Nursing Care of the Postpartum Family
A nurse is assessing a client 12 hours postpartum following a vaginal birth. Which finding is expected during this time?
A. Temperature of 101.2°F (38.4°C)
B. Pulse rate of 54 beats/min
C. Fundus boggy and above the umbilicus
D. Lochia serosa with foul odor
B. Pulse rate of 54 beats/min Rationale: Relative bradycardia (50–60 bpm) is normal immediately postpartum due to cardiovascular adaptations.
When does menstruation return for nonlactating women?
7 to 9 weeks after birth
Which newborn vital sign is within normal limits?
A. Heart rate 88 beats/min
B. Respiratory rate 68 breaths/min
C. Axillary temperature 36.8°C (98.2°F)
D. Blood pressure 90/60 mm Hg
C.
Which substance helps prevent alveolar collapse in the newborn’s lungs?
A. Catecholamines
B. Surfactant
C. Brown fat
D. Bilirubin
B.
What cheesy characteristic is commonly abundant on preterm babies?
Vernix caseosa
Which hormone combination is responsible for lactation?
A. Estrogen and progesterone
B. Prolactin and oxytocin
C. HCG and estrogen
D. Progesterone and cortisol
B. Prolactin and oxytocin
What should you always check first before you allow a postpartum patient to ambulate?
Check blood pressure
Which Apgar component assesses muscle tone?
A. Appearance
B. Pulse
C. Grimace
D. Activity
D.
Which finding is normal in a term newborn?
A. Apnea lasting 30 seconds
B. Respirations that are irregular with pauses under 15 seconds
C. Central cyanosis lasting 24 hours
D. Asymmetrical chest movement
B.
Name two reasons why babies often have trouble regulating their temperature and why premies can become hypothermic.
Big surface area, use up brown fat
Which findings are normal postpartum adaptations? (SELECT ALL THAT APPLY)
A. White blood cell count of 22,000/mm³
B. Fundus firm at the level of the umbilicus
C. Lochia alba on postpartum day 2
D. Decreased bladder tone
E. Estrogen and progesterone levels drop rapidly
Correct Answers: A, B, D, E
Rationale: Leukocytosis, uterine firmness, bladder tone changes, and hormone drops are expected. Lochia alba occurs later.
What does BUBBLEEE stand for?
Breasts, uterus, bowel, bladder, lochia, episiotomy, extremities, emotional status
A nurse is caring for a newborn immediately after birth. Which nursing action has the highest priority?
A. Measure length and weight
B. Apply identification bands
C. Dry and stimulate the infant
D. Administer vitamin K
Correct Answer: C
Rationale: Airway, breathing, and thermoregulation come first.
Which findings are expected normal newborn variations? (SELECT ALL THAT APPLY)
A. Caput succedaneum
B. Cephalohematoma
C. Milia
D. Mongolian spots
E. Closed posterior fontanel at birth
Correct Answers: A, B, C, D
Rationale: Closed fontanels at birth are abnormal.
Name four common problems associated with post-term babies.
Perinatal asphyxia: lack of oxygen to organ systems
Hypoglycemia
Polycythemia: excessive RBC in response to hypoxia= jaundice/high bilirubin levels
Meconium aspiration
Which intervention is most appropriate to relieve breast engorgement in a client who is not breastfeeding?
A. Frequent breast stimulation
B. Warm showers
C. Manual expression of milk
D. Ice packs to the breasts
Correct Answer: D. Ice packs to breasts
Rationale: Ice and avoidance of stimulation help suppress lactation.
What is uterine involution?
uterus returns to its normal size through contraction of muscle fibers to reduce those previously stretched during pregnancy, catabolism, which shrinks enlarged individual myometrial cells, and regeneration of uterine epithelium
Which mechanism of heat loss occurs when a newborn is placed on a cold scale?
A. Evaporation
B. Convection
C. Radiation
D. Conduction
D.
A nurse notes that a newborn’s respiratory rate is 64 breaths/min, nasal flaring is present, and the infant has mild retractions. What is the priority nursing action?
A. Feed the newborn
B. Document the findings
C. Provide supplemental oxygen
D. Place the newborn skin-to-skin
Correct Answer: C
Rationale: These findings suggest respiratory distress (e.g., TTN).
Which crosses the suture lines, cephalohematoma or caput succedaneum?
caput succedaneum
Which behavior best reflects the taking-in phase of maternal adaptation?
A. The mother seeks reassurance about infant care
B. The mother focuses on recounting her labor experience
C. The mother leaves the infant with family to rest
D. The mother expresses confidence in infant feeding
Correct Answer: B The mother focuses on recounting her labor experience.
This phase is : the time immediately after birth when the patient needs sleep, depends on others to meet her needs, and relives the events of the birth process
A nurse is caring for a 24-year-old client who is 18 hours postpartum following a spontaneous vaginal birth. The client received regional anesthesia during labor and has been breastfeeding. Assessment findings include:
Fundus firm, midline, at the level of the umbilicus
Lochia rubra, moderate, no clots
Pulse 56 beats/min
Blood pressure 108/64 mm Hg
Bladder palpable above the symphysis pubis
Client reports uterine cramping rated 6/10 while breastfeeding
Which nursing action is most appropriate at this time?
A. Administer prescribed opioid analgesic for uterine cramping
B. Encourage increased oral fluid intake
C. Assist the client to void and reassess the fundus
D. Notify the provider of postpartum bradycardia
C
Rationale:
Although several findings are normal postpartum (bradycardia, afterpains with breastfeeding, moderate lochia), a palpable bladder indicates urinary retention, which can interfere with uterine contraction and increase the risk for postpartum hemorrhage. The priority intervention is to assist the client to void, then reassess uterine tone and position. This addresses the most immediate potential complication.
A newborn has voided only once in the first 24 hours. Which action should the nurse take first?
A. Document the finding as normal
B. Increase formula volume
C. Assess hydration status and feeding adequacy
D. Notify the provider immediately
Correct Answer: C
Rationale: Newborn kidneys have limited concentrating ability; assessment comes before escalation.
A term newborn delivered with vacuum assistance is placed under a radiant warmer. The nurse observes the infant is pale, limp, gasping, and has a heart rate of 101 beats/min. What is the most appropriate initial nursing action?
A. Begin chest compressions
B. Provide positive-pressure ventilation
C. Administer supplemental oxygen
D. Continue drying and stimulation
Correct Answer: B
Rationale: HR is >100 but respirations are ineffective → ventilation is priority.
What is phenylketonuria and what restrictions are necessary?
A rare autosomal recessive disorder that causes the body to have the inability to convert phenylalanine, causes protein and dietary restriction.