Nursing Assessments in Postpartum Care

Questions and Answers

Which of the following assessments should the nurse prioritize next after a newborn's delivery?

Incision

Lochia (correct)

Urine

Breasts

What is the main focus of nursing practice during early postpartum discharge?

Teaching about the importance of family planning

Facilitating safe and effective self-and newborn care (correct)

Promoting comfort and restoration of health

Exploring the emotional status of the family

Which action is least effective for maintaining a neutral thermal environment for a newborn?

Covering the infant's head with a knit stockinette

Covering the scale with a warmed blanket prior to weighing

Placing the crib close to a nursery window for family viewing (correct)

Placing the infant under a radiant warmer after bathing

What should the nurse assess next if a newborn exhibits an asymmetrical Moro reflex response?

Fractured clavicle Signup and view all the answers

In a face presentation, how is the fetal head positioned?

Completely extended Signup and view all the answers

During the first four hours after a male circumcision, which priority assessment should the nurse focus on?

Hemorrhage Signup and view all the answers

Where would the fetal heart rate most likely be heard in a left-anterior breech presentation?

In the lower-left maternal abdominal quadrant Signup and view all the answers

What is the best response by the nurse to a mother asking about her newborn son's enlarged breasts?

A decrease in maternal hormones present before birth causes enlargement Signup and view all the answers

What immediate action should the nurse take for a male newborn showing signs of respiratory distress after birth?

Call the assessment data to the physician's attention Signup and view all the answers

What does a greenish tint in amniotic fluid typically indicate?

Meconium Signup and view all the answers

Which statement by a mother demonstrates effective teaching regarding umbilical cord care?

Daily soap and water cleansing is best Signup and view all the answers

What risk should the nurse be particularly alert for with a breech presentation?

Prolapsed umbilical cord Signup and view all the answers

How can dizygotic twins be described?

Two ova fertilized by separate sperm Signup and view all the answers

What term refers to the single cell that reproduces itself after conception?

Zygote Signup and view all the answers

Which development emerged from the challenge against routine analgesics and anesthetics during childbirth?

Prepared childbirth Signup and view all the answers

In patients with midpelvic contracture, which structure may prevent a fetus from passing during childbirth?

Ischial spines Signup and view all the answers

What is the primary outcome expected after performing an amniotomy during active labor?

Increased efficiency of contractions Signup and view all the answers

What pattern on the external monitor indicates umbilical cord compression during a contraction?

Variable decelerations Signup and view all the answers

What is the purpose of effleurage in early labor?

Light stroking of the abdomen for relaxation Signup and view all the answers

What behavior does a client exhibiting pain with every contraction in the second stage of labor most likely indicate?

Involuntary grunting Signup and view all the answers

What is the first action a nurse should take when a client receiving Pitocin shows hypertonic uterine contractions?

Stop the Pitocin infusion Signup and view all the answers

What prescribed treatment should a nurse expect for a client with hypotonic uterine dysfunction?

Oxytocin (Pitocin) infusion Signup and view all the answers

Which behavior best describes the client's response during painful contractions in the second stage of labor?

Verbal expressions of discomfort Signup and view all the answers

If a nurse observes a client in labor with increased uterine tension, which condition might this indicate?

Hypertonic uterine contractions Signup and view all the answers

What is the lower limit of viability for infants in terms of age of gestation?

21-24 weeks Signup and view all the answers

Which provision of the 1987 constitution guarantees the right of the unborn child to life from conception?

Article II section 12 Signup and view all the answers

Why would a nurse who performs an abortion for payment be held liable in the Philippines?

Abortion is both immoral and illegal in our country Signup and view all the answers

What is the main rationale for preferring vaginal delivery assisted by forceps under epidural anesthesia in gravido-cardiac cases?

To allow a gradual shifting of the blood into the maternal circulation Signup and view all the answers

When administering narcotic analgesics to a mother in labor, what special consideration should be taken into account?

Cervical dilatation has already reached at least 8 cm and the station is at least (+)2 Signup and view all the answers

What does a cervical dilation measurement of 7 cm at 10 A.M. indicate after being 6 cm at 8 A.M.?

Labor is progressing as expected Signup and view all the answers

Which of the following techniques during labor and delivery could potentially lead to uterine inversion?

Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation Signup and view all the answers

What does fetal presentation refer to?

Fetal body part that enters the maternal pelvis first Signup and view all the answers

What is the most likely cause of severe abdominal pain in a client at 36 weeks' gestation with a history of C-section and tetanic contractions?

Uterine rupture Signup and view all the answers

What does the notation '50%, 6 cm, -1' indicate about the laboring woman?

Fetal presenting part is 1 cm above the ischial spines Signup and view all the answers

Which finding indicates a reassuring fetal heart rate (FHR) pattern?

Average baseline rate ranges between 100 -- 140 BPM Signup and view all the answers

What should the nurse's immediate action be when late deceleration patterns are noted during labor induction with Pitocin?

Change the woman's position Signup and view all the answers

What is the most common and potentially harmful maternal complication of epidural anesthesia?

A drop in blood pressure Signup and view all the answers

What does a dilation of 6 cm signify in labor progress?

The labor is in the active stage Signup and view all the answers

Which of the following options correctly describes the pattern of behavior associated with the psychological response during labor?

Fear can delay the progress of labor Signup and view all the answers

Study Notes

Nursing Assessments and Priorities

Assess lochia, breasts, incision, and urine during postpartum care for comprehensive evaluation.
Priority in early postpartum discharge focuses on facilitating safe and effective self- and newborn care.
Least effective method to maintain newborn thermal environment includes placing a crib close to a nursery window.

Newborn Reflexes and Responses

An asymmetrical Moro reflex response may indicate a fractured clavicle requiring further assessment.
After male circumcision, priority assessment within the first 4 hours includes monitoring for hemorrhage.

Parental Concerns and Education

Enlarged breasts in newborns result from maternal hormones decreasing post-birth; no immediate concern.
Umbilical cord care taught effectively when the mother states that daily soap and water cleansing is best.

Fetal Position and Presentation

In face presentation, the fetal head is partially extended.
Expect greatest fetal heart rate audibility in the left-anterior breech presentation above the maternal umbilicus and to the left of midline.

Amniotic Fluid and Labor Complications

Greenish-tinted amniotic fluid typically indicates the presence of meconium.
Breech presentation alerts for risks including potential prolapsed umbilical cord.

Genetics and Reproductive Anatomy

Dizygotic twins arise from two separate ova fertilized by different sperm.
Zygote refers to the single cell resulting from conception that begins to divide.

Labor and Delivery Techniques

In the late 1950s, challenges to routine analgesic use during childbirth led to the development of prepared childbirth practices.
Midpelvic contracture may obstruct a fetus during labor, particularly around the ischial spines.

Menstrual Cycle and Hormones

Variations in menstrual cycle length arise mainly from differing phases of the ovarian cycle, particularly the proliferative phase.
Leydig cells are responsible for testosterone production in males.

Monitoring Labor Progress

After amniotomy, increased efficiency of contractions is expected.
Signs of umbilical cord compression during labor include variable decelerations on the monitor.
Effleurage is light stroking of the abdomen to promote relaxation during labor.

Responses to Labor Challenges

Hypertonic contractions in labor necessitate stopping Pitocin infusion as a priority intervention.
Hypotonic uterine dysfunction treatments may include administering an Oxytocin infusion.

Understanding Fetal Presentation

Fetal presentation describes the body part entering the maternal pelvis first, critical for labor progression.
In a laboring woman, 50%, 6 cm, -1 indicates that dilation is in progress, not complete.

Fetal Heart Rate Patterns

Reassuring FHR patterns typically show variability averaging between 6–10 BPM with an average baseline of 100-140 BPM.
Late decelerations, particularly with Pitocin infusion, require immediate intervention such as changing the woman's position or stopping Pitocin.

Complications of Anesthesia and Viability

Complications from epidural anesthesia can include severe postpartum headaches.
The lower limit of viability for infants is around 21-24 weeks of gestation.

Legal and Ethical Considerations

In the Philippines, performing and being compensated for abortion is illegal, ensuring accountability under law.
Vaginal delivery with forceps under epidural anesthesia has advantages for atraumatic delivery in gravido-cardiac cases.

Safe Practices During Labor

When administering narcotic analgesics, ensure labor progress is established, ideally reaching cervical dilation of at least 8 cm.
Proper technique during labor is essential to prevent complications like uterine inversion, such as avoiding excessive pressure on the fundus when bearing down.

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Description

This quiz focuses on nursing assessments and priorities during the postpartum period. It covers key areas such as lochia assessment, newborn reflexes, parental education, and fetal positioning. Evaluate your knowledge to ensure effective and safe nursing practices for mothers and newborns.