartum, but not in the first 4 hours.
Rationale 3:
Administering analgesics as needed, encouraging leg exercises every two hours, encouraging
the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing,
relaxation, and distraction all address the patient’s nursing care needs, which are similar to
those of other surgical patients.
Rationale 4:
Administering analgesics as needed, encouraging leg exercises every two hours, encouraging
the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing,
relaxation, and distraction all address the patient’s nursing care needs, which are similar to
those of other surgical patients.
Rationale 5:
Administering analgesics as needed, encouraging leg exercises every two hours, encouraging
the patient to cough and deep-breathe every 2–4 hours, and encouraging the use of breathing,
relaxation, and distraction all address the patient’s nursing care needs, which are similar to
those of other surgical patients.
6) The community health nurse is presenting a seminar to new mothers about breastfeeding.
When discussing weaning, which new mother’s statement suggests a need for further
teaching?
1. “Slow weaning should take place over a period of several months.”
2. “By weaning my baby slowly, I’m giving him time to change his eating method at his own
pace.”
3. “If I wean my baby slowly, I am less likely to develop breast engorgement.”
4. “Slowly weaning my baby is recommended to allow time for psychological adjustment.”
Answer: 1
Rationale 1:
During slow weaning, over a period of several weeks the mother substitutes more cup
feedings or bottle feedings for breastfeedings.
Rationale 2:
The slow method of weaning prevents breast engorgement, allows infants to alter their eating
methods at their own rates, and provides time for psychological adjustment.
Rationale 3:
The slow method of weaning prevents breast engorgement, allows infants to alter their eating
methods at their own rates, and provides time for psychological adjustment.
Rationale 4:
The slow method of weaning prevents breast engorgement, allows infants to alter their eating
methods at their own rates, and provides time for psychological adjustment.
7) The hospital is developing a new maternity unit. What aspects should be included in the
planning of this new unit to best promote family wellness?
1. Normal newborn nursery centrally located to all patient rooms
2. A kitchen with refrigerator stocked with juice and sandwiches
3. Small, cozy rooms with a patient bed and rocking chair
4. A nursing model based on providing couplet care
Answer: 4
Rationale 1:
Rooming-in better promotes family wellness than does having newborns in the nursery.
Rationale 2:
Although having snacks is good for postpartum patients, some cultures prohibit drinking cold
liquids after birth; warm liquids must also be available for optimal family wellness.
Rationale 3:
Small rooms can become overly crowded when siblings and grandparents come to visit.
Larger rooms that facilitate family attachment are better.
Rationale 4:
Couplet care, where the nurse cares for both the mother and the infant, best promotes family
wellness. Having one nurse care for the mother and another nurse care for the baby is much
less family-centered.
8) The patient having her second child is scheduled for a cesarean birth because the baby is in
a breech presentation. The patient states, “I’m wondering what will be different this time
compared with my first birth, which was vaginal.” What response is best?
1. “We’ll take good care of you and your baby. You’ll be home before you know it.”
2. “You’ll be wearing long stockings to prevent blood clots from forming in your legs.”
3. “You will have a lot of pain, but there are medications that we give when it gets bad.”
4. “You won’t be able to nurse until the baby is 12 hours old, because of your epidural.”
Answer: 2
Rationale 1:
This response focuses on the nurse, and does not provide specific information to answer the
patient’s question. This is a poor response.
Rationale 2:
Anti-embolism stockings are used until the patient is up and walking to prevent thrombus
formation.
Rationale 3:
Focusing on the pain is a negative emphasis. In addition, pain medications work best when
they are taken as the pain is intensifying; medication should not be delayed until the pain is
severe, as less relief will be obtained.
Rationale 4:
Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a
mother’s ability to breastfeed. She might need some assistance with positioning the infant due
to bed rest, but should be encouraged to breastfeed as soon as possible.
9) The nurse is caring for a patient who delivered by cesarean birth. The patient received a
general anesthetic. The nurse would encourage which of the following in order to prevent or
minimize abdominal distention?
1. Increased intake of cold beverages
2. Leg exercises every 2 hours
3. Abdominal tightening
4. Ambulation
5. Eating a high-protein general diet
Answer: 2,3,4
Rationale 1:
Increased intake of cold beverages and eating a high-protein general diet would increase the
distention through increase of gas and constipation.
Rationale 2:
Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or
minimize abdominal distention in a surgical patient who received a general anesthetic.
Rationale 3:
Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or
minimize abdominal distention in a surgical patient who received a general anesthetic.
Rationale 4:
Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or
minimize abdominal distention in a surgical patient who received a general anesthetic.
Rationale 5:
Increased intake of cold beverages and eating a high-protein general diet would increase the
distention through increase of gas and constipation.
10) The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday.
What action is the best indicator that the nurse understands the parenting adolescent?
1. The patient’s mother is included in all discussions and demonstrations.
2. The father of the baby is encouraged to change a diaper and give a bottle.
3. The nurse explains the characteristics and cues of the baby during the assessment.
4. A discussion on contraceptive methods is the first topic of teaching.
Answer: 3
Rationale 1:
Although the parents of adolescents are often involved with child care and childrearing, this
action is only appropriate if the patient desires to have her mother present for teaching and
discussions.
Rationale 2:
Involvement of the father is important, but having the mother learn more about her new baby
and what the behavior cues are is a higher priority.
Rationale 3:
This helps the patient learn about her baby and understand him as an individual, and
facilitates maternal–infant attachment. This is the highest priority.
Rationale 4:
Young teens are statistically more likely to have another child during their adolescence, but
establishing a rapport and facilitating understanding of and attachment to the newborn is a
higher priority.
11) The nurse is preparing to receive a newly delivered patient. The patient is a young single
mother who is relinquishing custody of her newborn through an open adoption. What action
is most important?
1. Assign the patient a room on the GYN surgical floor instead of the postpartum floor.
2. Prepare to have teaching done in time for discharging the patient at 24 hours postdelivery.
3. Make an effort to not bring up the topic of the baby, and discuss the mother’s health
instead.
4. Ask the patient if she wants to feed her baby, and how much contact she wants to have.
Answer: 4
Rationale 1:
Patients relinquishing their newborns should be given options for what their contact with the
infant will be and where they would feel most comfortable. Make no assumptions, but assess
instead.
Rationale 2:
Not all patients who relinquish their infants want early discharge. Make no assumptions, but
assess instead.
Rationale 3:
The patient’s preferences determine how much she wants to talk about her birth, her
newborn, or her decision to relinquish the child. Make no assumptions, but assess instead.
Rationale 4:
Assess the patient’s preferences by respectfully asking questions and making no assumptions
to facilitate a more positive experience for the birth mother.
12) The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse
would implement which of the following approaches to care?
1. Encourage the patient to see and hold her infant.
2. Encourage the patient to express her emotions.
3. Respect any special requests for the birth.
4. Acknowledge the grieving process in the patient.
5. Allow for access to the infant if the patient requests it.
Answer: 2,3,4,5
Rationale 1:
Encouraging the patient to see and hold her infant does not respect the patient’s right to
refuse interaction, and might make her feel guilty for not wanting to see the infant.
Rationale 2:
Encouraging the patient to express emotions, respecting any special request for the birth,
acknowledging the grieving process, and allowing for access to the infant at patient’s requests
all are aspects of providing care for the patient who decides to relinquish her infant.
Rationale 3:
Encouraging the patient to express emotions, respecting any special request for the birth,
acknowledging the grieving process, and allowing for access to the infant at patient’s requests
all are aspects of providing care for the patient who decides to relinquish her infant.
Rationale 4:
Encouraging the patient to express emotions, respecting any special request for the birth,
acknowledging the grieving process, and allowing for access to the infant at patient’s requests
all are aspects of providing care for the patient who decides to relinquish her infant.
Rationale 5:
Encouraging the patient to express emotions, respecting any special request for the birth,
acknowledging the grieving process, and allowing for access to the infant at patient’s requests
all are aspects of providing care for the patient who decides to relinquish her infant.
13) The maternal home care nurse is orienting a new nurse. During orientation, they are
discussing maternal psychological adaptations and stressors. Which statement by the
maternal home care nurse reflects the correct approach to addressing potential and actual
postpartum depression in maternal patients?
1. “Because emotional disorders and imbalances are a very sensitive subject, we try not to
offend patients by routinely bringing up the topic of postpartum depression.”
2. “For women with a history of depression, we include education about postpartum
depression.”
3. “Teaching about postpartum depression is a routine part of education for all maternal
patients.”
4. “If we suspect a woman may have developed postpartum depression, then we provide
specialized education about that topic.”
Answer: 3
Rationale 1:
Teaching content should include information on role changes and psychological adjustments
as well as skills. Risk factors and signs of postpartum depression should be reviewed with all
women.
Rationale 2:
Teaching content should include information on role changes and psychological adjustments
as well as skills. Risk factors and signs of postpartum depression should be reviewed with all
women.
Rationale 3:
Teaching content should include information on role changes and psychological adjustments
as well as skills. Risk factors and signs of postpartum depression should be reviewed with all
women.
Rationale 4:
Teaching content should include information on role changes and psychological adjustments
as well as skills. Risk factors and signs of postpartum depression should be reviewed with all
women.
14) During a home care visit, a couple expresses a desire for cosleeping, or sleeping in the
same bed with their newborn baby. Which nursing response is most appropriate?
1. “Current research suggests there are no physical risks related to cosleeping, and this
recommended as a healthy psychological approach to family bonding.
2. “Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping
on his stomach.”
3. “Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need
to following specific safety guidelines.”
4. “If you practice cosleeping, your baby should be placed on a comforter, as opposed to
directly on the mattress.”
Answer: 3
Rationale 1:
The American Academy of Pediatrics does not recommend cosleeping because it is
considered a risk factor for SIDS. Some families and cultures, however, may still participate
in this practice and thus warrant appropriate teaching measures. Cosleeping families should
be counseled to follow specific safety guidelines.
Rationale 2:
The American Academy of Pediatrics does not
recommend cosleeping because it is considered a risk factor for SIDS.
Families who practice cosleeping require appropriate teaching measures, which include
following safety guidelines such as making sure the baby is sleeping on his or her back.
Rationale 3:
The American Academy of Pediatrics does not
recommend cosleeping because it is considered a risk factor for SIDS.
Some families and cultures, however, may still participate in this
practice and thus warrant appropriate teaching measures.
Cosleeping families should be counseled to follow specific safety
guidelines
Rationale 4:
Safety guidelines related to cosleeping include placing the infant on a firm mattress, never on
comforters, pillows, or a waterbed.
Test Bank for Contemporary Maternal-Newborn Nursing
Patricia W Ladewig, Marcia L London, Michele Davidson
9780133429862, 9780134257020
