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Chapter 20: Postpartum Physiologic Changes

Lowdermilk: Maternity & Womens Health Care, 11th Edition
MULTIPLE CHOICE
1. A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to
locate this womans fundus?
a. 1 centimeter above the umbilicus
b. 2 centimeters below the umbilicus
c. Midway between the umbilicus and the symphysis pubis
d. Nonpalpable abdominally
ANS: A
The fundus descends approximately 1 to 2 cm every 24 hours. Within 12 hours after
delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth
postpartum week the fundus is normally halfway between the symphysis pubis and the
umbilicus. The fundus should be easily palpated using the maternal umbilicus as a
reference point.
DIF: Cognitive Level: Understand REF: p. 473
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
2. What are the most common causes for subinvolution of the uterus?
a. Postpartum hemorrhage and infection
b. Multiple gestation and postpartum hemorrhage
c. Uterine tetany and overproduction of oxytocin
d. Retained placental fragments and infection
ANS: D
Subinvolution is the failure of the uterus to return to a nonpregnant state. The most
common causes of subinvolution are retained placental fragments and infection.
Subinvolution may be caused by an infection and result in hemorrhage. Multiple
gestations may cause uterine atony, resulting in postpartum hemorrhaging. Uterine
tetany and overproduction of oxytocin do not cause subinvolution.
DIF: Cognitive Level: Understand REF: p. 473 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
3. Which client is most likely to experience strong and uncomfortable afterpains?
a. A woman who experienced oligohydramnios
b. A woman who is a gravida 4, para 4-0-0-4
c. A woman who is bottle-feeding her infant
d. A woman whose infant weighed 5 pounds, 3 ounces
ANS: B
Afterpains are more common in multiparous women. In a woman who experienced
polyhydramnios, afterpains are more noticeable because the uterus was greatly
distended. Breastfeeding may cause the afterpains to intensify. In a woman who
delivered a large infant, afterpains are more noticeable because the uterus was
greatly distended.
DIF: Cognitive Level: Understand REF: p. 474
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
4. A woman gave birth to a healthy infant boy 5 days ago. What type of lochia
does the nurse expect to find when evaluating this client?
a. Lochia rubra
b. Lochia sangra
c. Lochia alba
d. Lochia serosa
ANS: D
Lochia serosa, which consists of blood, serum, leukocytes, and tissue debris,
generally occurs around day 3 or 4 after childbirth. Lochia rubra consists of blood and
decidual and trophoblastic debris. The flow generally lasts 3 to 4 days and pales,
becoming pink or brown. Lochia sangra is not a real term. Lochia alba occurs in most
women after day 10 and can continue up to 6 weeks after childbirth.
DIF: Cognitive Level: Understand REF: p. 474
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
5. Which hormone remains elevated in the immediate postpartum period of the
breastfeeding woman?
a. Estrogen
b. Progesterone
c. Prolactin
d. Human placental lactogen
ANS: C
Prolactin levels in the blood progressively increase throughout pregnancy. In women
who breastfeed, prolactin levels remain elevated into the sixth week after birth.
Estrogen levels decrease significantly after expulsion of the placenta, reaching their
lowest levels 1 week into the postpartum period. Progesterone levels decrease
significantly after expulsion of the placenta, reaching their lowest levels 1 week into
the postpartum period. Human placental lactogen levels dramatically decrease after
expulsion of the placenta.
DIF: Cognitive Level: Remember REF: p. 476
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
6. Two days ago a woman gave birth to a full-term infant. Last night she awakened
several times to urinate and noted that her gown and bedding were wet from profuse
diaphoresis. Which physiologic alteration is the cause for the diaphoresis and diuresis
that this client is experiencing?
a. Elevated temperature caused by postpartum infection
b. Increased basal metabolic rate after giving birth
c. Loss of increased blood volume associated with pregnancy
d. Increased venous pressure in the lower extremities
ANS: C
Within 12 hours of birth, women begin to lose the excess tissue fluid that has
accumulated during pregnancy. One mechanism for reducing these retained fluids is
the profuse diaphoresis that often occurs, especially at night, for the first 2 or 3 days
after childbirth. Postpartal diuresis is another mechanism by which the body rids itself
of excess fluid. An elevated temperature causes chills and possibly dehydration, not
diaphoresis and diuresis. Diaphoresis and diuresis are sometimes referred to as
reversal of the water metabolism of pregnancy, not as the basal metabolic rate.
Postpartal diuresis may be caused by the removal of increased venous pressure in the
lower extremities.
DIF: Cognitive Level: Understand REF: p. 476 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
7. Which term best describes the interval between the birth of the newborn and the
return of the reproductive organs to their normal nonpregnant state?
a. Involutionary period because of what happens to the uterus
b. Lochia period because of the nature of the vaginal discharge
c. Mini-tri period because it lasts only 3 to 6 weeks
d. Puerperium, or fourth trimester of pregnancy
ANS: D
The puerperium, also called the fourth trimester or the postpartum period of
pregnancy, is the final period of pregnancy and lasts approximately 3 to 6 weeks.
Involution marks the end of the puerperium. Lochia refers to the various vaginal
discharges during the puerperium.
DIF: Cognitive Level: Remember REF: p. 473
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
8. A woman gave birth to a 7-pound, 6-ounce infant girl 1 hour ago. The birth was
vaginal and the estimated blood loss (EBL) was 1500 ml. When evaluating the
womans vital signs, which finding would be of greatest concern to the nurse?
Temperature 37.9 C, heart rate 120 beats per minute (bpm), respirations 20 breaths per min
a. blood pressure 90/50 mm Hg
Temperature 37.4 C, heart rate 88 bpm, respirations 36 breaths per minute, and blood press
b. 126/68 mm Hg
Temperature 38 C, heart rate 80 bpm, respirations 16 breaths per minute, and blood pressur
c. 110/80 mm Hg
 Temperature 36.8 C, heart rate 60 bpm, respirations 18 breaths per minute, and blood press
d. 140/90 mm Hg
ANS: A
An EBL of 1500 ml with tachycardia and hypotension suggests hypovolemia caused
by excessive blood loss. Temperature 37.4 C, heart rate 88 bpm, respirations 36
breaths per minute, and blood pressure 126/68 mm Hg are normal vital signs except
for an increased respiratory rate, which may be secondary to pain from the birth.
Temperature 38 C, heart rate 80 bpm, respirations 16 breaths per minute, and blood
pressure 110/80 mm Hg are normal vital signs except for the temperature, which may
increase to 38 C during the first 24 hours as a result of the dehydrating effects of
labor. Temperature 36.8 C, heart rate 60 bpm, respirations 18 breaths per minute, and
blood pressure 140/90 mm Hg are normal vital signs, although the blood pressure is
slightly elevated, which may be attributable to the use of oxytocic medications.
DIF: Cognitive Level: Analyze REF: pp. 477, 478
TOP: Nursing Process: Assessment | Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity
9. A client is concerned that her breasts are engorged and uncomfortable. What is
the nurses explanation for this physiologic change?
a. Overproduction of colostrum
b. Accumulation of milk in the lactiferous ducts and glands
c. Hyperplasia of mammary tissue
d. Congestion of veins and lymphatic vessels
ANS: D
Breast engorgement is caused by the temporary congestion of veins and lymphatic
vessels. An overproduction of colostrum, an accumulation of milk in the lactiferous
ducts and glands, and hyperplasia of mammary tissue do not cause breast
engorgement.
DIF: Cognitive Level: Apply REF: p. 477
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10.After delivery, excess hypertrophied tissue in the uterus undergoes a period of self-
destruction. What is the correct term for this process?
a. Autolysis
b. Subinvolution
c. Afterpains
d. Diastasis
ANS: A
Autolysis is caused by a decrease in hormone levels. Subinvolution is failure of the
uterus to return to a nonpregnant state. Afterpains are caused by uterine cramps 2 to 3
days after birth. Diastasis refers to the separation of muscles.
DIF: Cognitive Level: Remember REF: p. 473
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
11.Which statement regarding the postpartum uterus is correct?
a. At the end of the third stage of labor, the postpartum uterus weighs approximately 500 g.
b. After 2 weeks postpartum, it should be abdominally nonpalpable.
c. After 2 weeks postpartum, it weighs 100 g.
d. Postpartum uterus returns to its original (prepregnancy) size by 6 weeks postpartum.
ANS: B
The uterus does not return to its original size. At the end of the third stage of labor, the
uterus weighs approximately 1000 g. After 2 weeks postpartum, the uterus weighs
approximately 350 g. The normal self-destruction of excess hypertrophied tissue
accounts for the slight increase in uterine size after each pregnancy.
DIF: Cognitive Level: Understand REF: p. 473
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
12.A client asks the nurse when her ovaries will begin working again.
Which explanation by the nurse is most accurate?
a. Almost 75% of women who do not breastfeed resume menstruating within 1 month after bi
b. Ovulation occurs slightly earlier for breastfeeding women.
Because of menstruation and ovulation schedules, contraception considerations can be post
c. until after the puerperium.
d. The first menstrual flow after childbirth usually is heavier than normal.
ANS: D
The first flow is heavier, but within three or four cycles, the flow is back to normal.
Ovulation can occur within the first month, but for 70% of nonlactating women, it
returns in approximately 3 months. Women who are breastfeeding take longer to
resume ovulation. Because many women ovulate before their first postpartum
menstrual period, contraceptive options need to be discussed early in the puerperium.
DIF: Cognitive Level: Apply REF: p. 476 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
13. The nurse should be cognizant of which postpartum physiologic alteration?
Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal values with
a. few hours of childbirth.
b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth. Lowered
white blood cell count after pregnancy can lead to false-positive results on tests fo
c. infections.
Hypercoagulable state protects the new mother from thromboembolism, especially after a c
d. birth.
ANS: B
Respirations should decrease to within the womans normal prepregnancy range by 6
to 8 weeks after childbirth. Stroke volume increases and cardiac output remains high
for a couple of days. However, the heart rate and blood pressure quickly return to
normal. Leukocytosis increases 10 to 12 days after childbirth, which can obscure the
diagnosis of acute infections, producing false-negative test results. The
hypercoagulable state increases the risk of thromboembolism, especially after a
cesarean birth.
DIF: Cognitive Level: Understand REF: p. 478 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
14. Which condition, not uncommon in pregnancy, is likely to require careful medical
assessment during the puerperium?
a. Varicosities of the legs
b. Carpal tunnel syndrome
c. Periodic numbness and tingling of the fingers
d. Headaches
ANS: D
Headaches in the postpartum period can have a number of causes, some of which
deserve medical attention. Total or nearly total regression of varicosities is expected
after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression
on the median nerve is lessened. Periodic numbness of the fingers usually disappears
after childbirth unless carrying the baby aggravates the condition.
DIF: Cognitive Level: Understand REF: p. 479 TOP: Nursing Process: Evaluation
MSC: Client Needs: Physiologic Integrity
15. Several delivery changes in the integumentary system that appear during
pregnancy disappear after birth, although not always completely. What change
is almost certain to be completely reversed?
a. Nail brittleness
b. Darker pigmentation of the areolae and linea nigra
c. Striae gravidarum on the breasts, abdomen, and thighs
d. Spider nevi
ANS: A
The nails return to their prepregnancy consistency and strength. Some women have
permanent darker pigmentation of the areolae and linea nigra. Striae gravidarum
(stretch marks) usually do not completely disappear. For some women, spider nevi
persist indefinitely.
DIF: Cognitive Level: Understand REF: p. 480 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
16. Pelvic floor exercises, also known as Kegel exercises, will help to strengthen the
perineal muscles and encourage healing after childbirth. The nurse requests the client
to repeat back instructions for this exercise. Which response by the client indicates
successful learning?
a. I contract my thighs, buttocks, and abdomen.
b. I perform 10 of these exercises every day.
c. I stand while practicing this new exercise routine.
d. I pretend that I am trying to stop the flow of urine in midstream.
ANS: D
The woman can pretend that she is attempting to stop the passing of gas or the flow
of urine midstream, which will replicate the sensation of the muscles drawing upward
and inward. Each contraction should be as intense as possible without contracting the
abdomen, buttocks, or thighs. Guidelines suggest that these exercises should be
performed 24 to 100 times per day. Positive results are shown with a minimum of 24
to 45 repetitions per day. The best position to learn Kegel exercises is to lie supine
with the knees bent. A secondary position is on the hands and knees.
DIF: Cognitive Level: Analyze REF: p. 475 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance, Self-Care
17. Which statement by a newly delivered woman indicates that she knows what to
expect regarding her menstrual activity after childbirth?
My first menstrual cycle will be lighter than normal and then will get heavier every month
a. thereafter.
My first menstrual cycle will be heavier than normal and will return to my prepregnant vol
b. within three or four cycles.
c. I will not have a menstrual cycle for 6 months after childbirth.
d. My first menstrual cycle will be heavier than normal and then will be light for several mont
ANS: B
My first menstrual cycle will be heavier than normal and will return to my
prepregnant volume within three or four cycles is an accurate statement and indicates
her understanding of her expected menstrual activity. She can expect her first
menstrual cycle to be heavier than normal, which occurs by 3 months after childbirth,
and the volume of her subsequent cycles will return to prepregnant levels within three
to four cycles.
DIF: Cognitive Level: Apply REF: p. 476 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
18.The nurse is providing instruction to the newly delivered client regarding postbirth
uterine and vaginal discharge, called lochia. Which statement is the most appropriate?
a. Lochia is similar to a light menstrual period for the first 6 to 12 hours.
b. It is usually greater after cesarean births.
c. Lochia will usually decrease with ambulation and breastfeeding.
d. It should smell like normal menstrual flow unless an infection is present.
ANS: D
An offensive odor usually indicates an infection. Lochia flow should approximate a
heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia
is usually seen after cesarean births and usually increases with ambulation and
breastfeeding.
DIF: Cognitive Level: Understand REF: p. 475
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
19.Which description of postpartum restoration or healing times is accurate?
a. The cervix shortens, becomes firm, and returns to form within a month postpartum.
b. Vaginal rugae reappear by 3 weeks postpartum.
c. Most episiotomies heal within a week.
d. Hemorrhoids usually decrease in size within 2 weeks of childbirth.
ANS: B
Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent
as in nulliparous women. The cervix regains its form within days; the cervical os may
take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6
weeks to decrease in size.
DIF: Cognitive Level: Understand REF: p. 475 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
20. Which statement, related to the reconditioning of the urinary system
after childbirth, should the nurse understand?
a. Kidney function returns to normal a few days after birth.
b. Diastasis recti abdominis is a common condition that alters the voiding reflex.
Fluid loss through perspiration and increased urinary output accounts for a weight loss of m
c. than 2 kg during the puerperium.
With adequate emptying of the bladder, bladder tone is usually restored 2 to 3 weeks after
d. childbirth.
ANS: C
Excess fluid loss through other means besides perspiration and increased urinary
output occurs as well. Kidney function usually returns to normal in approximately
1 month. Diastasis recti abdominis is the separation of muscles in the abdominal
wall and has no effect on the voiding reflex. Bladder tone is usually restored 5 to 7
days after childbirth.
DIF: Cognitive Level: Understand REF: p. 476 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
21. What should the nurses next action be if the clients white blood cell (WBC) count
is 25,000/mm3 on her second postpartum day?
a. Immediately inform the physician.
b. Have the laboratory draw blood for reanalysis.
c. Recognize that this count is an acceptable range at this point postpartum.
d. Immediately begin antibiotic therapy.
ANS: C
During the first 10 to 12 days after childbirth, WBC values between 20,000 and
25,000/mm3 are common. Because a WBC count of 25,000/mm3 on her second
postpartum day is normal, alerting the physician is not warranted nor is reassessment
or antibiotics needed; the WBC count is not elevated.
DIF: Cognitive Level: Apply REF: p. 478
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
22. Which documentation on a womans chart on postpartum day 14 indicates a normal
involution process?
a. Moderate bright red lochial flow
b. Breasts firm and tender
c. Fundus below the symphysis and nonpalpable
d. Episiotomy slightly red and puffy
ANS: C
The fundus descends 1 cm per day; consequently, it is no longer palpable by
postpartum day 14. The lochia should be changed by this day to serosa. Breasts are
not part of the involution process. The episiotomy should not be red or puffy at this
stage.
DIF: Cognitive Level: Apply REF: p. 473
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
1. The breast-feeding mother should be taught to expect which changes to
the condition of the breasts? (Select all that apply.)
a. Breast tenderness is likely to persist for approximately 1 week after the start of lactation. As
lactation is established, a mass may form that can be distinguished from cancer by its po
b. shift from day to day.
c. In nonlactating mothers, colostrum is present for the first few days after childbirth.
d. If suckling is never begun or is discontinued, then lactation ceases within a few days to a w
e. Little change occurs to the breasts in the first 48 hours.
ANS: B, C, D
Breasts become fuller and heavier as colostrum transitions to milk; this fullness
should last 72 to 96 hours. The movable, noncancerous mass is a filled milk sac.
Colostrum is present for a few days whether or not the mother breastfeeds. A mother
who does not want to breastfeed should also avoid stimulating her nipples. Little
change to the breasts occurs in the first 24 hours of childbirth.
DIF: Cognitive Level: Understand REF: p. 477
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
2. Changes in blood volume after childbirth depend on several factors such as
blood loss during childbirth and the amount of extravascular water (physiologic
edema) mobilized and excreted. What amount of blood loss does the postpartum
nurse anticipate? (Select all that apply.)
a. 100 ml
b. 250 ml or less
c. 300 to 500 ml
d. 500 to 1000 ml
e. 1500 ml or greater
ANS: C, D
The average blood loss for a vaginal birth of a single fetus ranges from 300 to 500 ml
(10% of blood volume). The typical blood loss for women who gave birth by cesarean
is 500 to 1000 ml (15% to 30% of blood volume). During the first few days after
childbirth, the plasma volume further decreases as a result of diuresis. Pregnancy-
induced hypervolemia (i.e., an increase in blood volume of at least 35%) allows most
women to tolerate considerable blood loss during childbirth.
DIF: Cognitive Level: Understand REF: p. 477
TOP: Nursing Process: Assessment | Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
MATCHING
The physiologic changes that occur during the reversal of the processes of pregnancy
are distinctive; however, they are normal. To provide care during this recovery period,
the nurse must synthesize knowledge regarding anticipated maternal changes and
deviations from normal. Match the vital signs finding that the postpartum nurse may
encounter with its probable cause.
a. Elevated temperature within the first 24 hours
b. Rapid pulse
c. Elevated temperature at 36 hours postpartum
d. Hypertension
e. Hypoventilation
1. Puerperal sepsis
2. Unusually high epidural or spinal block
3. Dehydrating effects of labor
4. Hypovolemia resulting from hemorrhage
5. Excessive use of oxytocin
1. ANS: C DIF: Cognitive Level: Comprehend REF: p. 478
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. ANS: E DIF: Cognitive Level: Comprehend REF: p. 478
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
3. ANS: A DIF: Cognitive Level: Comprehend REF: p. 478
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
4. ANS: B DIF: Cognitive Level: Comprehend REF: p. 478
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
5. ANS: D DIF: Cognitive Level: Comprehend REF: p. 478
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity