NR 327 Chapter 17:
Postpartum Physiologic
Adaptations
MULTIPLE CHOICE
- A postpartum client overhears the nurse tell the health care provider that she has a
positive Homans sign and asks what it means. Which is the nurse’s best response?
a. “You have pitting edema in your ankles.”
b
. “You have deep tendon reflexes rated 2+.”
c. “You have calf pain when the nurse flexes your foot.”
d
. “You have a ’fleshy’ odor to your vaginal drainage.”
ANS: C
Discomfort in the calf with sharp dorsiflexion of the foot may indicate a deep vein
thrombosis. Edema is within normal limits for the first few days until the excess
interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+.
A fleshy odor, not a foul odor, is within normal limits.
PTS: 1 DIF: Cognitive Level: Application REF: 338
OBJ: Nursing Process Step: Implementation
MSC: Client Needs: Physiologic Integrity - Which client would be most likely to have severe afterbirth pains and request a
narcotic analgesic?
a. Gravida 5, para 5
b
. Primipara who delivered a 7-lb boy
c. Client who is bottle feeding her first child
d Client who wishes to breastfeed as soon as her baby is
. out of the neonatal intensive care unit
ANS: A
The discomfort of afterpains is more acute for multiparas because repeated stretching
of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends
to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle
feeding. The non-nursing mother may have engorgement problems. She should empty
her breasts regularly to stimulate milk production so she will have the milk when the
baby is strong enough to nurse.
PTS: 1 DIF: Cognitive Level: Understanding REF: 329
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity
- Which maternal event is abnormal in the early postpartal period?
a. Diuresis and diaphoresis
b
. Flatulence and constipation
c. Extreme hunger and thirst
d
. Lochial color changes from rubra to alba
ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and
then at about 11 days, the discharge becomes clear, colorless, or white. The body rids
itself of increased plasma volume. Urine output of 3000 mL/day is common for the first
few days after birth and is facilitated by hormonal changes in the mother. Bowel tone
remains sluggish for days. Many women anticipate pain during defecation and are
unwilling to exert pressure on the perineum. The new mother is hungry because of
energy used in labor and thirsty because of fluid restrictions during labor.
PTS: 1 DIF: Cognitive Level: Analysis REF: 329
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and
Maintenance
- Which fundal assessment finding at 12 hours after birth requires further assessment?
a. The fundus is palpable at the level of the umbilicus.
b The fundus is palpable two fingerbreadths above the
. umbilicus.
The fundus is palpable one fingerbreadth below the
c. umbilicus.
d The fundus is palpable two fingerbreadths below the
. umbilicus.
ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24 hours.A
fundus that
is above the umbilicus may indicate uterine atony or urinary retention. The fundus
palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum.
The fundus palpable one fingerbreadth below the umbilicus is an appropriate
assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths
below the umbilicus is an unusual finding for 12 hours postpartum, but is still
appropriate.
PTS: 1 DIF: Cognitive Level: Application REF: 329
OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity