Chapter 33 Postpartum Family Adaptation and Nursing Assessment My Nursing Test Banks

Olds Maternal-Newborn Nursing and Womens Health, 10e (Davidson)

Chapter 33 Postpartum Family Adaptation and Nursing Assessment

1) The nurse determines the fundus of a postpartum client to be boggy. Initially, what should the nurse do?

1. Document the findings.

2. Catheterize the client.

3. Massage the uterine fundus until it is firm.

4. Call the physician immediately.

Answer: 3

Explanation: 3. The nurse would massage the uterine fundus until it is firm by keeping one hand in position and stabilizing the lower portion of the uterus. With one hand used to massage the fundus, the nurse would put steady pressure on the top of the now-firm fundus and to see if she was able to express any clots.

Page Ref: 874

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.2.1 Determine nursing interventions that promote maternal comfort during the postpartum period.

1

Copyright 2016 Pearson Education, Inc.

2) The nurse is caring for a postpartum client who is experiencing afterpains following the birth of her third child. Which comfort measure should the nurse implement to decrease her pain?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Offer a warm water bottle for her abdomen.

2. Call the physician to report this finding.

3. Inform her that this is not normal, and she will need an oxytocic agent.

4. Administer a mild analgesic to help with breastfeeding.

5. Administer a mild analgesic at bedtime to ensure rest.

Answer: 1, 4, 5

Explanation: 1. A warm water bottle placed against the low abdomen may reduce the discomfort of afterpains.

4. The breastfeeding mother may find it helpful to take a mild analgesic agent approximately 1 hour before feeding her infant.

5. An analgesic agent such as ibuprofen is also helpful at bedtime if the afterpains interfere with the mothers rest.

Page Ref: 867

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.2.1 Determine nursing interventions that promote maternal comfort during the postpartum period.

2

Copyright 2016 Pearson Education, Inc.

3) The nurse would expect a physician to prescribe which medication to a postpartum client with heavy bleeding and a boggy uterus?

1. Methylergonovine maleate (Methergine)

2. Rh immune globulin (RhoGAM)

3. Terbutaline (Brethine)

4. Docusate (Colace)

Answer: 1

Explanation: 1. Methylergonovine maleate is the drug used for the prevention and control of postpartum hemorrhage.

Page Ref: 875

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Pharmacological and Parenteral Therapies

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Knowledge and Science: Value evidence-based approaches to yield best practices for nursing. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.3.2 Compare the various etiologies and management of postpartum hemorrhage.

4) A postpartum client has inflamed hemorrhoids. Which nursing intervention would be appropriate?

1. Encourage sitz baths.

2. Position the client in the supine position.

3. Avoid stool softeners.

4. Decrease fluid intake.

Answer: 1

Explanation: 1. Encouraging sitz baths is the correct approach because moist heat decreases inflammation and provides for comfort.

Page Ref: 882

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs. | AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.2.1 Determine nursing interventions that promote maternal comfort during the postpartum period.

3

Copyright 2016 Pearson Education, Inc.

5) The nurse assesses the postpartum client who has not had a bowel movement by the third postpartum day. Which nursing intervention would be appropriate?

1. Encourage the new mother, saying, It will happen soon.

2. Instruct the client to eat a low-fiber diet.

3. Decrease fluid intake.

4. Obtain an order for a stool softener.

Answer: 4

Explanation: 4. Obtaining an order for a stool softener is the correct intervention by the third day. In resisting or delaying the bowel movement, the woman may cause increased constipation and more pain when elimination finally occurs.

Page Ref: 879

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.2.1 Determine nursing interventions that promote maternal comfort during the postpartum period.

6) The nurse has received the end-of-shift report on the postpartum unit. Which client should the nurse see first?

1. Woman who is 2nd day post-cesarean, moderate lochia serosa

2. Woman day of delivery, fundus firm 2 cm above umbilicus

3. Woman who had a cesarean section, 1st postpartum day, 4 cm diastasis recti abdominis

4. Woman who had a cesarean section, 1st postpartum day, hypoactive bowel sounds all quadrants

Answer: 2

Explanation: 2. This client is the top priority. The fundus should not be positioned above the umbilicus after delivery. If the fundus is in the midline but higher than expected, it is usually associated with clots within the uterus.

Page Ref: 861

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

4

Copyright 2016 Pearson Education, Inc.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

7) The nurse expects an initial weight loss for the average postpartum client to be which of the following?

1. 5 to 8 pounds

2. 10 to 12 pounds

3. 12 to 15 pounds

4. 15 to 20 pounds

Answer: 2

Explanation: 2. An initial weight loss of 10 to 12 lbs. occurs as a result of the birth of infant, placenta, and amniotic fluid.

Page Ref: 866

Cognitive Level: Understanding

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: I. 3. Use skills of inquiry, analysis, and information literacy to address practice issues. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.2 Examine the normal physiologic changes expected in the postpartum client.

8) To assess the healing of the uterus at the placental site, what does the nurse assess?

1. Lab values

2. Blood pressure

3. Uterine size

4. Type, amount, and consistency of lochia

Answer: 4

Explanation: 4. The type, amount, and consistency of lochia determine the state of healing of the placental site, and a progressive color change from bright red at birth to dark red to pink to white or clear should be observed.

Page Ref: 862

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

5

Copyright 2016 Pearson Education, Inc.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

6

Copyright 2016 Pearson Education, Inc.

9) The nurse is providing discharge teaching to a woman who delivered her first child 2 days ago. The nurse understands that additional information is needed if the client makes which statement?

1. I should expect a lighter flow next week.

2. The flow will increase if I am too active.

3. My bleeding will remain red for about a month.

4. I will be able to use a pantiliner in a day or two.

Answer: 3

Explanation: 3. Lochia rubra is dark red in color. It is present for the first 2 to 3 days postpartum. Lochia serosa is a pinkish color and it follows from about the 3rd to the 10th day.

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment.

MNL LO: 5.1.2 Examine the normal physiologic changes expected in the postpartum client.

10) Every time the nurse enters the room of a postpartum client who gave birth 3 hours ago, the client asks something else about her birth experience. What action should the nurse take?

1. Answer questions quickly and try to divert her attention to other subjects.

2. Review the documentation of the birth experience and discuss it with her.

3. Contact the physician to warn him the client might want to file a lawsuit, based on her preoccupation with the birth experience.

4. Submit a referral to Social Services because of possible obsessive behavior.

Answer: 2

Explanation: 2. The client may talk about her labor and birth experience. The nurse should provide opportunities to discuss the birth experience in a nonjudgmental atmosphere if the woman desires to do so.

Page Ref: 882

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: QSEN Competencies: I. B. 15. Communicate care provided and needed at each transition in care. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4 Describe the common concerns of the mother that are considered in a postpartum assessment.

7

Copyright 2016 Pearson Education, Inc.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

11) Which statement by a new mother 1 week postpartum indicates maternal role attainment?

1. I dont think Ill ever know what Im doing.

2. This baby feels like a real stranger to me.

3. It works better for me to undress the baby and to nurse in the chair rather than the bed.

4. My sister took to mothering in no time. Why cant I?

Answer: 3

Explanation: 3. This statement indicates a stage of maternal role attainment in which the new mother feels comfortable enough to make her own decisions about parenting.

Page Ref: 867

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

12) On the first postpartum day, the nurse teaches the client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. The nurse understands this memory lapse to be related to which of the following?

1. The taking-hold phase

2. Postpartum hemorrhage

3. The taking-in period

4. Epidural anesthesia

Answer: 3

Explanation: 3. Soon after birth during the taking-in period, the woman tends to be passive and somewhat dependent. She follows suggestions, hesitates about making decisions, and is still rather preoccupied with her needs.

Page Ref: 867

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Communication

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

8

Copyright 2016 Pearson Education, Inc.

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.2 Examine the normal physiologic changes expected in the postpartum client.

13) The nursing instructor is conducting a class about attachment behaviors. Which statement by a student indicates the need for further instruction?

1. The en face position promotes bonding and attachment.

2. Ideally, initial skin-to-skin contact occurs after the baby has been assessed and bathed.

3. In reciprocity, the interaction of mother and infant is mutually satisfying and synchronous.

4. The needs of the mother and of her infant are balanced during the phase of mutual regulation.

Answer: 2

Explanation: 2. Ideally, initial skin-to-skin contact is immediate. The benefits of this practice are supported by a preponderance of evidence.

Page Ref: 870

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

9

Copyright 2016 Pearson Education, Inc.

14) The nurse is working with a new mother who follows Muslim traditions. Which expectations and actions are appropriate for this client?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. To 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 father will take an active role in infant care.

5. She will prefer a male physician.

Answer: 2, 3

Explanation: 2. In Muslim cultures, emphasis on childrearing and infant care activities is on the mother and female relatives.

3. Women of the Islamic faith may have specific modesty requirements; the woman must be completely covered, with only her feet and hands exposed.

Page Ref: 870, 871

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Therapeutic Environment

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Be open to others ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

MNL LO: 5.2.1 Determine nursing interventions that promote maternal comfort during the postpartum period.

10

Copyright 2016 Pearson Education, Inc.

15) The community nurse is working with a client from Southeast Asia who has delivered her first child. Her mother has come to live with the family for several months. The nurse understands that the main role of the grandmother while visiting is to do which of the following?

1. Help the new mother by allowing her to focus on resting and caring for the baby.

2. Teach her son-in-law the right way to be a father because this is his first child.

3. Make sure that her daughter does not become abusive towards the infant.

4. Pass on the cultural values and beliefs to the newborn grandchild.

Answer: 1

Explanation: 1. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.

Page Ref: 879

Cognitive Level: Analyzing

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Be open to others ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

MNL LO: 5.2.2 Apply strategies to promote maternal well-being after birth including nutrition, rest, and activity.

11

Copyright 2016 Pearson Education, Inc.

16) Which strategies would the nurse utilize to promote culturally competent care for the postpartum client?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Examine ones own cultural beliefs, biases, stereotypes, and prejudices.

2. Respect the values and beliefs of others.

3. Limit the alternative food choices offered clients to minimize conflicts.

4. Incorporate the familys cultural practices into the care.

5. Evaluate whether the familys cultural practices fit into Western norms.

Answer: 1, 2, 4

Explanation: 1. It is important for nurses to recognize that they are approaching their patients care from their own perspective and that, to individualize care for each mother, they need to assess the womans preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level.

2. It is important for nurses to recognize that they are approaching their patients care from their own perspective and that, to individualize care for each mother, they need to assess the womans preferences, her level of acculturation and assimilation to Western culture, her linguistic abilities, and her educational level.

4. The nurse should have the mother exercise her choices when possible and support those choices, with the help of cultural awareness and a sound knowledge base.

Page Ref: 871

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: VII. 7. Collaborate with other healthcare professionals and patients to provide spiritually and culturally appropriate health promotion and disease and injury prevention interventions. | NLN Competencies: Relationship-Centered Care: Be open to others ideas; show humility, mutual trust, empathy, support, and a capacity for grace. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

12

Copyright 2016 Pearson Education, Inc.

17) How does the nurse assess for Homans sign?

1. Extending the foot and inquiring about calf pain.

2. Extending the leg and inquiring about foot pain.

3. Flexing the knee and inquiring about thigh pain.

4. Dorsiflexing the foot and inquiring about calf pain.

Answer: 4

Explanation: 4. To assess for thrombophlebitis, the nurse should have the woman stretch her legs out, with the knees slightly flexed and the legs relaxed. The nurse then grasps the foot and dorsiflexes it sharply. If pain is elicited, the nurse notifies the physician/CNM that the woman has a positive Homans sign. The pain is caused by inflammation of a vessel.

Page Ref: 878

Cognitive Level: Remembering

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient-centered care. | AACN Essentials Competencies: IX. 16. Demonstrate the application of psychomotor skills for efficient, safe and compassionate delivery of patient care. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

18) Which of the following symptoms would be an indication of postpartum blues?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Overeating

2. Anger

3. Mood swings

4. Constant sleepiness

5. Crying

Answer: 2, 3, 5

Explanation: 2. Anger would be a symptom of postpartum blues.

3. Mood swings would be a symptom of postpartum blues.

5. Weepiness and crying would be a symptom of postpartum blues.

Page Ref: 868

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX. 16. Demonstrate the application of psychomotor skills for efficient, safe, and compassionate delivery of patient care. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Implementation

13

Copyright 2016 Pearson Education, Inc.

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

19) Nursing interventions that foster the process of becoming a mother include which of the following?

1. Encouraging detachment from the nurse-patient relationship

2. Promoting maternal-infant attachment

3. Building awareness of and responsiveness to infant interactive capabilities

4. Instruct about promoting newborn independence

5. Preparing the woman for the maternal social role

Answer: 2, 3, 5

Explanation: 2. Promoting maternal-infant attachment is a nursing intervention that fosters the process of becoming a mother.

3. Building awareness of and responsiveness to infant interactive capabilities is a nursing intervention that fosters the process of becoming a mother.

5. Preparing the woman for the maternal social role is a nursing intervention that fosters the process of becoming a mother.

Page Ref: 867

Cognitive Level: Applying

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

14

Copyright 2016 Pearson Education, Inc.

20) The postpartum nurse is caring for a client who gave birth to full-term twins earlier today. The nurse will know to assess for symptoms of which of the following?

1. Increased blood pressure

2. Hypoglycemia

3. Postpartum hemorrhage

4. Postpartum infection

Answer: 3

Explanation: 3. The nurse will assess for postpartum hemorrhage. Overstretching of uterine muscles with conditions such as multiple gestation, polyhydramnios, or a very large baby may set the stage for slower uterine involution.

Page Ref: 861, 862, 872

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

21) The nurse is observing a new graduate perform a postpartum assessment. Which action requires intervention by the nurse?

1. Asking the client to void and donning clean gloves

2. Listening to bowel sounds and then asking when her last bowel movement occurred

3. Offering the patient pre-medication 2 hours before the assessment

4. Completing the assessment and explaining the results to the client

Answer: 3

Explanation: 3. The patient should be offered premedication 30-45 minutes before assessing the fundus, especially if the patient has had a cesareansection.

Page Ref: 873

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network. | NLN Competencies: Quality and Safety: Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

15

Copyright 2016 Pearson Education, Inc.

16

Copyright 2016 Pearson Education, Inc.

22) The client delivered her first child vaginally 7 hours ago. She has not voided since delivery. She has an IV of lactated Ringers solution running at 100 mL/hr. Her fundus is firm and to the right of midline. What is the best nursing action?

1. To massage the fundus vigorously

2. To assess the clients pain level

3. To increase the rate of the IV

4. To assist the client to the bathroom

Answer: 4

Explanation: 4. Emptying the bladder is the top priority.

Page Ref: 864

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

23) During a postpartum examination of a client who delivered an 8-pound newborn 6 hours ago, the following assessment findings are noted: fundus firm and at the umbilicus, and moderate lochia rubra with a steady trickle of blood from the vagina. What is the assessment finding that would necessitate follow-up?

1. Firm fundus

2. Fundus at the umbilical level

3. Moderate lochia rubra

4. Steady trickle of blood

Answer: 4

Explanation: 4. The continuous seepage of blood is more consistent with cervical or vaginal lacerations. Lacerations should be suspected if the uterus is firm and of expected size and if no clots can be expressed. This finding would indicate a follow-up.

Page Ref: 862

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Reduction of Risk Potential

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a

17

Copyright 2016 Pearson Education, Inc.

womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

24) Which of the following behaviors noted in the postpartum client would require the nurse to assess further?

1. Responds hesitantly to infant cries.

2. Expresses satisfaction about the sex of the baby.

3. Friends and family visit the client and give advice.

4. Talks to and cuddles with the infant frequently.

Answer: 1

Explanation: 1. The mother tends to respond verbally to any sounds emitted by the newborn, such as cries, coughs, sneezes, and grunts. Responding hesitantly to infant cries might need further assessment to determine what the mother is feeling.

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

18

Copyright 2016 Pearson Education, Inc.

25) The nurse is performing a postpartum assessment on a newly delivered client. When checking the fundus, there is a gush of blood. The client asks why that is happening. What is the nurses best response?

1. We see this from time to time. Its not a big deal.

2. The gush is an indication that your fundus isnt contracting.

3. Dont worry. Ill make sure everything is fine.

4. Blood pooled in the vagina while you were in bed.

Answer: 4

Explanation: 4. A gush of blood when a fundal massage is undertaken may occur because of normal pooling of blood in vagina when the woman lies down to rest or sleep.

Page Ref: 872

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care; Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

26) Which of the following conditions would predispose a client for thrombophlebitis?

1. Severe anemia

2. Cesarean delivery

3. Anorexia

4. Hypocoagulability

Answer: 1

Explanation: 1. Severe anemia would predispose a client for thrombophlebitis.

Page Ref: 878

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

19

Copyright 2016 Pearson Education, Inc.

27) The community nurse is meeting a new mother for the first time. The client delivered her first child 5 days ago after a 12-hour labor. Neither the mother nor the infant had any complications during the birth or postpartum period. Which statement by the client would indicate to the nurse that the client is experiencing postpartum blues?

1. I am so happy and blessed to have my new baby.

2. One minute Im laughing and the next Im crying.

3. My husband is helping out by changing the baby at night.

4. Breastfeeding is going quite well now that the engorgement is gone.

Answer: 2

Explanation: 2. The postpartum blues consist of a transient period of depression that occurs during the first few days of puerperium. Symptoms may include mood swings, anger, weepiness, anorexia, difficulty sleeping, and a feeling of letdown.

Page Ref: 868

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. B. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Threats to the integrity of relationships, and the potential for conflict and abuse. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

20

Copyright 2016 Pearson Education, Inc.

28) The nurse is teaching a prenatal class about postpartum changes. The nurse explains that factors that might interfere with uterine involution include which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Prolonged labor

2. Difficult birth

3. Full bladder

4. Breastfeeding

5. Infection

Answer: 1, 2, 3, 5

Explanation: 1. During prolonged labor, the muscles relax because of prolonged time of contraction during labor.

2. During a difficult birth, the uterus is manipulated excessively, causing fatigue.

3. As the uterus is pushed up and usually to the right, pressure on a full bladder interferes with effective uterine contraction.

5. Inflammation and infection interfere with uterine muscles ability to contract effectively.

Page Ref: 861

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 1. Demonstrate effective use of technology and standardized practices that support safety and quality. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety; Communicate potential risk factors and actual errors. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.2 Examine the normal physiologic changes expected in the postpartum client.

21

Copyright 2016 Pearson Education, Inc.

29) When preparing for and performing an assessment of the postpartum client, which of the following would the nurse do?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Ask the client to void before assessing the uterus.

2. Inform the client of the need for regular assessments.

3. Defer client teaching to another time.

4. Perform the procedures as gently as possible.

5. Take precautions to prevent exposure to body fluids.

Answer: 1, 2, 4, 5

Explanation: 1. Palpating the fundus when the woman has a full bladder may give false information about the progress of involution. Ask the woman to void before assessment.

2. The nurse should provide an explanation of the purposes of regular assessment to the woman.

4. The woman should be relaxed before starting, and procedures should be performed as gently as possible, to avoid unnecessary discomfort.

5. Gloves should be worn before starting the assessment.

Page Ref: 871

Cognitive Level: Understanding

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan. | NLN Competencies: Quality and Safety: Use technologies that contribute to safety. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

22

Copyright 2016 Pearson Education, Inc.

30) Which physical assessment findings would the nurse consider normal for the postpartum client following a vaginal delivery?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Elevated blood pressure

2. Fundus firm and midline

3. Moderate amount of lochia serosa

4. Edema and bruising of perineum

5. Inflamed hemorrhoids

Answer: 2, 4

Explanation: 2. A firm fundus that is midline indicates the normal progression of uterine involution.

4. During the early postpartum period, the soft tissue in and around the perineum may appear edematous with some bruising.

Page Ref: 881, 863

Cognitive Level: Applying

Client Need/Sub: Physiological Integrity: Physiological Adaptation

Standards: QSEN Competencies: V. B. 2. Demonstrate effective use of strategies to reduce risk of harm to self or others. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

23

Copyright 2016 Pearson Education, Inc.

31) The postpartum client is about to go home. The nurse includes which subject in the teaching plan?

1. Replacement of fluids

2. Striae

3. Diastasis of the recti muscles

4. REEDA scale

Answer: 3

Explanation: 3. Diastasis recti abdominis can be improved with exercise and abdominal muscle tone can improve significantly best taught when the mother is receptive to instruction during the postpartum assessment.

Page Ref: 863

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1 Delineate the basic physiologic changes that occur in the postpartum period as a womans body returns to its pre-pregnant state.

MNL LO: 5.1.1 Examine the components of a postpartum assessment.

24

Copyright 2016 Pearson Education, Inc.

32) During the first several postpartum weeks, the new mother must accomplish certain physical and developmental tasks, including which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Establish a therapeutic relationship with her physician

2. Adapt to altered lifestyles and family structure resulting from the addition of a new member

3. Restore her intellectual abilities

4. Restore physical condition

5. Develop competence in caring for and meeting the needs of her infant

Answer: 2, 4, 5

Explanation: 2. During the first several postpartum weeks, the new mother must adapt to altered lifestyles and family structure resulting from the addition of a new member.

4. During the first several postpartum weeks, the new mother must restore her physical condition.

5. During the first several postpartum weeks, the new mother must develop competence in caring for and meeting the needs of her infant.

Page Ref: 880

Cognitive Level: Applying

Client Need/Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5 Examine the physical and developmental tasks that the mother must accomplish during the postpartum period.

MNL LO: 5.2.3 Determine nursing interventions that promote health maintenance in the postpartum client.

25

Copyright 2016 Pearson Education, Inc.

33) The nurse is beginning 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 whether father-infant attachment is taking place.

4. Assist the mother in identifying the babys behavior cues.

Answer: 4

Explanation: 4. Helping the mother to identify her babys behavior cues facilitates the acquaintance phase of maternal-infant attachment.

Page Ref: 869

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

26

Copyright 2016 Pearson Education, Inc.

34) At her 6-week postpartum checkup, a new mother voices concerns to the nurse. She states that she is finding it hard to have time alone to even talk on the phone without interruption. Her family lives in another state, and she has contact with them only by phone. She is still having difficulty getting enough sleep and worries that she will not be a good mother. Appropriate nursing interventions would include providing which of the following?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Anticipatory guidance about the realities of being a parent.

2. Parenting literature and reference manuals.

3. Phone numbers and locations of local parenting groups.

4. Referral for specialized interventions related to postpartum blues.

5. Phone numbers and names of postpartum doulas.

Answer: 1, 2, 3, 5

Explanation: 1. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles.

2. Postpartum nurses need to be aware of the long-term adjustments and stresses that the childbearing family faces as its members adjust to new and different roles.

3. New mother support groups are helpful for women who lack a social support system.

5. Postpartum doulas are professionals trained to help the new mother after the birth of the baby.

Page Ref: 867, 868

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

27

Copyright 2016 Pearson Education, Inc.

35) A nurse is caring for several postpartum clients. Which client is demonstrating a problem attaching to her newborn?

1. The client who is discussing how the baby looks like her father

2. The client who is singing softly to her baby

3. The client who continues to touch her baby with only her fingertips

4. The client who picks her baby up when the baby cries

Answer: 3

Explanation: 3. In a progression of touching activities, the mother proceeds from fingertip exploration of the newborns extremities toward palmar contact with larger body areas and finally to enfolding the infant with the whole hand and arms. If the client continues to touch with only her fingertips, she might not be developing adequate early attachment.

Page Ref: 869

Cognitive Level: Analyzing

Client Need/Sub: Psychosocial Integrity: Coping Mechanisms

Standards: QSEN Competencies: I. B. 1. Elicit patient values, preferences, and expressed needs as part of clinical interview, implementation of care plan, and evaluation of care. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Factors that contribute to or threaten health. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

28

Copyright 2016 Pearson Education, Inc.

36) The nurse is caring for a client who recently emigrated from a Southeast Asian country. The mother has been resting since the birth, while her sister has changed the diapers and fed the infant. What is the most likely explanation for this behavior?

1. The client is not attaching to her infant appropriately.

2. The client is not going to be a good mother, and the baby is at risk.

3. The client has no mother present to role-model behaviors.

4. The client is exhibiting normal behavior for her culture.

Answer: 4

Explanation: 4. Rest, seclusion, and dietary restraint practices in many traditional non-Western cultures (South Asian groups) are designed to assist the woman and her baby during postpartum vulnerable periods.

Page Ref: 879

Cognitive Level: Understanding

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values. | AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches. | NLN Competencies: Relationship-Centered Care: Promote and accept the patients emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6 Explain the impact of cultural influence upon the postpartum period.

MNL LO: 5.2.2 Apply strategies to promote maternal well-being after birth including nutrition, rest, and activity.

29

Copyright 2016 Pearson Education, Inc.

37) The community nurse is working with a client whose only child is 8 months old. Which statement does the nurse expect the mother to make?

1. I have a lot more time to myself than I thought I would have.

2. My confidence level in my parenting is higher than I anticipated.

3. I am constantly tired. I feel like I could sleep for a week.

4. My baby likes everyone, and never fusses when shes held by a stranger.

Answer: 3

Explanation: 3. Physical fatigue often affects adjustments and functions of the new mother. The nurse can also provide information about the fatigue that a new mother experiences, strategies to promote rest and sleep at home, and the impact fatigue can have on a womans emotions and sense of control.

Page Ref: 879

Cognitive Level: Analyzing

Client Need/Sub: Safe and Effective Care Environment: Management of Care

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3 Differentiate the physiologic and psychosocial components of a postpartum assessment.

MNL LO: 5.1.3 Explore maternal postpartum psychological adaptation.

30

Copyright 2016 Pearson Education, Inc.

38) The nurse is preparing a class for mothers and their partners who have just recently delivered. One topic of the class is infant attachment. Which statement by a participant indicates an understanding of this concept?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. We should avoid holding the baby too much.

2. Looking directly into the babys eyes might frighten him.

3. Talking to the baby is good because hell recognize our voices.

4. Holding the baby so we have direct face-to-face contact is good.

5. We should only touch the baby with our fingertips for the first month.

Answer: 3, 4

Explanation: 3. Attachment behaviors include cuddling, soothing, and calling the baby by name.

4. Attachment behaviors include holding the baby in the en face position.

Page Ref: 882

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

31

Copyright 2016 Pearson Education, Inc.

39) Which factors would the nurse observe that would indicate a new mothers early attachment to the newborn?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Select all that apply.

1. Face-to-face contact and eye contact

2. Failure to choose a name for the baby

3. Decreased interest in the infants cues

4. Pointing out familial traits of the newborn

5. Displaying satisfaction with the infants sex

Answer: 1, 4, 5

Explanation: 1. Face-to-face contact and eye contact indicates that the mother is attracted to the infant and is attending to the infants behavior.

4. The ability to point out family traits shows that she is pleased with the babys appearance and recognizes the infant as belonging to the family unit.

5. Showing pleasure with the infants appearance and sex indicates bonding is occurring.

Page Ref: 880

Cognitive Level: Applying

Client Need/Sub: Psychosocial Integrity: Family Dynamics

Standards: QSEN Competencies: I. B. 10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management. | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care. | NLN Competencies: Relationship-Centered Care: Communicate information effectively; listen openly and cooperatively. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7 Identify the factors that influence the development of parent-infant attachment in the nursing assessment of early attachment.

MNL LO: 5.1.4 Contrast newborn attachment and bonding behaviors and their effect on familial adaptation.

Leave a Reply