Chapter 20 - Postpartum Physiologic Changes

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.

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.

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

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.

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?
a. Temperature 37.9 C, heart rate 120 beats per minute (bpm), respirations 20
breaths per minute, and blood pressure 90/50 mm Hg
b. Temperature 37.4 C, heart rate 88 bpm, respirations 36 breaths per minute, and
blood pressure 126/68 mm Hg
c. Temperature 38 C, heart rate 80 bpm, respirations 16 breaths per minute, and
d. Temperature 36.8 C, heart rate 60 bpm, respirations 18 breaths per minute, and
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
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

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.

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.

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 birth.
b. Ovulation occurs slightly earlier for breastfeeding women.
c. Because of menstruation and ovulation schedules, contraception considerations can
be postponed 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
13. The nurse should be cognizant of which postpartum physiologic alteration?

a. Cardiac output, pulse rate, and stroke volume all return to prepregnancy normal
values within a few hours of childbirth.
b. Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth.
c. Lowered white blood cell count after pregnancy can lead to false-positive results
on tests for infections.
d. Hypercoagulable state protects the new mother from thromboembolism, especially
after a cesarean 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.
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
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.
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?
a. My first menstrual cycle will be lighter than normal and then will get heavier
every month thereafter.
b. My first menstrual cycle will be heavier than normal and will return to my
prepregnant volume 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 months after.
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
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.

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.
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.
c. Fluid loss through perspiration and increased urinary output accounts for a weight
loss of more than 2 kg during the puerperium.
d. With adequate emptying of the bladder, bladder tone is usually restored 2 to 3
weeks after 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.
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.

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.

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.
b. As lactation is established, a mass may form that can be distinguished from cancer
by its positional 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 week.
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.

TOP: Nursing Process: Planning | Nursing Process: Implementation
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.

TOP: Nursing Process: Assessment | Nursing Process: Planning
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

2. ANS: E DIF: Cognitive Level: Comprehend REF: p. 478
3. ANS: A DIF: Cognitive Level: Comprehend REF: p. 478
4. ANS: B DIF: Cognitive Level: Comprehend REF: p. 478
5. ANS: D DIF: Cognitive Level: Comprehend REF: p. 478

Chapter 20 - Postpartum Physiologic Changes

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Chapter 20: Postpartum Physiologic Changes

Lowdermilk: Maternity & Womens Health Care, 11th Edition

DIF: Cognitive Level: Understand REF: p. 473

3. Which client is most likely to experience strong and uncomfortable afterpains?

DIF: Cognitive Level: Understand REF: p. 474

DIF: Cognitive Level: Understand REF: p. 474

DIF: Cognitive Level: Remember REF: p. 476

DIF: Cognitive Level: Remember REF: p. 473

DIF: Cognitive Level: Apply REF: p. 477

DIF: Cognitive Level: Remember REF: p. 473

11. Which statement regarding the postpartum uterus is correct?

DIF: Cognitive Level: Understand REF: p. 473

13. The nurse should be cognizant of which postpartum physiologic alteration?

DIF: Cognitive Level: Understand REF: p. 475

19. Which description of postpartum restoration or healing times is accurate?

DIF: Cognitive Level: Apply REF: p. 478

DIF: Cognitive Level: Apply REF: p. 473

DIF: Cognitive Level: Understand REF: p. 477

DIF: Cognitive Level: Understand REF: p. 477

1. ANS: C DIF: Cognitive Level: Comprehend REF: p. 478

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