Which of the following expectations about postpartum changes has the client correctly understood?

“My baby’s stools should transition to a yellow color within the next day or two.”.

“I should anticipate my breasts becoming harder, warmer, and more tender when my milk comes in.”.

“I should expect to feel a decrease in abdominal discomfort over the next few days.”.

“I should anticipate feeling more energetic as my body recovers from childbirth.”. .

Answer and Explanation

The Correct Answer is B

Choice A rationale

While it’s true that a newborn’s stools will transition in color, it typically takes a few days longer than one or two. Initially, the stools are a greenish-black color known as meconium. Over the next few days, as the baby begins digesting breast milk or formula, the stools will gradually transition to a yellow color.

Choice B rationale

This statement is correct. After childbirth, the breasts undergo a process known as engorgement when they start to produce milk. This can cause the breasts to become harder, warmer, and more tender. This is a normal part of the postpartum period and is a sign that the body is preparing to feed the baby.

Choice C rationale

While it’s true that abdominal discomfort generally decreases over time after childbirth, it’s important to note that the rate of decrease can vary greatly among individuals. Factors such as the type of delivery (vaginal or cesarean), individual pain tolerance, and the presence of any complications can all influence the rate of decrease in abdominal discomfort.

Choice D rationale

While it’s true that many women do feel more energetic as their bodies recover from childbirth, this is not always the case. Factors such as sleep deprivation, hormonal changes, and the physical demands of caring for a newborn can all contribute to feelings of fatigue and exhaustion. Therefore, while some women may feel more energetic, others may continue to feel tired for several weeks or even months after giving birth.

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Correct Answer is C

Explanation

Choice A rationale:
Perineal pad clots are not the greatest risk for this patient. While it’s important to monitor the amount and type of lochia, the nurse’s notes indicate that the patient has a moderate amount of lochia rubra, which is normal within the first few days postpartum. Large clots could indicate a problem such as a retained placental fragment, but this is not mentioned in
the scenario.
Choice B rationale:
Pelvic pain is a common complaint after childbirth due to uterine contractions, especially during breastfeeding, and usually resolves within a few days. The patient’s pain is rated as 4 on a scale of 0 to 10, which is considered moderate. While it’s important to manage the patient’s pain, it’s not the greatest risk in this scenario.
Choice C rationale:
A boggy uterus poses the greatest risk for this patient. A boggy or soft uterus indicates uterine atony, which is a lack of normal muscle tone that can lead to excessive bleeding. This is a serious condition that can lead to postpartum hemorrhage if not treated promptly. The nurse’s notes indicate that the patient’s fundus is boggy and located above the umbilicus, which is a concern. The fundus should be firm and gradually descend into the pelvis within the first few days postpartum.
Choice D rationale:
Breast engorgement is a common discomfort that occurs when the breasts are overly full with milk. It typically occurs within the first week postpartum as the milk supply increases. The nurse’s notes indicate that the patient’s breasts are soft, warm, and tender to touch, which is normal. While it’s important to manage the patient’s comfort, breast
engorgement is not the greatest risk in this scenario.

A. Insert a urinary catheter. B. Massage the fundus. C. Have the patient urinate. D. Administer an analgesic.

Correct Answer is C

Explanation

Choice A rationale

Inserting a urinary catheter is not typically the first action when the fundus is displaced. It is more commonly done when the bladder is distended and the patient is unable to urinate.

Choice B rationale

Massaging the fundus is usually done when the uterus is soft or boggy to help it contract and prevent postpartum hemorrhage. However, in this case, the fundus is firm, indicating that the uterus is well contracted.

Choice C rationale

Having the patient urinate is the appropriate action when the fundus is displaced to the right of the midline. This displacement often indicates a full bladder, which can push the uterus to the side. After the patient urinates, the uterus often returns to the midline position.

Choice D rationale

Administering an analgesic is not the first action when the fundus is displaced. Pain medication is typically given for postpartum discomfort or afterbirth pains, not for a displaced fundus.

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Which of the following expectations about postpartum changes has the client correctly understood?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is 36 hours postpartum. Exhibits After reviewing the information in the patient’s medical record, which of the following complications pose a greater risk for the patient?

Correct Answer is C

Explanation

A nurse is caring for a patient who experienced a vaginal birth 3 hours ago. Upon palpation, the fundus is displaced to the right of the midline, is firm, and is two fingerbreadths above the umbilicus. What actions should the nurse complete at this time?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent. What action should the nurse take?

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A nurse is caring for a client who is in active labor when the client’s membranes rupture. The fetal monitor tracing shows late decelerations. What is the first action the nurse should take?

A nurse is providing care for a newborn diagnosed with hydrocephalus. Which of the following symptoms should the nurse anticipate?

A nurse is conducting an assessment on a client who is 4 hours postpartum following a vaginal delivery. Which of the following findings should the nurse prioritize?

A nurse is providing discharge instructions to a client who is 3 days postoperative following a cesarean birth. Which of the following statements from the client indicates that the teaching has been effective? (Select all that apply.)

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?