Postpartum Period Nclex RN Answers And Rationals

01 Answer: c, e
Rationale: A postpartum client should be suspected of psychosis if she exhibits delusions or hallucinations,generally starting within 4 weeks postpartum. Typically,the woman has a past history of a psychiatric disorder and treatment. A history of bipolar disorder is an important risk factor. The disorder occurs in less then 1% of postpartum mothers. It’s considered a medical emergency. Suicide and infanticide are common.
02.Answer: a
Rationale: Blood loss from the uterus that exceeds 500 ml in a 24 hour period is considered postpartum hemorrhage. If uterine atony is the cause, the uterus feels soft and relaxed. A full bladder can prevent the uterus from contracting completely, increasing the risk of hemorrhage. Puerperal infection is an infection of the uterus and structures above; its characteristic sign is fever. Two major types of deep vein thrombosis occur in the postpartum period: pelvic and femoral. Each has different signs and symptoms, but both occur later in the postpartum period (femoral, after 10 days postpartum;pelvic, after 14 days). Mastitis is an inflammation of the mammary glands that disrupts normal lactation and usually develops 1 to 4 weeks postpartum.
03.Answer: b, c
Rationale: Checking vital signs provides information about the client’s circulatory status and identifies significant changes that may need to be reported to the physician. By palpating the client’s fundus, the nurse also gains valuable data. A boggy uterus may lead to excessive bleeding. Starting an I.V. infusion requires a physician’s order. Placing the client in high Fowler’s position may lower the blood pressure and be harmful to the client. Administration of a pain medication doesn’t address the current problem
04.Answer: a
Rationale: A full bladder may displace the uterine fundus to the left or right of the abdomen. A straight catheterization is unnecessarily invasive if the client can urinate on her own. Nursing interventions should be completed before notifying the primary health care provider in a nonemergency situation.
05.Answer b
Rational: The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 postcesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.
06.Answer a
Rational: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.
07.Answer d
Rational: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction
08.Answer a
Rational: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).
09.Answer c
Rational: Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.
10.Answer b
Rational: During a postpartum assessment, the nurse is likely to come into contact with the client's blood or body fluids, especially when examining the perineal region. Therefore, the nurse must wear latex gloves; hand washing alone would neither provide adequate protection nor comply with universal precautions. The nurse should wear a barrier gown and protective eyewear in addition to latex gloves only when anticipating splashing of blood or body fluids such as during childbirth. Splashing isn't likely to occur during a postpartum assessment.