Chapter 14: Nursing Care of the Family during the Fourth Trimester My Nursing Test Banks

Lowdermilk: Maternity Nursing, 8th Edition

Chapter 14: Nursing Care of the Family during the Fourth Trimester

Test Bank 

MULTIPLE CHOICE

1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, Im bleeding a lot. The most likely cause of postpartum hemorrhage in this woman is:

a. Retained placental fragments.
b. Unrepaired vaginal lacerations.
c. Uterine atony.
d. Puerperal infection.

ANS: C

Feedback
A Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman.
B Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth.
C This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony.
D Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours after delivery.

DIF:Cognitive Level: AnalysisREF:397

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

2. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurses first action is to:

a. Begin an intravenous (IV) infusion of Ringers lactate solution.
b. Assess the womans vital signs.
c. Call the womans primary health care provider.
d. Massage the womans fundus.

ANS: D

Feedback
A The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action.
B Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurses first action.
C The physician would be notified after the nurse completes the assessment of the woman.
D The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

DIF:Cognitive Level: ApplicationREF:399

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

3. A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders?

a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.

ANS: D

Feedback
A A multiparous classification is not an indication for these orders.
B A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions.
C Use of epidural anesthesia has no correlation with these orders.
D These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids.

DIF:Cognitive Level: ComprehensionREF:400

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

4. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?

a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.

ANS: A

Feedback
A This patients rubella titer indicates that she is not immune and that she needs to receive a vaccine.
B These data do not indicate that the patient needs a blood transfusion.
C Rh immune globulin is indicated only if the patient has a negative Rh status and the infant has a positive Rh status.
D A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.

DIF:Cognitive Level: ComprehensionREF:406

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

5. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:

a. Running warm water on her breasts during a shower.
b. Applying ice to the breasts for comfort.
c. Expressing small amounts of milk from the breasts to relieve pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B

Feedback
A This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves.
B This intervention is appropriate for treating engorgement in a mother who is bottle-feeding.
C A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk.
D A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.

DIF:Cognitive Level: ApplicationREF:406

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

6. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurses most appropriate response is:

a. Didnt you like your lunch?
b. Does your doctor know that you are planning to eat that?
c. What is that anyway?
d. Ill warm the soup in the microwave for you.

ANS: D

Feedback
A Cultural dietary preferences must be respected.
B Women may request that family members bring favorite or culturally appropriate foods to the hospital.
C Cultural dietary preferences must be respected. A statement such as this does not show cultural sensitivity.
D This statement shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response.

DIF:Cognitive Level: ApplicationREF:410, 411

OBJ:Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

7. Which finding could prevent early discharge of a newborn who is now 12 hours old?

a. Birth weight of 3000 g
b. One meconium stool since birth
c. Voided, clear, pale urine three times since birth
d. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.

ANS: D

Feedback
A Birth weight of 3000 g is a normal infant finding and would not prevent early discharge.
B One meconium stool since birth is a normal infant finding and would not prevent early discharge.
C Voiding three times since birth is a normal infant finding and would not prevent early discharge.
D This finding indicates that the infant is having some difficulty with breastfeeding. The infant needs to complete at least two successful feedings (normal sucking and swallowing) before an early discharge.

DIF:Cognitive Level: ComprehensionREF:394

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation

8. In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:

a. Has recovered from epidural or spinal anesthesia.
b. Has hidden bleeding underneath her.
c. Has regained some flexibility.
d. Is a candidate to go home after 6 hours.

ANS: A

Feedback
A If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.
B This would be an assessment for postpartum bleeding.
C Asking the woman to perform this function has nothing to do with determining flexibility.
D It would be very unlikely that a patient who has just delivered a baby with epidural or spinal anesthesia would be a candidate for discharge after 6 hours.

DIF:Cognitive Level: ComprehensionREF:403

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Evaluation

9. Under the Newborns and Mothers Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.

a. 24, 73
b. 24, 96
c. 48, 96
d. 48, 120

ANS: C

Feedback
A The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
B The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
C The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.
D The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.

DIF:Cognitive Level: KnowledgeREF:393

OBJ: Client Needs: Safe and Effective Care Environment TOP: Nursing Process: Planning

10. In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:

a. The father of the infant.
b. Her mother (the infants grandmother).
c. Her eldest daughter (the infants sister).
d. The nurse.

ANS: D

Feedback
A In couplet care, the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.
B In couplet care, the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.
C In couplet care, the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.
D In couplet care, the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.

DIF:Cognitive Level: KnowledgeREF:395

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

11. Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:

a. Formally initializing individualized care by confirming the womans and infants identification (ID) numbers on their respective wrist bands. (This is your baby.).
b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. (Its a dangerous world out there.)
c. Including other family members in the teaching of self-care and child care. (Were all in this together.)
d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

ANS: D

Feedback
A Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. Mothering the mother is more a process of encouraging and supporting the woman in her new role.
B Having the mother check IDs is a security measure for protecting the baby from abduction. Mothering the mother is more a process of encouraging and supporting the woman in her new role.
C Teaching the whole family is just good nursing practice. Mothering the mother is more a process of encouraging and supporting the woman in her new role.
D Many professionals believe that the nurses nurturing and support function is more important than providing physical care and teaching.

DIF:Cognitive Level: ComprehensionREF:408

OBJ:Client Needs: Psychosocial Integrity

TOP: Nursing Process: Implementation

12. Excessive blood loss after childbirth can have several causes; the most common is:

a. Vaginal or vulvar hematomas.
b. Unrepaired lacerations of the vagina or cervix.
c. Failure of the uterine muscle to contract firmly.
d. Retained placental fragments.

ANS: C

Feedback
A Although these are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
B Although this is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.
C Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention.
D Although this is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

DIF:Cognitive Level: KnowledgeREF:399

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Evaluation

13. A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:

a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. Determine which pad is best.
c. Demonstrate that other nurses usually underestimate blood loss.
d. Reveal to the nurse supervisor that one of them needs some time off.

ANS: A

Feedback
A Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances.
B Possibly. More likely the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation.
C Doubtful. Nurses usually overestimate blood loss, if anything. More likely the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation.
D More likely the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation.

DIF:Cognitive Level: ApplicationREF:400

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

14. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is:

a. Pouring water from a squeeze bottle over the womans perineum.
b. Placing oil of peppermint in a bedpan under the woman.
c. Asking the physician to prescribe analgesics.
d. Inserting a sterile catheter.

ANS: D

Feedback
A Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early.
B The oil of peppermint releases vapors that may relax the necessary muscles. It is easy, noninvasive, and should be tried early.
C If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter.
D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills).

DIF:Cognitive Level: ComprehensionREF:401

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Implementation

15. If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:

a. Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
b. Having her flex, extend, and rotate her feet, ankles, and legs.
c. Having her sit in a chair.
d. Notifying the physician immediately if a positive Homans sign occurs.

ANS: C

Feedback
A TED hose and SCD boots are recommended. Just sitting in a chair will not help.
B Bed exercises such as these are useful. Just sitting in a chair will not help.
C Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear might.
D A positive Homans sign (calf muscle pain or warmth, redness, or tenderness) requires the physicians immediate attention.

DIF:Cognitive Level: ComprehensionREF:403

OBJ:Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

16. With regard to rubella and Rh issues, nurses should be aware that:

a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for 1 month after vaccination.
c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B

Feedback
A Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated.
B Women should understand they must practice contraception for 1 month after being vaccinated.
C Rh immune globulin is administered intramuscularly; it should never be given to an infant.
D Rh immune globulin suppresses the immune system and therefore might thwart the rubella vaccination.

DIF:Cognitive Level: ComprehensionREF:406

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

17. A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:

a. Discusses her labor and birth experience excessively.
b. Believes that her baby is more attractive and clever than any others.
c. Has not given the baby a name.
d. Has a partner or family members who react very positively about the baby.

ANS: C

Feedback
A A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis might be impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment.
B The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the babys sex. The mother might voice concern that the baby reminds her of a family member whom she does not like.
C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change.
D Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

DIF:Cognitive Level: SynthesisREF:409

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Evaluation

TRUE/FALSE

1. Regardless of her obstetric status, no woman should be discharged from the recovery area until she has completely recovered from the effects of anesthesia and has been cleared by a member of the anesthesia care team.

ANS: T

It takes several hours to recover from anesthesia. Obstetric recovery areas are held to the same standard of care expected for any postanesthesia recovery.

DIF:Cognitive Level: ComprehensionREF:393

OBJ:Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

2. If a mother and her family have freely chosen early discharge from the hospital, the nurse and the health care provider are not legally responsible if complications occur and her condition had not been stabilized within normal limits.

ANS: F

If complications should occur after discharge, the nursing and medical staff could be sued for abandonment.

DIF:Cognitive Level: ComprehensionREF:395

OBJ: Client Needs: Safe and Effective Care Environment TOP: Nursing Process: Evaluation

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