ch. 23 maternity prep u
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 750 ml 500 ml 250 ml 1000 ml
1000 ml
The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client? decreased respiratory rate elevated blood pressure weak and rapid pulse warm and flushed skin
weak and rapid pulse
A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis? sadness delirium feelings of guilt insomnia
delirium
Which manifestation would alert the nurse to suspect that a postpartum client has septic pelvic thrombophlebitis (SPT)? lower back pain pain in lower abdomen recurrent vaginal infection uterine cramping
pain in lower abdomen
client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "I'll check on you in a few hours." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "I'll contact your health care provider."
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse? "The hormones of pregnancy may cause anxiety or depression postpartum." "Your old coping methods will adequately get you through this period of adjustment." "Expect your other children to react positively to their new brother/sister." "Caring for your new infant is instinctual and will come naturally to you."
"The hormones of pregnancy may cause anxiety or depression postpartum."
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? "When I put on a new pad, I'll start at the back and go forward." "I need to call my doctor if my temperature goes above 100.4° F (38° C)." "I'll point the spray of the peri-bottle so the water flows front to back." "If I have chills or my discharge has a strange odor, I'll call my doctor."
"When I put on a new pad, I'll start at the back and go forward."
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues? a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding a 38-year-old G1P1 who is constantly holding the baby and touching the baby's hands and fingers an 18-year-old mother who is currently holding her baby and looking face-to-face at the baby without saying a word a 29-year-old mother who has lots of family visiting, offering to help her with meals and cleaning for the next few months
30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 1000 mL 300 mL 500 mL 750 mL
500 mL
Which woman is at highest risk for postpartum hemorrhage? A 40-year-old primigravida at 37 weeks with twins when twin A has mild polyhydramnios A 33-year-old P1001 at 40 weeks who had placenta previa in her last pregnancy A 35-year-old primigravida who was in labor for 14 hours and gave birth to an 8-lb newborn A 20-year-old P2002 at 35 weeks with hypothyroidism
A 40-year-old primigravida at 37 weeks with twins when twin A has mild polyhydramnios
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother? Ambulate the client as soon as her vital signs are stable. Limit oral intake of fluids for the first 24 hours to prevent nausea. Roll a bath blanket or towel and place it firmly behind the knees. Assist client in performing leg exercises every 2 hours
Ambulate the client as soon as her vital signs are stable.
A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Blanch a toe, and count the seconds it takes to color again. Bend her knee, and palpate her calf for pain. Assess for pedal edema. Ask her to raise her foot and draw a circle.
Assess for pedal edema.
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? She says she is extremely thirsty. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Her perineum is obviously edematous on inspection.
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? Shortness of breath is a common adverse effect of the medication. Wear knee-high stockings when possible. Avoid iron replacement therapy. Avoid over-the-counter (OTC) salicylates.
Avoid over-the-counter (OTC) salicylates.
The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Degree of responsiveness, respiratory rate, fundus location Attachment, lochia color, complete blood cell count Height, level of orientation, support systems Blood pressure, pulse, reports of dizziness
Blood pressure, pulse, reports of dizziness
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Monitor the pain level. Assess the fundal height. Check the lochia. Assess the temperature.
Check the lochia.
It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour. Client maintains a urinary output greater than 30 ml per hour. Fundus remains firm and midline with progressive descent. Client's temperature remains below 100.4°F (38.8°C) orally.
Client's temperature remains below 100.4°F (38.8°C) orally.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who conceived following fertility treatments a primiparous client who had a vaginal birth a client who had an 8-hour labor a client who had a nonelective cesarean birth
a client who had a nonelective cesarean birth
A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition? "The mother loses contact with reality." "Getting some outside help for housework can lessen feelings of being overwhelmed." "Extended psychotherapy is needed for treatment." "Postpartum blues is a long-term emotional disturbance."
Getting some outside help for housework can lessen feelings of being overwhelmed."
The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out? In approximately 10 days On and off for 2 to 3 weeks For 6 weeks Stops in 1 to 2 weeks
In approximately 10 days
he nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? Shock Infection Dehydration Normal vital signs
Infection
When teaching a postpartum client about possible complications following the birth, which would be the best information to include? Interference with the maternal-newborn attachment process Alteration in normal maternal hormonal function Delayed development of the newborn Ineffectiveness of breastfeeding
Interference with the maternal-newborn attachment process
group of nurses are reviewing information about mastitis and its causes in an effort to develop a teaching program on prevention for postpartum women. The nurses demonstrate understanding of the information when they focus the teaching on ways to minimize risk of exposure to which organism? Proteus E. coli Klebsiella S. aureus
S. aureus
The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? Flat in bed On her left side Trendelenburg Semi-Fowler
Semi-Fowler
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? Symptoms include fever, chills, malaise, and localized breast tenderness. The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client.
Symptoms include fever, chills, malaise, and localized breast tenderness.
The nurse is reviewing orders written for a postpartum client with a fourth-degree perineal laceration. Which order should the nurse question before implementing? administering acetaminophen and codeine for pain urging to drink all the milk provided during meals administering an enema providing a sitz bath
administering an enema
The nurse is reviewing orders written for a postpartum client with a fourth-degree perineal laceration. Which order should the nurse question before implementing? administering an enema providing a sitz bath urging to drink all the milk provided during meals administering acetaminophen and codeine for pain
administering an enema
Which measurement best describes delayed postpartum hemorrhage? blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 3000 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 300 ml, occurring within the first 24 hours after birth blood loss in excess of 1,000 ml, occurring within 24 hours after birth
blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth
A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. hunger feeling overwhelmed restlessness feelings of worthlessness sleeping well
feeling overwhelmed restlessness feelings of worthlessness
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? infection thromboembolic disorder of the lower extremities hormonal shifting of relaxin and estrogen normal response to the body converting back to prepregnancy state
thromboembolic disorder of the lower extremities
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine contraction uterine prolapse uterine subinvolution uterine atony
uterine atony
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? hemoglobin level of 12 g/dl (120 g/L) thrombophlebitis uterine atony moderate amount of lochia rubra
uterine atony
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? "I will call my health care provider if my stools are black and tarry." "I will use a soft toothbrush to brush my teeth." "I can take ibuprofen if I have any pain." "I need to avoid drinking any alcohol."
"I can take ibuprofen if I have any pain."
Which situation should concern the nurse treating a postpartum client within a few days of birth? The client would like to watch the nurse give the baby her first bath. The client feels empty since she gave birth to the neonate. The client is nervous about taking the baby home. The client would like the nurse to take her baby to the nursery so she can sleep.
The client feels empty since she gave birth to the neonate.
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? Hematoma Disseminated intravascular coagulation Uterine atony Perineal lacerations
Uterine atony
A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? Uterine bleeding present Uterine protrusion into the vagina Pain in the lower abdomen Foul smelling lochia
Uterine protrusion into the vagina
A postpartum client is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the client? Assess ambulation. Evaluate current hematocrit level. Measure blood pressure. Measure urine output.
Measure blood pressure.
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Apply cold compresses to the breast. Avoid frequent breastfeeding. Perform handwashing before breastfeeding.
Perform handwashing before breastfeeding.
A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? dyspnea, diaphoresis, hypotension, and chest pain dyspnea, bradycardia, hypertension, and confusion weakness, anorexia, change in level of consciousness, and coma pallor, tachycardia, seizures, and jaundice
dyspnea, diaphoresis, hypotension, and chest pain
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? Maladjustment Postpartum depression Postpartum blues Postpartum psychosis
Postpartum psychosis
A postpartum client calls the nurse to her room and states that she knows something awful is going to happen to her. What should the nurse do? Tell her she is being silly; nothing is going to happen to her. Ask if she would like to see the social worker. Call a code. Report this immediately to the health care provider.
Report this immediately to the health care provider.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? Teach that adequate hydration helps clear the infection quicker. Ask primary care provider to prescribe an analgesic. Advise her to take acetaminophen to ease symptoms. Instruct to use a sitz bath while voiding.
Teach that adequate hydration helps clear the infection quicker.
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? fluid volume overload hemorrhage infection pulmonary emboli
hemorrhage
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? hypovolemia hypertension hyperglycemia hypothyroidism
hypovolemia
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. loss of confidence inability to concentrate manifestations of mania bizarre behavior decreased interest in life
loss of confidence inability to concentrate decreased interest in life
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? breast yeast engorgement plugged milk duct mastitis
mastitis
Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? nifedipine indomethacin magnesium sulfate oxytocin agent
oxytocin agent
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? hemorrhage fluid volume overload infection pulmonary emboli
hemorrhage
An expectant mother is on heparin for previous blood clots and voicing concerns about how her medications will affect her baby. The nurse would inform the mother that: she should discontinue the heparin and change to another anticoagulant. heparin does not cross the placenta and is safe for her to take. it is recommended to stop taking the heparin while she is pregnant. any medication that an expectant mother takes can cause sequelae for the infant
heparin does not cross the placenta and is safe for her to take.
The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? "I will stop breastfeeding until I finish my antibiotics." "When breastfeeding, it is recommended to begin nursing on the infected breast first." "I am able to pump my breast milk for my baby and throw away the milk." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable."
"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? Notify the health care provider. Encourage the client to void. Massage the uterine fundus. Apply warm soaks to the area.
Notify the health care provider.
A postpartum client has continuous seepage of blood from the vagina. Upon nursing assessment, the nurse confirms a firm uterus, 1 cm below the umbilicus. The nurse increases her nursing assessment to include assessment for: retained placental fragments. a cervical laceration. uterine atony. a urinary tract infection.
uterine atony.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? venous duplex ultrasound of the right leg transthoracic echocardiogram venogram of the right leg noninvasive arterial studies of the right leg
venous duplex ultrasound of the right leg
The nurse is assessing vital signs on the client and notes a normal blood pressure along with an elevated pulse when the patient moves from a lying to a standing or sitting position. What would this indicate? Overhydration Delayed labor Low fluid volume Arrested labor
Low fluid volume
Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother? CBC with differential indirect Coombs test ANA titer screen
indirect Coombs test
A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "I should brush my teeth vigorously to stimulate the gums." "If my lochia increases, I need to call my health care provider." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "I need to avoid using any aspirin-containing products."
"I should brush my teeth vigorously to stimulate the gums."
nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "I keep hearing voices telling me to take my baby to the river." "It's strange, one minute I'm happy, the next I'm sad." "I just feel so overwhelmed and tired." "I'm feeling so guilty and worthless lately."
"I'm feeling so guilty and worthless lately."
A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? Administer the drug as an IV bolus injection. Piggyback the IV infusion into a primary line. Withhold the drug if the woman is hypertensive. Give as a vaginal or rectal suppository.
Piggyback the IV infusion into a primary line.
A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? Encourage her to drink large amounts of fluid. Suggest that she take an oral analgesic. Administer amoxicillin, as prescribed. Obtain a clean-catch urine specimen.
Obtain a clean-catch urine specimen.
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Calcium gluconate Domperidone Oxytocin Magnesium sulfate
Oxytocin
The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? postpartum hemorrhage deep venous thrombosis metritis uterine atony
deep venous thrombosis
The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? lack of social support from family or friends drop in estrogen and progesterone levels after birth preexisting conditions in the client medications used during labor and birth
drop in estrogen and progesterone levels after birth
The client has a nursing diagnosis of deficient fluid volume related to blood loss. Which nursing actions would the nurse include in this client's plan of care? Administer medications to decrease blood loss. Administer a liter of hypertonic IV fluid over 30 minutes. Place the client on strict intake and output. Encourage intake of oral fluids. Start a pad count for 24 hours.
encourage oral intake of fluids
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? an inverted nipple on the affected breast no breast milk in the affected breast hardening of an area in the affected breast an ecchymotic area on the affected breast
hardening of an area in the affected breast
A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? manually removing the placenta at birth administering broad-spectrum antibiotics applying pressure to the umbilical cord to remove the placenta inspecting the placenta after delivery for intactness
inspecting the placenta after delivery for intactness