Chapter 17- Postpartum Physiologic Adaptations
MULTIPLE CHOICE
1. A postpartum client overhears the nurse telling the health care provider that she has
... [Show More] a positive Homans
signand 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
2. 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. The client who is bottle-feeding her first child
d. The 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
3. Which maternal event is abnormal in the early postpartum 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
the 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
4. Which fundal assessment finding at 12 hours after birth requires further assessment?...
CONTINUES... [Show Less]