Maternal-Infant Nursing (Postpartum Period) Answers and Rationale

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1.    Answer: D

Rationale:  To help relieve mastitis, the nurse should advise the client to massage the affected area gently during breast-feeding; breast-feed at least every 2 to 3 hours; apply a warm, wet washcloth to her breast before each feeding; and avoid wearing a brassiere when breast-feeding.

2.    Answer: A

Rationale:  As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.

3.    Answer: C

Rationale:  Bethanechol stimulates the smooth muscle of the bladder, causing it to release retained urine. Bethanechol doesn’t act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle.

4.    Answer: A

Rationale:  A cold pack applied to an episiotomy during the first 24 hours after delivery may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. While perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection — not reduce discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it doesn’t relieve perineal discomfort.

5.    Answer: B

Rationale:  The diaphragm acts as a reservoir for spermicidal jelly or cream and must be left in place for at least 6 hours after intercourse to ensure spermicidal action. Inserting the diaphragm 4 hours before intercourse or removing it immediately afterward doesn’t ensure spermicidal effectiveness. A diaphragm must be used with spermicidal jelly or cream.

6.    Answer: C

Rationale:  Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn’t significant. Breast tenderness and mittelschmerz aren’t reliable indicators of ovulation.

7.    Answer: A

Rationale:  Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

8.    Answer: D

Rationale:  Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.

9.    Answer: C

Rationale:  Although all of the options accurately describe features of subdermal contraceptive implants, the main advantage of this contraceptive method is effective, continuous contraception that isn’t user dependent. The effectiveness of other methods, such as the condom, diaphragm, and oral contraceptives, depends at least partly on the user’s knowledge, skills, and motivation.

10.    Answer: D

Rationale:  Wearing gloves whenever exposure to blood or body fluids is anticipated is a standard precaution recommended by the Centers for Disease Control and Prevention. Although gloves protect both the client and the nurse from infectious organisms and guard against the nurse’s cold hands, the nurse wears them primarily to maintain universal precautions, which is required by the Occupational Safety and Health Administration.

11.    Answer: C

Rationale:  Taking-hold behaviors, the third step in parent-infant attachment, are best described by activities that involve tactile contact. These behaviors indicate that the parents have made significant strides toward taking care of their infant. Meeting the mother’s needs first, looking at the infant, and talking about the baby are typically associated with the taking-in period.

12.    Answer: A

Rationale:  Because of the mechanism of action of oral contraceptives, the onset of action is somewhat delayed. Full contraceptive benefits don’t occur until an oral contraceptive agent has been taken for at least 10 days.

13.    Answer: B

Rationale:  After a vasectomy, sterilization isn’t ensured until the client’s sperm count measures zero. This usually requires 6 to 36 ejaculations. Having intercourse immediately after the procedure or as soon as discomfort disappears may lead to pregnancy.

14.    Answer: C

Rationale:  Catheterization isn’t routinely done to protect the bladder from trauma. It’s done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the plan of care during the fourth stage of labor.

15.    Answer: B

Rationale:  By the 2nd postpartum day, the fundus should be firm and two fingerbreadths below the umbilicus. The fundus should be at the level of the umbilicus on the day of delivery and falls below the umbilicus by approximately one fingerbreadth (1 cm) per day, until it has contracted into the pelvis by the 9th or 10th day. The fundus should be firm, not soft. A soft or boggy fundus indicates that the uterus isn’t contracting properly. The fundus should be palpated in the midline of the abdomen; if the woman has a full bladder, however, the fundus may be deviated to the right or left.

16.    Answer: A

Rationale:  Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on baby care, and lochia monitoring are important aspects of care, the mother’s ability to feed and care for her infant takes priority.

17.    Answer: A

Rationale:  Tensing the buttocks before sitting or rising may ease edema, ecchymosis, or other discomfort caused by perineal sutures; the client should maintain the tension briefly. Supporting body weight on the arms of a chair strains the client’s arms and prevents her from assuming a full, comfortable sitting position. Placing a pillow behind her back may cause her to lean forward, putting even more pressure on the perineum. Sitting on an inflatable ring relieves pressure on some areas of the perineum but places more pressure on others.

18.    Answer: D

Rationale:  Engorgement in a breast-feeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Binding the breasts isn’t appropriate because the constriction will diminish the milk supply. Frozen cabbage leaves work well to reduce the pain and swelling and should be applied every 4 hours. Facing the shower head can stimulate the breasts and intensify the problem. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant.

19.    Answer: D

Rationale:  Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They also improve vaginal tone and help prevent stress incontinence and hemorrhoids. Kegel exercises can’t prevent urine retention, relieve lower back pain, or tone abdominal muscles.

20.    Answer: B

Rationale:  After a client gives birth, the height of her fundus should decrease about one fingerbreadth (about 1 cm) each day. Immediately after birth, the fundus may be above the umbilicus. At 6 to 12 hours after birth, it should be at the level of the umbilicus. By the end of the 1st postpartum day, the fundus should be one fingerbreadth below the umbilicus. After 10 days, it should be below the symphysis pubis.

21.    Answer: D

Rationale:  Lochia rubra, the first stage of lochia, typically lasts for the first 4 postpartum days. Bright red, it contains a mixture of blood, mucus, and tissue debris. There is no such thing as lochia nigra. Lochia alba, a creamy brown, white, or almost colorless discharge, appears during the 2nd and 3rd weeks postpartum. Lochia serosa, a pinkish serous discharge, typically occurs on postpartum days 5 to 7.

22.    Answer: B

Rationale:  Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the 1st hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery.

23.    Answer: C

Rationale:  Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after delivery. Episiotomy discomfort sometimes persists for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks’ postpartum. A temperature of 99.2° F (37.3° C) isn’t significant.

24.    Answer: C

Rationale:  To determine the fertile period, the client should subtract 18 days from her shortest menstrual cycle and 11 days from her longest cycle; if she doesn’t wish to become pregnant, she should abstain from unprotected intercourse between the days calculated. For example, if her menstrual cycles range from 28 to 30 days, her fertile period encompasses days 10 to 19 of her cycle. Abstaining from unprotected intercourse on certain days (option A) doesn’t determine the fertile period; also, for most women, abstaining on days 14 through 16 wouldn’t be sufficient to cover the entire fertile period. Options B and D are incorrect applications of the calendar method.

25.    Answer: D

Rationale:  Breast-feeding should continue for the first 6 months after birth when possible. Breast milk can be pumped at work to give to the baby at the day-care center. This will also keep the mother’s milk production up.

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