Question 1   See full question

The nurse is conducting discharge teaching with a postpartum woman. What

would be an important instruction for this client?
You Selected:

  Call her caregiver if lochia moves from serosa to rubra.

Correct response:

  Call her caregiver if lochia moves from serosa to rubra.

  Explanation:

Most cases of late postpartum hemorrhage occur after the woman leaves the
health care or birthing facility. Therefore, client education before discharge
about expected changes and danger signs and symptoms is crucial. Instruct
the woman to call her primary care provider if she experiences any signs of
infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling
lochia. She should also report lochia that increases (versus decreasing) in
amount, or reversal of the pattern of lochia (i.e., moves from serosa back to
rubra).
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.
682.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 682
Question 2   See full question
A nurse is developing a program to help reduce the risk of late postpartum
hemorrhage in clients in the labor and birth unit. Which measure would the
nurse emphasize as part of this program?
You Selected:

  inspecting the placenta after delivery for intactness

Correct response:

  inspecting the placenta after delivery for intactness

  Explanation:
After the placenta is expelled, a thorough inspection is necessary to confirm
its intactness because tears or fragments left inside may indicate an
accessory lobe or placenta accreta. These can lead to profuse hemorrhage
because the uterus is unable to contract fully. Administering antibiotics
would be appropriate for preventing infection, not postpartum hemorrhage.
Manual removal of the placenta or excessive traction on the umbilical cord
can lead to uterine inversion, which in turn would result in hemorrhage.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.
682.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 682
Question 3   See full question
A client experienced prolonged labor with prolonged premature rupture of
membranes. The nurse would be alert for which condition in the mother and
the newborn?
You Selected:

  infection

Correct response:

  infection

  Explanation:

Although hemorrhage, trauma, and hypovolemia may be problems, the

prolonged labor with the prolonged premature rupture of membranes places
the client at high risk for a postpartum infection. The rupture of membranes
removes the barrier of amniotic fluid, so bacteria can ascend.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
683-684.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 683-684
Question 4   See full question
A nurse is assessing a postpartum client. Which finding would the cause the
nurse the greatestconcern?
You Selected:

  sharp stabbing chest pain with shortness of breath

Correct response:

  sharp stabbing chest pain with shortness of breath

  Explanation:

Sharp stabbing chest pain with shortness of breath suggests pulmonary

embolism, an emergency that requires immediate action. Leg pain on
ambulation with mild edema suggests superficial venous thrombosis. Calf
pain on dorsiflexion of the foot may indicate deep vein thrombosis or a
strained muscle or contusion. Perineal pain with swelling along the
episiotomy might be a normal finding or suggest an infection. Of the
conditions, pulmonary embolism is the most urgent.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.
689.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689
Question 5   See full question
While providing care to a woman who is experiencing postpartum
hemorrhage, the nurse weighs her perineal pads to estimate blood loss. The
pad weighs 20 g. The nurse documents this as which amount?
You Selected:

  20 mL

Correct response:

  20 mL

  Explanation:

When weighing perineal pads to determine blood loss, 1 gram of pad weight
is equivalent to 1 mL of blood loss. A pad that weighs 20 g would indicate a
20-mL blood loss.
Reference:
  Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:
Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
677-678.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-678
Question 6   See full question
A nurse is making a home visit to a postpartum client. Which finding would
lead the nurse to suspect that a woman is experiencing postpartum
psychosis?
You Selected:

  delirium

Correct response:

  delirium

  Explanation:

Postpartum psychosis is at the severe end of the continuum of postpartum

emotional disorders. It is manifested by depression that escalates to
delirium, hallucinations, anger toward self and infant, bizarre behavior,
mania, and thoughts of hurting herself and the infant. Feelings of guilt,
sadness, and insomnia are associated with postpartum depression.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.
695.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695
Question 7   See full question
A nurse is caring for a pregnant client. The client has been diagnosed with
uterine fibroids. The nurse knows that which of the following is likely to occur
in this client in the postpartum period?
Correct response:

  Postpartum hemorrhage

  Explanation:
The nurse should know that a client with uterine fibroids or other uterine
anomalies is likely to experience postpartum hemorrhage. Altered uterine
contractility is one of the risk factors that will lead to postpartum
hemorrhage. Altered uterine contractility does not occur as a result of
uterine fibroids. Endometritis is the primary cause of postpartum infections.
Postpartum infections are not caused by uterine fibroids. Uterine fibroids are
not known to cause urinary tract infections
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
676-677.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-677
Question 8   See full question
Which instruction should the nurse offer a client as primary preventive
measures to prevent mastitis?
You Selected:

  Perform handwashing before breastfeeding.

Correct response:

  Perform handwashing before breastfeeding.

  Explanation:

As a primary preventive measure to prevent mastitis, the nurse should

instruct the client to perform good handwashing before breastfeeding. The
nurse should instruct the client to frequently breastfeed to prevent
engorgement and milk stasis. If the breast is distended before feeding, the
nurse should instruct the client to apply cold, not warm, moist heat to the
breast. Gently massaging the affected area of the breast also helps.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
689-690.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690
Question 9   See full question
Which intervention would be helpful to a bottle-feeding client who is
experiencing hard or engorged breasts?
You Selected:

  applying ice

Correct response:

  applying ice

  Explanation:

Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing

the area, and discouraging further letdown of milk. Restricting fluids does not
reduce engorgement and should not be encouraged. Warm compresses will
promote blood flow and hence, milk production, worsening the problem of
engorgement. Bromocriptine has been removed from the market for
lactation suppression.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
689-690.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690
Question 10   See full question
The nurse is teaching a client about mastitis. Which statement should the
nurse include in her teaching?
You Selected:

  Symptoms include fever, chills, malaise, and localized breast

tenderness.

Correct response:

  Symptoms include fever, chills, malaise, and localized breast

tenderness.

  Explanation:

Mastitis is an infection of the breast characterized by flulike symptoms, along

with redness and tenderness in the breast. The most common causative
agent is Staphylococcus aureus. Breast abscess is rarely a complication of
mastitis if the client continues to empty the affected breast. Mastitis usually
occurs in one breast, not bilaterally.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
689-690.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690
Question 11   See full question
Which factor puts a multiparous client on her first postpartum day at risk for
developing hemorrhage?
You Selected:

  uterine atony

Correct response:

  uterine atony

  Explanation:

Multiparous women typically experience a loss of uterine tone due to

frequent distentions of the uterus from previous pregnancies. As a result,
this client is also at higher risk for hemorrhage. Thrombophlebitis does not
increase the risk of hemorrhage during the postpartum period. The
hemoglobin level and lochia flow are within acceptable limits.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.p.
677-678
Question 12   See full question
A woman recovering from cesarean birth in the hospital and who was
catheterized complains of a feeling of burning on urination and a feeling of
frequency. Which of the following should be the next nursing action?
You Selected:

  Obtain a clean-catch urine specimen

Correct response:
   Obtain a clean-catch urine specimen

  Explanation:

The client in this scenario shows classic signs of a urinary tract infection. The
priority nursing action at this point is to obtain a clean-catch urine specimen
to confirm the infection. The other answers are therapeutic management
interventions that would take place after confirmation of the infection via the
clean-catch urine specimen.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, p.
692.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 692
Question 13   See full question
On a follow-up visit to the clinic, a nurse suspects that a postpartum client is
experiencing postpartum psychosis. Which finding would most likely lead
the nurse to suspect this condition?
You Selected:

  delusional beliefs

Correct response:

  delusional beliefs

  Explanation:

Postpartum psychosis is at the severe end of the continuum of postpartum

emotional disorders. It is manifested by depression that escalates to
delirium, hallucinations, delusional beliefs, anger toward self and infant,
bizarre behavior, mania, and thoughts of hurting herself and the infant.
Feelings of anxiety, sadness, and insomnia are associated with postpartum
depression.
Question 14   See full question
What medication would the nurse administer to a client experiencing uterine
atony and bleeding leading to postpartum hemorrhage?
Correct response:

  Oxytocin
  Explanation:

A tocolytic such as oxytocin causes the uterus to contract to improve uterine

tone and reduce bleeding. Magnesium sulfate is administered to clients with
preeclampsia or eclampsia or hypertension problems. Domperidone is used
to increase lactation in women. Calcium gluconate is an antagonist used in
clients experiencing side effects of magnesium sulfate.
Question 15   See full question
A woman who delivered her infant by cesarean section 1 week ago called her
physician’s office to report chills, fever of 101.6℉ (38.7℃) and a poor
appetite. She also tells the nurse that she is having strong afterbirth pains
and her lochia has increased in volume and has an odor. Labwork shows an
elevated WBC count. Which of these reported findings is the most significant
finding related to the suspected diagnosis of endometritis?
Correct response:

  Fever

  Explanation:

Increased temperature is the most significant finding in this time period to

support the suspicion of endometritis. The other findings are usually seen in
this illness but the fever is the most significant finding. An elevated WBC
count can be seen in a normal postpartal woman with values of up to 20,000
to 30, 000/ mm3.
Question 16   See full question
The nursing instructor is leading a discussion exploring the various
conditions that can result in postpartum hemorrhage. The instructor
determines the session is successful when the students correctly choose
which condition is most frequently the cause of postpartum hemorrhage?
You Selected:

  Uterine atony

Correct response:

  Uterine atony

  Explanation:

Early postpartum hemorrhage usually results from one of the following

conditions: uterine atony, lacerations, or hematoma. Most cases of early
postpartum hemorrhage result from uterine atony, which is due to the
uterine muscles remaining relaxed and not contracting as they should.
Disseminated intravascular coagulation is a complication which can occur
with excessive postpartum hemorrhage.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
677-678.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-678
Question 17   See full question
The nurse observes an ambulating postpartal woman limping and avoiding
putting pressure on her right leg. Which assessments should the
nurse prioritize in this client?
Correct response:

  Assess for warmth, erythema, and pedal edema.

  Explanation:

This client is demonstrating potential symptoms of DVT, but is avoiding

putting pressure on the leg and limping when ambulating. DVT
manifestations are caused by inflammation and obstruction of venous return
and can be assessed by the presence of calf swelling, warmth, erythema,
tenderness, and pedal edema. The client would not need to bend the knee to
assess for pain in the calf. Asking the client to raise her toe and draw a circle
is assessing reflexes, and blanching a toe is assessing capillary refill (which
may be affected by the DVT but is not indicative of a DVT).
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
686-687.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 686-687
Question 18   See full question
The nurse is monitoring several postpartum women for potential
complications related to the birthing process. Which assessment should a
nurse prioritize on an hourly basis?
Correct response:
   Pad count

  Explanation:

The way to monitor for bleeding every hour is to assess pads and percentage
of the pad saturated by blood in the previous hour. It would not be necessary
to do a complete blood count every hour, nor hourly urines. Vital signs are
not typically taken every hour.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
677-678.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-678
Question 19   See full question
The nurse is assessing a client 48 hours postpartum and notes on
assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg.
The nurse should suspect the vital signs indicate which potential situation?
You Selected:

  Infection

Correct response:

  Infection

  Explanation:

Temperatures elevated above 100.4° F (38° C) 24 hours after birth are

indicative of possible infection. All but the temperature for this client are
within normal limits, so they are not indicative of shock or dehydration.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
675-676, 684
Question 20   See full question
The nurse is preparing discharge instructions for a postpartum woman who
has developed DVT after a long and difficult birthing process. The nurse will
include instruction on which medication for this client?
You Selected:

  Anticoagulants

Correct response:

  Anticoagulants

  Explanation:

The nurse should instruct the client on the anticoagulant, which will be
prescribed due to the DVT. The client may be advised to use NSAIDs for pain
control. Narcotic analgesics would not be appropriate, especially if the client
is breast-feeding her infant. Beta blockers would not be appropriate for this
situation.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia:

Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25:
Nursing Care of a Family Experiencing a Postpartum Complication, pp.
687-689.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687-689

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Answer Key
Question 1   See full question
Review of a primiparous woman's labor and birth record reveals a prolonged
second stage of labor and extended time in the stirrups. Based on an interpretation
of these findings, the nurse would be especially alert for which condition?
You Selected:

 thrombophlebitis

Correct response:

 thrombophlebitis

 Explanation:

The woman is at risk for thrombophlebitis due to the prolonged second stage of
labor, necessitating an increased amount of time in bed, and venous pooling that
occurs when the woman's legs are in stirrups for a long period of time. These
findings are unrelated to retained placental fragments, which would lead to uterine
subinvolution, or hypertension.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 686.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 686

Question 2   See full question

A nurse is developing a program to help reduce the risk of late postpartum
hemorrhage in clients in the labor and birth unit. Which measure would the nurse
emphasize as part of this program?
You Selected:

 inspecting the placenta after delivery for intactness

Correct response:
  inspecting the placenta after delivery for intactness

 Explanation:

After the placenta is expelled, a thorough inspection is necessary to confirm its

intactness because tears or fragments left inside may indicate an accessory lobe or
placenta accreta. These can lead to profuse hemorrhage because the uterus is
unable to contract fully. Administering antibiotics would be appropriate for
preventing infection, not postpartum hemorrhage. Manual removal of the placenta
or excessive traction on the umbilical cord can lead to uterine inversion, which in
turn would result in hemorrhage.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 682.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 682

Question 3   See full question

A nurse is assessing a postpartum client. Which finding would the cause the nurse
the greatest concern?
You Selected:

 sharp stabbing chest pain with shortness of breath

Correct response:

 sharp stabbing chest pain with shortness of breath

 Explanation:

Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism,
an emergency that requires immediate action. Leg pain on ambulation with mild
edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot
may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain
with swelling along the episiotomy might be a normal finding or suggest an
infection. Of the conditions, pulmonary embolism is the most urgent.

Reference:
  Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 689.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689

Question 4   See full question

While providing care to a woman who is experiencing postpartum hemorrhage, the
nurse weighs her perineal pads to estimate blood loss. The pad weighs 20 g. The
nurse documents this as which amount?
You Selected:

 20 mL

Correct response:

 20 mL

 Explanation:

When weighing perineal pads to determine blood loss, 1 gram of pad weight is
equivalent to 1 mL of blood loss. A pad that weighs 20 g would indicate a 20-mL
blood loss.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 677-678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-678

Question 5   See full question

A client who gave birth vaginally 16 hours ago states she does not need to void at
this time.
The nurse reviews the documentation and finds that the client has not voided for 7
hours. Which response by the nurse is indicated?
You Selected:
  “It’s not uncommon after birth for you to have a full bladder even though you
can’t sense the fullness.”

Correct response:

 “It’s not uncommon after birth for you to have a full bladder even though you
can’t sense the fullness.”

 Explanation:

After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As
a result of anesthesia and trauma, the client may be unable to sense the filling
bladder. It is premature to catheterize the client without allowing her to attempt to
void first. There is no need to contact the care provider at this time as the client is
demonstrating common adaptations in the early postpartum period. Allowing the
client’s bladder to fill for another 2 to 3 hours might cause overdistention.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 690

Question 6   See full question

A Hispanic client who gave birth several hours ago is experiencing postpartum
hemorrhage. She had a cesarean birth and received deep, general anesthesia. She
has a history of postpartum hemorrhage with her previous births. The blood is a
dark red. Which cause of the hemorrhage is most likely in this client?
You Selected:

 uterine atony

Correct response:

 uterine atony

 Explanation:

Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum
hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions
that contribute to uterine atony include having received deep anesthesia or
analgesia and a prior history of postpartum hemorrhage. A cervical laceration is
less likely because the blood is dark, not bright red, and bleeding from such a
laceration usually occurs immediately after detachment of the placenta.
Disseminated intravascular coagulation is typically associated with premature
separation of the placenta, a missed early miscarriage, or fetal death, none of which
is evident in this scenario. A retained placental fragment is possible, and could
contribute to the atony, but there is no evidence for this in the scenario.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 677.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677

Question 7   See full question

A woman recovering from cesarean birth in the hospital and who was catheterized
complains of a feeling of burning on urination and a feeling of frequency. Which of
the following should be the next nursing action?
You Selected:

 Obtain a clean-catch urine specimen

Correct response:

 Obtain a clean-catch urine specimen

 Explanation:

The client in this scenario shows classic signs of a urinary tract infection. The
priority nursing action at this point is to obtain a clean-catch urine specimen to
confirm the infection. The other answers are therapeutic management
interventions that would take place after confirmation of the infection via the clean-
catch urine specimen.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 692.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 692

Question 8   See full question

The nurse observes an ambulating postpartal woman limping and avoiding putting
pressure on her right leg. Which assessments should the nurse prioritize in this
client?
You Selected:

 Assess for warmth, erythema, and pedal edema.

Correct response:

 Assess for warmth, erythema, and pedal edema.

 Explanation:

This client is demonstrating potential symptoms of DVT, but is avoiding putting

pressure on the leg and limping when ambulating. DVT manifestations are caused
by inflammation and obstruction of venous return and can be assessed by the
presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The
client would not need to bend the knee to assess for pain in the calf. Asking the
client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is
assessing capillary refill (which may be affected by the DVT but is not indicative of a
DVT).

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 686-687.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 686-687

Question 9   See full question

The nurse is assessing a client 48 hours postpartum and notes on assessment:
temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should
suspect the vital signs indicate which potential situation?
You Selected:

 Infection
Correct response:

 Infection

 Explanation:

Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of
possible infection. All but the temperature for this client are within normal limits, so
they are not indicative of shock or dehydration.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 675-676, 684

Question 10   See full question

The nurse is assessing a postpartum client at a 6-week well-care check and notes
questionable behavior on assessment. Which behaviors should the nurse prioritize
and report to the RN or health care provider?
You Selected:

 Restless and agitated, concerned with self and not the infant

Correct response:

 Restless and agitated, concerned with self and not the infant

 Explanation:

When a woman presents with restlessness, irritability and concern only for self
needs and not the infant's needs, further evaluation for possible postpartum
psychosis should be a priority. The other choices would be considered normal
reactions for a postpartum woman.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695
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Answer Key
Question 1   See full question
The nurse is giving an educational presentation to the local Le Leche league
chapter. One woman asks about mastitis. What would be the nurse's best
response?
You Selected:

 Risk factors include nipple piercing.

Correct response:

 Risk factors include nipple piercing.

 Explanation:
Certain risk factors contribute to the development of mastitis. These include
inadequate or incomplete breast emptying during feeding or lack of frequent
feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or
bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 2   See full question

A nurse is making a home visit to a postpartum client. Which finding would lead the
nurse to suspect that a woman is experiencing postpartum psychosis?
You Selected:

 delirium

Correct response:

 delirium

 Explanation:

Postpartum psychosis is at the severe end of the continuum of postpartum

emotional disorders. It is manifested by depression that escalates to delirium,
hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts
of hurting herself and the infant. Feelings of guilt, sadness, and insomnia are
associated with postpartum depression.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695

Question 3   See full question

When assessing a client who is 5 days pospartum, which of the following would
alert the nurse to suspect that the client is experiencing late postpartum
hemorrhage?
You Selected:

 Rubra colored lochia

Correct response:

 Rubra colored lochia

 Explanation:

The nurse should monitor for rubra colored lochia, malodorous vaginal discharge,
and increased uterine cramping when actual hemorrhage occurs in a client
experiencing late postpartum hemorrhage. Fundal tenderness is a sign of
endometritis. Oliguria is suggestive of bacteremia in clients. Increased rectal
pressure is a sign of postpartal hematoma in a client

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-678

Question 4   See full question

When completing the morning postpartum data collection, the nurse notices the
client’s perineal pad is completely saturated. Which action should be the nurse’s
first response?
You Selected:

 Ask the client when she last changed her perineal pad

Correct response:

 Ask the client when she last changed her perineal pad

 Explanation:
If the morning assessment is done relatively early, it’s possible that the client hasn’t
yet been to the bathroom, in which case her perineal pad may have been in place
all night. Secondly, her lochia may have pooled during the night, resulting in a
heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a
boggy uterus, wouldn’t be recommended as a first response until the client had
gone to the bathroom, changed her perineal pad, and emptied her bladder. The
nurse wouldn’t want to call the primary care provider unnecessarily. If the nurse
were uncertain, it would be appropriate to have another qualified individual check
the client but only after a complete assessment of the client’s status.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-678

Question 5   See full question

Which situation should concern the nurse treating a postpartum client within a few
days of birth?
You Selected:

 The client feels empty since she gave birth to the neonate.

Correct response:

 The client feels empty since she gave birth to the neonate.

 Explanation:

A client experiencing postpartum blues may say she feels empty now that the
infant is no longer in her uterus. She may also verbalize that she feels unprotected
now. The other options are considered normal and would not be cause for concern.
Many first-time mothers are nervous about caring for their neonates by themselves
after discharge. New mothers may want a demonstration before doing a task
themselves. A client may want to get some uninterrupted sleep, so she may ask
that the neonate be taken to the nursery.

Reference:
  Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 693-695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 693-695

Question 6   See full question

Which factor puts a multiparous client on her first postpartum day at risk for
developing hemorrhage?
You Selected:

 uterine atony

Correct response:

 uterine atony

 Explanation:

Multiparous women typically experience a loss of uterine tone due to frequent

distentions of the uterus from previous pregnancies. As a result, this client is also at
higher risk for hemorrhage. Thrombophlebitis does not increase the risk of
hemorrhage during the postpartum period. The hemoglobin level and lochia flow
are within acceptable limits.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p.p. 677-678

Question 7   See full question

The nurse is performing a postpartum check on a 40-year-old client. Which nursing
measure is appropriate?
You Selected:

 Instruct the client to empty her bladder before the examination.

Correct response:

 Instruct the client to empty her bladder before the examination.

 Explanation:

An empty bladder facilitates the examination of the fundus. The client should be in
a supine position with her arms at her sides and her knees bent. The arms-
overhead position is unnecessary. Clean gloves should be used when assessing the
perineum; sterile gloves are not necessary. The postpartum examination should
not be done quickly. The nurse can take this time to teach the client about the
changes in her body after birth.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 679.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 679

Question 8   See full question

The nurse is assisting in developing a care plan for a client who had an episiotomy.
Which interventions would be included for the nursing diagnosis: Acute pain related
to perineal sutures as manifested by client stating pain of 8 out of 10? Select all that
apply:
You Selected:

 Encourage Kegel exercises with each voiding

 Administer sitz baths three to four times per day

Correct response:

 Administer sitz baths three to four times per day

 Encourage Kegel exercises with each voiding

 Explanation:

Pain is common after an episiotomy. Sitz baths help decrease inflammation and
tension in the perineal area. Kegel exercises improve circulation to the area and
help reduce edema. Ice packs should be applied to the perineum for the first 24
hours only; after that time, heat should be used. Topical pain gels should be applied
to the suture area to reduce discomfort, as ordered. The perineal pad should be
changed frequently to prevent irritation and potential infection caused by the
discharge.
Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pP. 685-686

Question 9   See full question

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is
experiencing postpartum psychosis. Which finding would most likely lead the nurse
to suspect this condition?
You Selected:

 delusional beliefs

Correct response:

 delusional beliefs

 Explanation:

Postpartum psychosis is at the severe end of the continuum of postpartum

emotional disorders. It is manifested by depression that escalates to delirium,
hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior,
mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness,
and insomnia are associated with postpartum depression.

Question 10   See full question

The nurse is preparing discharge instructions for a postpartum woman who has
developed DVT after a long and difficult birthing process. The nurse will include
instruction on which medication for this client?
You Selected:

 Anticoagulants

Correct response:

 Anticoagulants

 Explanation:

The nurse should instruct the client on the anticoagulant, which will be prescribed
due to the DVT. The client may be advised to use NSAIDs for pain control. Narcotic
analgesics would not be appropriate, especially if the client is breast-feeding her
infant. Beta blockers would not be appropriate for this situation.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 687-689.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687-689
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Answer Key
Question 1   See full question
The nurse is caring for a postpartum woman who exhibits a large amount of
bleeding. Which areas would the nurse need to assess before the woman
ambulates?
You Selected:

 Blood pressure, pulse, reports of dizziness

Correct response:

 Blood pressure, pulse, reports of dizziness

 Explanation:

Continue to monitor the woman's vital signs for changes. If she reports dizziness or
light-headedness when getting up, obtain her blood pressure while lying, sitting,
and standing, noting any change of 10 mm Hg or more.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 678, 680-681

Question 2   See full question

A fundal massage is sometimes performed on a postpartum woman. The nurse
would perform this procedure to address which condition?
You Selected:

 uterine atony

Correct response:

 uterine atony

 Explanation:

Fundal massage is performed for uterine atony, which is failure of the uterus to
contract and retract after birth. The nurse would place the gloved dominant hand
on the fundus and the gloved nondominant hand on the area just above the
symphysis pubis. Using a circular motion, the nurse massages the fundus with the
dominant hand. Then the nurse checks for firmness and, if firm, applies gentle
downward pressure to express clots that may have accumulated. Finally, the nurse
assists the woman with perineal care and applying a new perineal pad.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 678

Question 3   See full question

A nurse is assigned to care for a client with deep vein thrombosis who has to
undergo anticoagulation therapy. Which instruction should the nurse offer the
client as a caution when the client receives anticoagulation therapy?
You Selected:

 Avoid products containing aspirin.

Correct response:

 Avoid products containing aspirin.

 Explanation:

The nurse should caution the client to avoid products containing aspirin, which
inhibits the synthesis of clotting factors and can further prolong clotting time and
precipitate bleeding. The nurse should instruct the client to avoid crossing the legs
as a preventive measure. The nurse should not instruct the client to refrain from
performing any leg exercises; instead, the nurse should instruct the client to
perform leg exercises such as flexion and extension of the feet and pushing the
back of the knees into the mattress and then flexing slightly to promote venous
return. The nurse should instruct the client to avoid prolonged straining during
defecation and to avoid heavy lifting and exercises.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 687-689.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687-689

Question 4   See full question

When giving a postpartum client self-care instructions, the nurse instructs her to
report heavy or excessive bleeding. How should the nurse describe “heavy
bleeding?”
You Selected:

 Saturating 1 pad in 1 hour

Correct response:

 Saturating 1 pad in 1 hour

 Explanation:

Bleeding is considered heavy when a woman saturates 1 sanitary pad in 1 hour.

Excessive bleeding occurs when a postpartum client saturates 1 pad in 15 minutes.
Moderate bleeding occurs when the bleeding saturates less than 6(15 cm) of 1 pad
in 1 hour.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-677.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-677

Question 5   See full question

Which recommendation should be given to a client with mastitis who is concerned
about breastfeeding her neonate?
You Selected:

 She should continue to breastfeed; mastitis will not infect the neonate.

Correct response:

 She should continue to breastfeed; mastitis will not infect the neonate.
 Explanation:

The client with mastitis should be encouraged to continue breastfeeding while

taking antibiotics for the infection. No supplemental feedings are necessary
because breastfeeding does not need to be altered and actually encourages
resolution of the infection. Analgesics are safe and should be administered as
needed.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 6   See full question

A postpartal woman is developing a thrombophlebitis in her right leg. Which
assessment should the nurse no longer use to assess for thrombophlebitis?
You Selected:

 Dorsiflex her right foot and ask if she has pain in her calf.

Correct response:

 Dorsiflex her right foot and ask if she has pain in her calf.

 Explanation:

A positive Homans’ sign (pain in the upper calf upon dorsiflexion) is not a definitive
diagnostic sign as it is insensitive and nonspecific and is no longer recommended as
an indicator of DVT. That is because calf pain can also be caused by other
conditions. Ask the woman if she has pain or tenderness in the lower extremities
and assess for reddness and warmth and if she has increased pain when she
ambulates or bears weight.

Question 7   See full question

What medication would the nurse administer to a client experiencing uterine atony
and bleeding leading to postpartum hemorrhage?
You Selected:
  Oxytocin

Correct response:

 Oxytocin

 Explanation:

A tocolytic such as oxytocin causes the uterus to contract to improve uterine tone
and reduce bleeding. Magnesium sulfate is administered to clients with
preeclampsia or eclampsia or hypertension problems. Domperidone is used to
increase lactation in women. Calcium gluconate is an antagonist used in clients
experiencing side effects of magnesium sulfate.

Question 8   See full question

The nurse is caring for a woman who delivered via a cesarean delivery
approximately 16 hours earlier. Which assessment finding should the nurse
prioritize?
You Selected:

 Gradually decreasing temperature and pulse rate

Correct response:

 Steadily decreasing volume of urine

 Explanation:

Decreasing amounts of urine indicate hypovolemic complications and need to be

further assessed by the RN and/or health care provider. This may be an indication
the client is hemorrhaging and is in danger of going into shock and must be
evaluated immediately. A gradually decreasing temperature and pulse rate and
excessive diaphoresis are normal findings at this stage and would not need
prioritized attention. The uterine height would not be a priority at this time.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689, 691-692

Question 9   See full question

The nursing instructor is leading a discussion exploring the various conditions that
can result in postpartum hemorrhage. The instructor determines the session is
successful when the students correctly choose which condition is most frequently
the cause of postpartum hemorrhage?
You Selected:

 Uterine atony

Correct response:

 Uterine atony

 Explanation:

Early postpartum hemorrhage usually results from one of the following conditions:
uterine atony, lacerations, or hematoma. Most cases of early postpartum
hemorrhage result from uterine atony, which is due to the uterine muscles
remaining relaxed and not contracting as they should. Disseminated intravascular
coagulation is a complication which can occur with excessive postpartum
hemorrhage.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 677-678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-678

Question 10   See full question

The nurse is monitoring the woman who is 1 hour postpartum and notes on
assessment the uterine fundus is boggy, to the right, and approximately 2 cm
above the umbilicus. The nurse would conclude this is most likely related to which
potential complication?
You Selected:

 Excessive bleeding

Correct response:

 Bladder distention
 Explanation:

The displacement of the uterus to one side is suggestive of bladder distension. The
bladder should be emptied and then fundal massage instituted to encourage the
uterus to contract and stop the excessive bleeding. If the uterus was in the midline,
then this would be related solely to uterine bleeding. It's important to ensure the
bladder is empty before starting the fundal massage to ensure the uterus will stay
contracted. A urinary infection would be noted to cause burning on urination. A
ruptured bladder would be indicative of hematuria as well as pelvic pain.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-681.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-681
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Answer Key
Question 1   See full question
The nurse determines that a woman is experiencing postpartum hemorrhage after
a vaginal birth when the blood loss is greater than which amount?
You Selected:

 500 mL

Correct response:

 500 mL

 Explanation:

Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a

vaginal birth or more than 1,000 mL after a cesarean birth.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 676.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676

Question 2   See full question

A multipara client develops thrombophlebitis after birth. Which assessment
findings would lead the nurse to intervene immediately?
You Selected:

 dyspnea, diaphoresis, hypotension, and chest pain

Correct response:

 dyspnea, diaphoresis, hypotension, and chest pain

 Explanation:

Sudden unexplained shortness of breath and reports of chest pain along with
diaphoresis and hypotension suggest pulmonary embolism, which requires
immediate action. Other signs and symptoms include tachycardia, apprehension,
hemoptysis, syncope, and sudden change in the woman's mental status secondary
to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary
embolism.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 689.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689

Question 3   See full question

A client experienced prolonged labor with prolonged premature rupture of
membranes. The nurse would be alert for which condition in the mother and the
newborn?
You Selected:

 infection

Correct response:

 infection

 Explanation:

Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged

labor with the prolonged premature rupture of membranes places the client at high
risk for a postpartum infection. The rupture of membranes removes the barrier of
amniotic fluid, so bacteria can ascend.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 683-684.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 683-684

Question 4   See full question

A nurse is caring for a client in the postpartum period. When observing the client’s
condition, the nurse notices that the client tends to speak incoherently. The client’s
thought process is disoriented, and she frequently indulges in obsessive concerns.
The nurse notes that the client has difficulty in relaxing and sleeping. The nurse
interprets these findings as suggesting which condition?
You Selected:

 postpartum depression

Correct response:

 postpartum psychosis

 Explanation:

The client’s signs and symptoms suggest that the the client has developed
postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting
suspicious and incoherent behavior, confusion, irrational statements, and
obsessive concerns about the baby’s health and welfare. Delusions, specific to the
infant, are present. Sudden terror and a sense of impending doom are
characteristic of postpartum panic disorders. Postpartum depression is
characterized by a client feeling that her life is rapidly tumbling out of control. The
client thinks of herself as an incompetent parent. Emotional swings, crying easily—
often for no reason, and feelings of restlessness, fatigue, difficulty sleeping,
headache, anxiety, loss of appetite, decreased ability to concentrate, irritability,
sadness, and anger are common findings are characteristics of postpartum blues.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695

Question 5   See full question

Which intervention would be helpful to a bottle-feeding client who is experiencing
hard or engorged breasts?
You Selected:

 applying ice
Correct response:

 applying ice

 Explanation:

Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the

area, and discouraging further letdown of milk. Restricting fluids does not reduce
engorgement and should not be encouraged. Warm compresses will promote
blood flow and hence, milk production, worsening the problem of engorgement.
Bromocriptine has been removed from the market for lactation suppression.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 6   See full question

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous
thrombophlebitis. The nurse should include which instruction in her discharge
teaching?
You Selected:

 Avoid over-the-counter (OTC) salicylates.

Correct response:

 Avoid over-the-counter (OTC) salicylates.

 Explanation:

Discharge teaching should include informing the client to avoid OTC salicylates,
which may potentiate the effects of anticoagulant therapy. Iron will not affect
anticoagulation therapy. Restrictive clothing should be avoided to prevent the
recurrence of thrombophlebitis. Shortness of breath should be reported
immediately because it may be a symptom of pulmonary embolism.

Reference:
  Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 687.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687

Question 7   See full question

Over 75% of women who give birth experience postpartum depression.
You Selected:

 False

Correct response:

 False

 Explanation:

Although almost every woman notices some immediate (1 to 10 days postpartum)

feelings of sadness (postpartal "blues") after childbirth, these feelings develop into
postpartum depression in about 20%.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 693.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 693

Question 8   See full question

In talking to a mother who is 6 hours post-delivery, the mother reports that she has
changed her perineal pad twice in the last hour. What question by the nurse would
best elicit information needed to determine the mother’s status?
You Selected:

 “What time did you last change your pad?”

Correct response:

 “How much blood was on the two pads?”

 Explanation:

The nurse needs to determine the amount of bleeding the client is experiencing;
therefore, the best question to ask the mother is the amount of blood noted on her
perineal pads when she changes them. If she had an epidural, she may not feel any
pain or discomfort with the bleeding. Although a full bladder can prevent the uterus
from contracting, the nurse’s main concern is the amount of lochia the mother is
having.

Question 9   See full question

A postpartum client is recovering from the birth and emergent repair of a cervical
laceration. Whch sign on assessment should the nurse prioritize and report to the
RN and/or health care provider?
You Selected:

 Weak and rapid pulse

Correct response:

 Weak and rapid pulse

 Explanation:

Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of
impending shock include a weak and rapid pulse, decreased blood pressure,
tachypnea, and cool and clammy skin. These findings should be reported
immediately to the RN and/or health care provider so that proper intervention for
the client may be instituted.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 678, 681

Question 10   See full question

A woman presents to the clinic at 1-month postpartum and reports her left breast
has a painful, reddened area. On assessment, the nurse discovers a localized red
and warm area. The nurse predicts the client has developed which disorder?
You Selected:
  Mastitis

Correct response:

 Mastitis

 Explanation:

Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral.

Assessment should reveal a localized reddened area which is warm and painful to
palpation. The scenario described is not indicative of a plugged milk duct or
engorgement. Yeast is not recognized to cause mastitis.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 689.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689
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Answer Key
Question 1   See full question
The nurse collects a urine specimen for culture from a postpartum woman with a
suspected urinary tract infection. Which organism would the nurse expect the
culture to reveal?
You Selected:

 Escherichia coli

Correct response:

 Escherichia coli

 Explanation:

E. coli is the most common causative organism for urinary tract infections. S. aureus
is the most common causative organism for mastitis. G. vaginalis is a common
cause of metritis. K. pneumoniae is a common cause of metritis, but some species of
Klebsiella may cause urinary tract infections.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 684.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 684

Question 2   See full question

A woman who is 2 weeks postpartum calls the clinic and says, “My left breast hurts.”
After further assessment on the phone, the nurse suspects the woman has
mastitis. In addition to pain, the nurse would question the woman about which
symptom?
You Selected:

 an ecchymotic area on the affected breast

Correct response:

 hardening of an area in the affected breast

 Explanation:

Mastitis is characterized by a tender, hot, red, painful area on the affected breast.
An inverted nipple is not associated with mastitis. With mastitis, the breast is
distended with milk, the area is inflamed (not ecchymotic), and there is breast
tenderness.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 3   See full question

A nurse is caring for a client who has had a cesarean birth and has developed a
wound infection. What precautions should be taken by the nurse as a primary
prevention measure?
You Selected:

 Keep the incisions clean and dry

Correct response:

 Keep the incisions clean and dry

 Explanation:

When caring for a client who has developed a wound infection, the nurse should
keep the incision clean and dry to eliminate the opportunity for bacterial growth
and proliferation. The nurse should apply ice and heat alternatively to decrease
swelling when caring for a client who has undergone incision and drainage of a
hematoma. Sitz baths are performed every 4 to 6 hours, not every 24 hours. Sitz
baths aid in promoting comfort to the perineum after vaginal delivery. The nurse
should apply ice packs every 12 to 24 hours when caring for a client with
postpartum lacerations.
Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 683-684.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 683-684

Question 4   See full question

The nurse is teaching a client with newly diagnosed mastitis about her condition.
The nurse would inform the client that she most likely contracted the disorder from
which organism?
You Selected:

 Staphylococcus aureus

Correct response:

 Staphylococcus aureus

 Explanation:

The most common cause of mastitis is S. aureus, transmitted from the neonate’s
mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not
associated with mastitis. GBS infection is associated with neonatal sepsis and
death.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 5   See full question

The nurse is observing a client who gave birth yesterday. Where should the nurse
expect to find the top of the client’s fundus?
You Selected:

 One fingerbreadth below the umbilicus

Correct response:

 One fingerbreadth below the umbilicus

 Explanation:

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

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 679-680.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 679-680

Question 6   See full question

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17
hours of labor. Which condition puts this client at risk for infection?
You Selected:

 length of labor

Correct response:

 length of labor

 Explanation:

A prolonged length of labor places the mother at increased risk for developing an
infection. The average size of the neonate, vaginal birth, and Rh status of the client
do not place the mother at increased risk.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 683.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 683

Question 7   See full question

Retention of placental fragments commonly leads to hypertension.
You Selected:

 True

Correct response:

 True

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 693.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 693

Question 8   See full question

The nurse is caring for a client who has been diagnosed with a deep vein
thrombosis. Which assessment finding should the nurse prioritize and report
immediately?
You Selected:

 Calf pain

Correct response:

 Dyspnea

 Explanation:

A DVT is often suspected when an individual with an increased risk develops calf
pain, pyrexia, and edema in one lower extremity. After the individual has been
positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible
pulmonary embolism and should be handled as an emergency. The RN and/or
primary care provider should be notified immediately so emergent care can be
started, as this is often fatal.
Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 689.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689

Question 9   See full question

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a
postpartum visit. He reports his wife is acting differently, is extremely talkative and
energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to
be totally neglecting the infant. The nurse should suspect the client is exhibiting
signs and symptoms of which disorder?
You Selected:

 Postpartum psychosis

Correct response:

 Postpartum psychosis

 Explanation:

Postpartum psychosis in a client can present with extreme mood changes and odd
behavior. Her sudden change in behavior from normal, along with a lack of self-
care and care for the infant, are signs of psychosis and need to be assessed by a
provider as soon as possible. Postpartum depression affects the woman's ability to
function; however, her perception of reality remains intact. Postpartum blues is a
transitory phase of sadness and crying common among postpartum women.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695

Question 10   See full question

The nurse is caring for a postpartum woman who is diagnosed with endometritis.
Which position should the nurse encourage the client to maintain?
You Selected:

 Semi-Fowler

Correct response:

 Semi-Fowler

 Explanation:

A semi-Fowler's position encourages lochia to drain so it will not become stagnant

and cause further infection. Placing the woman flat in bed, on her left side, or in the
Trendelenburg position would not accomplish this goal and could result in the
infection spreading to other parts of the body.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 685.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 685
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Answer Key
Question 1   See full question
The nurse is giving an educational presentation to the local Le Leche league
chapter. One woman asks about mastitis. What would be the nurse's best
response?
You Selected:

 Risk factors include nipple piercing.

Correct response:

 Risk factors include nipple piercing.

 Explanation:

Certain risk factors contribute to the development of mastitis. These include

inadequate or incomplete breast emptying during feeding or lack of frequent
feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or
bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 2   See full question

The nurse is caring for a client within the first four hours after her cesarean birth.
Which nursing intervention would be most appropriate to prevent
thrombophlebitis?
You Selected:

 Ambulate the client as soon as her vital signs are stable.

Correct response:

 Ambulate the client as soon as her vital signs are stable.

 Explanation:

The best prevention for a thrombophlebitis is ambulation as soon as possible after

recovery. Ambulation requires blood movement throughout the cardiovascular
system decreasing thrombophlebitis risks. Placing a bath blanket behind the knees
interrupts circulation and could cause a thrombus. Fluids are encouraged not
limited. Leg exercises may put strain on the abdominal incision.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 687.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687

Question 3   See full question

Review of a primiparous woman's labor and birth record reveals a prolonged
second stage of labor and extended time in the stirrups. Based on an interpretation
of these findings, the nurse would be especially alert for which condition?
You Selected:

 thrombophlebitis

Correct response:

 thrombophlebitis

 Explanation:
The woman is at risk for thrombophlebitis due to the prolonged second stage of
labor, necessitating an increased amount of time in bed, and venous pooling that
occurs when the woman's legs are in stirrups for a long period of time. These
findings are unrelated to retained placental fragments, which would lead to uterine
subinvolution, or hypertension.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 686.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 686

Question 4   See full question

A nurse is developing a program to help reduce the risk of late postpartum
hemorrhage in clients in the labor and birth unit. Which measure would the nurse
emphasize as part of this program?
You Selected:

 inspecting the placenta after delivery for intactness

Correct response:

 inspecting the placenta after delivery for intactness

 Explanation:

After the placenta is expelled, a thorough inspection is necessary to confirm its

intactness because tears or fragments left inside may indicate an accessory lobe or
placenta accreta. These can lead to profuse hemorrhage because the uterus is
unable to contract fully. Administering antibiotics would be appropriate for
preventing infection, not postpartum hemorrhage. Manual removal of the placenta
or excessive traction on the umbilical cord can lead to uterine inversion, which in
turn would result in hemorrhage.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 682.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 682

Question 5   See full question

When developing the plan of care for a client with postpartum endometritis, which
intervention would the nurse most likely include?
You Selected:

 Using semi-Fowler’s position to encourage uterine drainage

Correct response:

 Using semi-Fowler’s position to encourage uterine drainage

 Explanation:

The semi-Fowler’s position is used to encourage uterine drainage in the client with
postpartum endometritis. Nursing interventions such as performing vigorous but
gentle fundal massage, inserting an indwelling urinary catheter to keep the bladder
empty, and performing bimanual compression of the uterine structure should be
performed when caring for clients with hemorrhage and uterine atony.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 684-685.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 684-685

Question 6   See full question

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still
enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is
most likely for this client?
You Selected:

 Ineffective peripheral tissue perfusion related to interference with circulation

secondary to development of thrombophlebitis

Correct response:
  Risk for fatigue related to chronic bleeding due to subinvolution

 Explanation:

Subinvolution is incomplete return of the uterus to its prepregnant size and shape.
With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and
soft. Lochial discharge usually is still present. The symptoms in the scenario are
closest to those of subinvolution.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 682.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 682

Question 7   See full question

It is discovered that a new mother has developed a puerperal infection. What is the
most likely expected outcome that the nurse will identify for this client related to
this condition?
You Selected:

 Client's temperature remains below 100.4° F or 38° C orally.

Correct response:

 Client's temperature remains below 100.4° F or 38° C orally.

 Explanation:

As fever would accompany a puerperal infection, a likely expected outcome would

be to reduce the client's temperature and keep it in a normal range. The other
expected outcomes do not pertain as directly to puerperal infection as does the
reduced temperature.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 684.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 684

Question 8   See full question

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal
pad has become saturated in approximately 15 minutes. Which action should the
nurse prioritize?
You Selected:

 Assess the woman's vital signs.

Correct response:

 Assess the woman's fundus.

 Explanation:

The nurse should prioritize assessing the uterine fundus to eliminate it as a source
of the bleeding. Assessing the vital signs would be the next step, especially if the
massage is ineffective, to determine if the client is becoming unstable. The nurse
would then alert the RN or health care provider about the increased bleeding
and/or unstable vital signs. The LPN would not initiate an IV infusion without an
order from the health care provider but should be prepared to do so, if it is
ordered.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 679-680.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 679-680

Question 9   See full question

The nurse is monitoring the woman who is 1 hour postpartum and notes on
assessment the uterine fundus is boggy, to the right, and approximately 2 cm
above the umbilicus. The nurse would conclude this is most likely related to which
potential complication?
You Selected:

 Urinary infection
Correct response:

 Bladder distention

 Explanation:

The displacement of the uterus to one side is suggestive of bladder distension. The
bladder should be emptied and then fundal massage instituted to encourage the
uterus to contract and stop the excessive bleeding. If the uterus was in the midline,
then this would be related solely to uterine bleeding. It's important to ensure the
bladder is empty before starting the fundal massage to ensure the uterus will stay
contracted. A urinary infection would be noted to cause burning on urination. A
ruptured bladder would be indicative of hematuria as well as pelvic pain.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-681.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-681

Question 10   See full question

A nurse is caring for a postpartum client whose most recent assessment reveals a
large, purple area of edema on the left side of her perineum. What is the nurse's
best action?
You Selected:

 Report the finding promptly to the primary care provider

Correct response:

 Report the finding promptly to the primary care provider

 Explanation:

This client's presentation is consistent with a hematoma, which indicates a

hemorrhage and which must be treated promptly. Reporting this change in status is
priority over hot/cold treatments. This is not an expected finding.
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Answer Key
Question 1   See full question
One of the primary assessments a nurse makes every day is for postpartum
hemorrhage. What does the nurse assess the fundus for?
You Selected:

 Consistency, shape, and location

Correct response:

 Consistency, shape, and location

 Explanation:

Assess the fundus for consistency, shape, and location. Remember that the uterus
should be firm, in the midline, and decrease 1 cm each postpartum day.
Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 677-680.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 677-680

Question 2   See full question

After the nurse teaches a local woman's group about postpartum affective
disorders, which statement by the group indicates that the teaching was successful?
You Selected:

 "Postpartum depression develops gradually, appearing within the first 6

weeks."

Correct response:

 "Postpartum depression develops gradually, appearing within the first 6

weeks."

 Explanation:

Postpartum depression usually has a more gradual onset, becoming evident within
the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th
postpartum day and resolves by the 10th day. Postpartum psychosis generally
surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization
for up to several months. Psychotropic drugs are almost always a part of treatment,
along with individual psychotherapy and support group therapy.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp, 693-695

Question 3   See full question

The nurse is conducting a class for postpartum women about mood disorders. The
nurse describes a transient, self-limiting mood disorder that affects mothers after
birth. The nurse determines that the women understood the description when they
identify the condition as postpartum:
You Selected:

 blues.

Correct response:

 blues.

 Explanation:

Postpartum blues are manifested by mild depressive symptoms of anxiety,

irritability, mood swings, tearfulness, increased sensitivity, feelings of being
overwhelmed, and fatigue. They are usually self-limiting and require no formal
treatment other than reassurance and validation of the woman's experience as well
as assistance in caring for herself and her newborn. Postpartum depression is a
major depressive episode associated with birth. Postpartum psychosis is at the
severe end of the continuum of postpartum emotional disorders. Bipolar disorder
refers to a mood disorder typically involving episodes of depression and mania.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 693-695.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 693-695

Question 4   See full question

When assessing the postpartum woman, the nurse uses indicators other than pulse
rate and blood pressure for postpartum hemorrhage because:
You Selected:

 these measurements may not change until after the blood loss is large.

Correct response:

 these measurements may not change until after the blood loss is large.

 Explanation:

The typical signs of hemorrhage do not appear in the postpartum woman until as
much as 1,800 to 2,100 mL of blood has been lost. In addition, accurate
determination of actual blood loss is difficult because of blood pooling inside the
uterus and on perineal pads, mattresses, and the floor.

Reference:

 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-677, 680-681

Question 5   See full question

A nurse is caring for a client in the postpartum period. When observing the client’s
condition, the nurse notices that the client tends to speak incoherently. The client’s
thought process is disoriented, and she frequently indulges in obsessive concerns.
The nurse notes that the client has difficulty in relaxing and sleeping. The nurse
interprets these findings as suggesting which condition?
You Selected:

 postpartum psychosis

Correct response:

 postpartum psychosis

 Explanation:

The client’s signs and symptoms suggest that the the client has developed
postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting
suspicious and incoherent behavior, confusion, irrational statements, and
obsessive concerns about the baby’s health and welfare. Delusions, specific to the
infant, are present. Sudden terror and a sense of impending doom are
characteristic of postpartum panic disorders. Postpartum depression is
characterized by a client feeling that her life is rapidly tumbling out of control. The
client thinks of herself as an incompetent parent. Emotional swings, crying easily—
often for no reason, and feelings of restlessness, fatigue, difficulty sleeping,
headache, anxiety, loss of appetite, decreased ability to concentrate, irritability,
sadness, and anger are common findings are characteristics of postpartum blues.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, p. 695.
 Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 695

Question 6   See full question

The nurse would be alert for which of the following complications when caring for a
38-year-old postpartal client with a history of obesity and diabetes?
You Selected:

 Thromboembolic complications

Correct response:

 Thromboembolic complications

 Explanation:

The nurse should monitor the client for thromboembolic complications. The risk for
thromboembolic complications increase when the client is older than 35, is obese,
and has a history of diabetes or a pre-existing cardiovascular disease. Uterine
prolapse occurs more commonly in perimenopausal clients. A client diagnosed with
a puerperal infection is at increased risk for septic pelvic thrombophlebitis.
Endometritis is the primary cause of postpartum infections.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 686-687.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 686-687

Question 7   See full question

A postpartum client who had a cesarean birth reports right calf pain to the nurse.
The nurse observes that the client has nonpitting edema from her right knee to her
foot. The nurse knows to prepare the client for which test first?
You Selected:

 Venous duplex ultrasound of the right leg

Correct response:
  Venous duplex ultrasound of the right leg

 Explanation:

Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT).
Postpartum clients and clients who have had abdominal surgery are at increased
risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the
veins and assesses blood flow patterns. A venogram is an invasive test that utilizes
dye and radiation to create images of the veins and wouldn’t be the first choice.
Transthoracic echocardiography looks at cardiac structures and isn’t indicated at
this time. Right calf pain and edema are symptoms of venous outflow obstruction,
not arterial insufficiency.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 687-688.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 687-688

Question 8   See full question

On assessment of a client who gave birth 3 hours ago, the nurse finds that the
client has completely saturated a perineal pad within 15 minutes. Which actions are
immediately initiated? Select all that apply:
You Selected:

 Assess the client’s vital signs

 Begin an I.V. infusion of lactated Ringer’s solution
 Palpate the client’s fundus

Correct response:

 Assess the client’s vital signs

 Palpate the client’s fundus

 Explanation:

Assessing vital signs provides information about the client’s circulatory status and
identifies significant changes to report to the health care provider. By palpating the
client’s fundus, the nurse also gains valuable assessment data. A boggy uterus may
lead to excessive bleeding. Starting an I.V. infusion requires a health care provider’s
order. Placing the client in high Fowler’s position may lower blood pressure and be
harmful to the client. Administration of a pain medication doesn’t address the
current problem.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 676-678.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 676-678

Question 9   See full question

A client presents to the clinic with her 3-week-old infant complaining of general flu-
like symptoms and a painful right breast. Assessment reveals temperature 101 o8F
(38.8oC) and the right breast nipple with a hard area that is red and warm. Which
instruction should the nurse prioritize for this client?
You Selected:

 Complete the 10-day antibiotic prescription even if she begins to feel better.

Correct response:

 Complete the 10-day antibiotic prescription even if she begins to feel better.

 Explanation:

Mastitis is an infection of the breast tissue with common complaints of general flu-
like symptoms that occur suddenly, along with tenderness, pain, and heaviness in
the breast. Inspection reveals erythema and edema in an area localized to one
breast, commonly in a pie-shaped wedge. The area is hard, warm, and tender on
palpation. Nursing care focuses on supporting continued breast feeding, preventing
milk stasis and administering antibiotics for a full 10 days. The woman should
empty her breast every 1.5 to 2 hours to help prevent milk stasis and the spread of
the mastitis. The use of analgesics, warm showers, and warm compresses to relieve
discomfort may be encouraged; increasing her fluid intake will keep the mother
well-hydrated and able to produce an adequate milk supply. However, these
actions would not be considered the most important aspects of self-care.

Reference:
  Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 689-690.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 689-690

Question 10   See full question

The nurse is assessing a client who is 14 hours postpartum and notes very heavy
lochia flow with large clots. Which action should the nurse prioritize?
You Selected:

 Palpate her fundus.

Correct response:

 Palpate her fundus.

 Explanation:

The nurse should assess the status of the uterus by palpating the fundus and
determining its condition. If it is boggy, the nurse would then initiate fundal
massage to help it contract and encourage the passage of the lochia and any
potential clots that may be in the uterus. Assessing the blood pressure and
assessing her perineum would follow if indicated. It would be best if the woman is
in the semi-Fowler's position to allow gravity to help the lochia to drain from the
uterus. The nurse would also ensure the bladder was not distended.

Reference:
 Pillitteri, A. Maternal and Child Health Nursing, 7th ed., Philadelphia: Wolters
Kluwer Health/Lippincott Williams & Wilkins, 2014, Chapter 25: Nursing Care
of a Family Experiencing a Postpartum Complication, pp. 679-680.
Chapter 25: Nursing Care of a Family Experiencing a Postpartum
Complication - Page 679-680
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