Patient Scenario #1: Nursing Care of a Postpartal Family (Answer Key)

A POSTPARTAL WOMAN
Faye Chang is a 28-year-old, G4P3 woman you care for in a labor-delivery-recovery room
following birth of a 6 lb, 13 oz girl.

CHIEF CONCERN:
“Pain. Sore breasts. Stomach cramps. Is it all right if I get up and walk? Do you know I’m a
vegetarian? Don’t want to see any meat on a meal tray.”

HISTORY OF CHIEF CONCERN:

The client gave birth to a 6 lb 13 oz infant girl, 37 weeks’ gestation, at 1:05 PM with no
analgesia. She is concerned new baby is abnormally small because other children both were
more than 8 lb at birth.

FAMILY PROFILE:
The client was married when she was 20 years old, but marriage ended after a trophoblast
proliferation pregnancy. She is currently living with her boyfriend and two children in a two-
bedroom house; she works as a clerk in a mail-order catalog house. Her boyfriend works as a
night club manager. Finances are reported as “okay.” Her boyfriend appeared supportive
throughout labor. She voiced pleasure at sex and appearance of new child.

HISTORY OF PAST ILLNESSES:

Faye had a venomous snake bite at age 15 years while on a camping trip. Antivenin was given
immediately; there are no sequelae. Only hospitalization was for two previous childbirths.

GYNECOLOGIC HISTORY:
Menarche was at age 17 years; cycle duration is 30 days. Menstrual flow duration is 7 days. Both
she and sexual partner were treated for chlamydia last year. It was relying on sexual partner to
use condoms as method of reproductive life planning prior to this pregnancy.
OBSTETRIC HISTORY:
Faye had hydatidiform mole pregnancy 8 years ago, followed for 1 year with hCG levels. She
never had any elevation in levels. She had three pregnancies: boy, 8 lb 6 oz, vaginal delivery,
alive and well, 12 years ago; boy, 8 lb 8 oz, vaginal delivery, alive and well, 10 years ago; girl, 6
lb 13 oz, vaginal delivery, 2 hours ago, no anomalies at birth. This pregnancy was not intended
but not unwelcome. She doesn’t drink alcohol but did smoke “occasionally” during pregnancy.
She took daily prenatal vitamin.

REVIEW OF SYSTEMS:
Essentially negative

PHYSICAL EXAMINATION:
General appearance: Distressed-appearing; young adult Asian woman
HEENT: Hair: unwashed; oily; some postpartal hair loss beginning
Chest: Heart rate: 70 beats/min; no murmurs present; lungs: no adventitious sounds present;
respiratory rate: 22 breaths/min
Abdomen: Soft; fundal height 1 F under umbilicus and firm and midline; linea nigra and striae
present
Perineum: Edematous; mediolateral episiotomy line intact; lochia: rubra, moderate, no clots
Extremities: Homans’ sign negative; no edema over tibia

Ms. Chang is diagnosed as having a usual postpartal course.

STUDY QUESTIONS:
1. Ms. Chang is 4 hours postbirth and appears to be most concerned about her own care at the
present time. When planning her immediate care, you would choose your assessments and
interventions in the knowledge that she is in which postpartal stage?
a. Taking in
b. Taking hold
c. Letting go
d. Containment
2. Based on her current health status, the best nursing diagnosis for Ms. Chang would be which
of the following?
a. Anxiety related to unexpected care of new infant
b. Pain related to breast and abdominal discomfort
c. Deficient fluid volume related to poor oral intake
d. Impaired parenting related to inexperience

3. You are planning nursing interventions that will address Ms. Chang’s pain. Which would be
the best expected outcome for Ms. Chang?
a. Client voices that her pain has diminished to a tolerable level.
b. Client sleeps an acceptable amount of time and states that she feels rested.
c. Client states that she knows her pain medicine will be effective.
d. Client states that her pain is minimal and cares for self and infant.

4. During your interactions with Ms. Chang, you notice that she rarely looks directly at her
newborn. How would you document this in Ms. Chang’s electronic health record?
a. Client does not assume an enface position with newborn.
b. Client appears not to enjoy holding her new newborn.
c. Ms. Chang is having difficulty accepting mothering.
d. New mother does not hold her infant comfortably.

5. You have selected interventions that will promote Ms. Chang’s attachment, or relating well, to
her newborn. This behavior is frequently described as which of the following?
a. Negotiation
b. Bonding
c. Concern
d. Fortitude

6. Ms. Chang asks you if her older children should visit her in the hospital. Thinking of the
QSEN competency of patient-centered care, what advice is most appropriate?
a. “It’s better if older children see their new sibling first in their own home.”
b. “Seeing a sibling in a hospital could make them think the newborn is ill.”
c. “Seeing their new brother or sister immediately should help bonding.”
d. “It’s important that your son and daughter do what makes you happiest.”

7. Ms. Chang’s boyfriend tells you Ms. Chang has cried several times since the birth of the baby.
What factor most likely accounts for this emotional lability?
a. An increase in estrogen
b. An increase in prolactin
c. Loss of blood volume
d. A decrease in estrogen

8. You have assessed Ms. Chang’s uterus and have noted that it is beginning to return to its
prepregnant state. How should you document this phenomenon in the electronic health record?
a. Atrophy
b. Involution
c. Retrographic change
d. Endometrial discharge

9. Ms. Chang is breastfeeding. What effect should the nurse anticipate that this will have on
uterine size during the postpartal period?
a. It slows the process of involution by approximately 25%.
b. It promotes diuresis and limits the amount of lochia.
c. It aids uterine contraction because of oxytocin release.
d. It causes the cervix to expand because of estrogen release.

10. When Ms. Chang is 1 day postpartum, which of the following descriptions of lochia would
you identify as being normal?
a. Pink with occasional red streaking
b. White because of mucous infiltration
c. Brown because blood is now old
d. Red with occasional small clots
11. Assessing uterine size is important during the postpartum period. If Ms. Chang is 1 day
postpartum, you would expect to locate her uterus at what location?
a. 1 cm under her rib cage
b. 3 cm below her umbilicus
c. 1 cm below her umbilicus
d. 3 cm above her symphysis pubis

12. You are preparing to palpate Ms. Chang’s abdomen for uterine position. What nursing action
should you perform?
a. Place a hand at the base of the uterus to prevent uterine inversion.
b. Insert one hand vaginally to slow the vaginal flow while palpating.
c. Mark the point of the fundus on the abdomen with a pen or marker.
d. Place ice on the abdomen to cause contraction prior to palpation.

13. Suppose Ms. Chang were 3 days postpartum. What would be an expected outcome when you
are assessing her lochia?
a. Lochia is red with pinpoint clots present.
b. Lochia appears yellow because of serum.
c. Lochia’s color is now white, and texture is firm.
d. Lochia is pink with no strong odor.

14. Ms. Chang tells you she seems to be voiding a large amount of urine. What is the usual
amount of urine women in the postpartum period void each 24 hours?
a. 500 to 1,200 ml
b. Approximately 1,000 ml
c. 2,000 to 3,000 ml
d. 4,000 to 5,000 ml

15. Ms. Chang worries she will develop a thrombophlebitis. When assessing her, you should be
aware of what risk factor for this problem during the postpartal period?
a. They develop fatty plaques from the stress of labor.
b. Involution causes the uterus to obstruct blood vessels.
c. Their fibrinogen level is still elevated from pregnancy.
d. Amniotic fluid mixing with plasma causes rapid clotting.

16. On her first day postpartum, Ms. Chang’s temperature is 38°C (100.4°F). How should you
interpret this assessment finding?
a. She must be developing a postpartal infection.
b. This is a normal finding for the first day postpartum.
c. Her temperature should be mildly hypothermic for 24 hours.
d. She must be developing a stress reaction to parenting.

17. On the third day postpartum, Ms. Chang tells the home care nurse that her breasts feel warm
and tender. How should the nurse interpret this assessment finding?
a. She is experiencing breast engorgement, which is normal.
b. Her infant must be a particular vigorous feeder.
c. This suggests that mastitis may be developing.
d. She needs to drink more fluid to reduce inflammation.

18. If Ms. Chang had an episiotomy with perineal pain, what would be the preferred pain-relief
measure for her on the third day postpartum?
a. Perineal application of ice
b. Topical hydrocortisone
c. Oral hydromorphone (Dilaudid)
d. Perineal heat application

19. Ms. Chang reports she is afraid to have a bowel movement because that may cause perineal
pain. How should you advise her?
a. This problem will resolve spontaneously.
b. The use of a stool softener may be indicated.
c. She should eat soft foods for the next several days to increase bowel peristalsis.
d. She should avoid having a bowel movement until her perineum has begun to heal.
OPEN-ENDED QUESTIONS:
20. What if Ms. Chang tells you in the hospital that she knows she had a perfect baby so should
be happy but she can’t stop crying? At what point would you suggest counseling for her?
I will explaine the situation because of hormonal changed may she feels that way. I suggest non-
pharmaocological like distraction method, providing support through significant others and
family member. If she still feels depressed I will counsel with her primary care for referral.

21. What if Ms. Chang’s boyfriend tells you their new baby looks nothing like him and asks you
how soon he can request a DNA analysis to establish if he’s the father or not? How would you
advise him?
DNA analysis cannot be done after if the baby has borned

FILL IN THE BLANK QUESTIONS:

22. The process of a uterus returning to its prepregnant state is termed
____Involution_________.

23. The uterine discharge after birth is termed ______Lochia_______.

MULTIPLE RESPONSE QUESTIONS:

24. Which of the following are important assessments to make in the postpartal period to keep a
woman safe from hemorrhage? (Select all that apply.)
a. Blood pressure and pulse
b. Uterine tone and consistency
c. Ability to walk steadily
d. Tympanic temperature
e. Assessment of appetite

25. Ms. Chang will be busy after she returns home because she works outside the home in
addition to caring for two other children. What discharge instructions should you include in your
health teaching? (Select all that apply.)
a. She should try to maintain a smoke-free house rather than return to smoking.
b. She should try to breastfeed for a minimum of 6 months even while working.
c. She should call and make an appointment for a health visit at 4 to 6 weeks.
d. She needs to plan rest times as exhaustion can lead to postpartal depression.