NUR114 CH14

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Author:
TomWruble
ID:
183025
Filename:
NUR114 CH14
Updated:
2012-12-04 15:53:27
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nur114e2 Nursing Care Family during Fourth Trimester
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Nursing Care of the Family during the Fourth Trimester
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  1. The nurse starts preparing the new mother for discharge at their first ___ contact.
    postpartum
  2. In the postpartum period, nursing interventions include ___, ___, and ___; ___; and ___.
    • preventing excessive bleeding
    • bladder distention
    • infection
    • relieving pain and discomfort
    • promoting or suppressing lactation
  3. The most important interventions for preventing excessive bleeding are ___ and ___
    • maintaining good uterine tone
    • preventing bladder distention
  4. The mother should void spontaneously within ___ after giving birth
    6 to 8 hours
  5. After uncomplicated vaginal births, women are commonly scheduled for a ___ postpartum follow-upexamination
    6-week
  6. Engorgement
    Swelling of breast tissue brough about by an increase in blood and lymph, occurring as early milk (colostrum) transitions to mature milk at 72 to 96 hours after birth.
  7. Uterine atony
    Relaxation of the uterine muscle possibly leading to excessive postpartum bleeding and postpartum hemorrhage.
  8. Methylergometrine (Methergine) is a smooth muscle constrictor that mostly acts on the uterus. It is most commonly used to ___ following childbirth
    prevent or control excessive bleeding
  9. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

    A. Massage the fundus.
    B. Assist the woman to empty her bladder
    C. Recognize this as an expected finding during the first 24 hours following birth
    D. Administer Methergine, 0.2 mg PO, that has been ordered prn.
    B. Assist the woman to empty her bladder

    The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow.
    (this multiple choice question has been scrambled)
  10. T/F: When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should massage the fundus.
    F: A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax.
  11. T/F: When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should administer Methergine, 0.2 mg PO, that has been ordered prn.
    F: Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm.
  12. T/F: When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should administer Methergine, 0.2 mg PO, that has been ordered prn.
    F: Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm.
  13. Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours’ postpartum?

    A. Postural hypotension
    B. Temperature of 100.4° F
    C. Bradycardia—pulse rate of 55 beats/min
    D. Pain in left calf with dorsiflexion of left foot
    D. Pain in left calf with dorsiflexion of left foot

    Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homan’s sign and are suggestive of thrombophlebitis and should be investigated.
    (this multiple choice question has been scrambled)
  14. Postural hypotension is or is not an expected finding related to circulatory changes after birth.
    is
  15. A temperature of 100.4° F in the first 24 hours most likely indicates ___, which is easily corrected by ___.
    • dehydration
    • increasing oral fluid intake
  16. A heart rate of ___ is an expected finding in the initial postpartum period.
    55 beats/min
  17. The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:

    A. Administer Methergine, 0.2 mg IM, which has been ordered prn.
    B. Call the physician.
    C. Place her on a bedpan to empty her bladder.
    D. Massage her fundus.
    D. Massage her fundus.

    A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm.
    (this multiple choice question has been scrambled)
  18. T/F: The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to call the physician.
    F: The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage.
  19. T/F: The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to administer Methergine, 0.2 mg IM, which has been ordered prn.
    F: Methergine can be administered per order after massaging the fundus, especially if the fundus does not become or remain firm with massage.
  20. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

    A. Uses soap and warm water to wash the vulva and perineum.
    B. Washes from symphysis pubis back to episiotomy.
    C. Changes her perineal pad every 2 to 3 hours.
    D. Uses the peribottle to rinse upward into her vagina.
    D. Uses the peribottle to rinse upward into her vagina.

    The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.
    (this multiple choice question has been scrambled)
  21. Postpartum woman's perineal care: Changing the perineal pad every ___ in an appropriate measure.
    2 to 3 hours
  22. Which measure would be least effective in preventing postpartum hemorrhage?

    A. Massage the fundus every hour for the first 24 hours following birth.
    B. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered.
    C. Encourage the woman to void every 2 hours.
    D. Teach the woman the importance of rest and nutrition to enhance healing.
    A. Massage the fundus every hour for the first 24 hours following birth.

    The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.
    (this multiple choice question has been scrambled)
  23. T/F: Effective in preventing postpartum hemorrhage: encourage the woman to void every 2 hours
    T: Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage
  24. T/F: Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.
    True
  25. While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of:

    A. Consumer demand.
    B. The federal government.
    C. Health maintenance organizations (HMOs) and private insurers.
    D. Hospitals.
    C. Health maintenance organizations (HMOs) and private insurers.

    The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Hense the 1998 federal Newborns' and Mothers' Act.
    (this multiple choice question has been scrambled)
  26. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:

    A. During the first visit with the physician in the unit.
    B. At the time of admission to the nurse’s unit.
    C. When the infant is presented to the mother at birth.
    D. When the take-home information packet is given to the couple.
    B. At the time of admission to the nurse’s unit.

    Discharge planning and the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.
    (this multiple choice question has been scrambled)
  27. The ___ test is used to detect the amount of fetal blood in the maternal circulation.
    Kleihauer-Betke

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