Chapter 12: The Postpartum Woman

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?

postpartum depression The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.

A postpartum woman tells the home care nurse, "My hemorrhoids are really uncomfortable. Is there anything I can do?" Which suggestion(s) by the nurse would be appropriate? Select all that apply.

"Applying ice to the area can help." "Witch hazel pads can have a cooling effect." "I will show you how to use a sitz bath." The presence of swollen hemorrhoids may heighten discomfort in the perineum. Local comfort measures such as ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths can relieve pain.

The nurse provides discharge instructions to a postpartum patient. Which patient statement indicates that teaching has been effective?

"I should plan to return to my full-time job after 6 weeks." It is usually advised that a woman not return to an outside job for at least 3 to 6 weeks, not only for her own health but also for enjoyment of the early weeks with the newborn. Stair climbing should be limited to one flight/day for the first week at home. Coitus is safe as soon as the patient's lochia has turned to alba and, if present, an episiotomy is healed. The patient should notify the primary care provider if there is an increase, not a decrease, in lochial discharge.

A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?

100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.

A nurse is providing care to a woman who is 6 hours postpartum. The nurse suspects urinary retention based on which finding?

50 to 70 mL urine per void every hour Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow and a need for catheterization. A uterus at the level of the umbilicus, moderate lochia rubra, and clear yellow urine are normal findings.

The nurse is concerned that a new mother is developing a postpartum complication. What did the nurse most likely assess in this patient?

Absence of lochia Lochia should never be absent during the first 1 to 3 weeks because absence of lochia may indicate postpartal infection. Red-colored lochia for the first 24 hours is normal. Lochia that is the color of menstrual blood is normal. Lochia appearing pinkish-brown on the fourth postpartum day is normal.

A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. What should the nurse point out to the client that this may be related to?

Decreased progesterone levels Decreased progesterone and estrogen levels are believed to cause postpartum blues in which the client might cry without reason and have some difficulty sleeping. Decreased thyroid hormone levels have been noted to be related with postpartum depression. Decreased hemoglobin levels is related to anemia.

When assessing a client's uterine fundus during the fourth stage of labor, the nurse palpates a soft, uncontracted fundus. Which of the following would the nurse do next?

Gently massage the boggy fundus The nurse should gently massage a boggy fundus with the hand, maintaining the position of the second hand that is guarding the uterus, until the uterus becomes firm. Instructing the client to exercise, suggesting complete bed rest, and avoiding lifting heavy weight are not the most appropriate interventions when a boggy fundus is detected.

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply.

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions? An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, abortion or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.

A woman delivered her infant 2 hours ago and calls to tell the nurse that she needs to go to the bathroom. When the nurse arrives, the mother is getting out of bed alone. What should the nurse do?

Have the client sit dangling her legs off the side of the bed for 5 minutes. The first time a woman gets up following delivery, it is recommended that she sit up on the side of the bed, dangling her legs for 5 minutes to prevent postural hypotension and lightheadedness. If the woman then feels fine, the nurse will accompany her to the bathroom and back to bed.

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?

Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?

Health-seeking behaviors related to care of newborn The new mother is asking the nurse to validate actions being performed while providing newborn care. The nursing diagnosis most appropriate for the new mother at this time would be health-seeking behaviors related to care of the newborn. The new mother is not demonstrating signs of ineffective coping. There is no information to support a risk for altered family coping or risk for impaired parenting.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply.

Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas. The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.

The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report?

Maternal blood type Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh, and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.

The nurse is evaluating the effectiveness of teaching on perineal care provided to a postpartum patient. Which outcome indicates that teaching has been effective?

Patient performs perineal care independently with every morning shower. The nurse should instruct the postpartum patient to include perineal care as part of a daily bath or shower and after every voiding or bowel movement. The patient should stand before flushing the commode when performing perineal care because water from the commode can splash the perineum and cause an infection. The patient should be instructed to wash the perineum from front to back to reduce the potential for contamination from the rectal area.

The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action should the nurse prioritize to prevent inversion of the uterus while completing this assessment?

Place a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus.

The nurse notices that a new mother who is beginning postpartum day 2 handles the newborn tentatively and does not kiss the child when holding him. What should the nurse suspect as the probable reason for this behavior?

Reacting normally to accepting a new child More often, a woman enters into a relationship with her newborn tentatively and with qualms and conflicts that must be addressed before the relationship can be meaningful. This is because parental love is only partly instinctive. The tentative behavior does not indicate disappointment with the child's sex, difficulty accepting role changes, or cultural customs that do not include kissing children.

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?

Sims position Assuming a Sims position several times a day aids in good venous return to the rectal area and reduces the discomfort of hemorrhoids. Supine, knee-chest, and Trendelenburg are not recommended positions to aid in the pain of hemorrhoids.

A postpartum client delivered her infant 1 day ago and the nurse is monitoring her blood pressure. What position would the nurse place the client in to get the most accurate reading?

Sitting on the side of the bed for 2 to 3 minutes In order to get the most accurate reading on a client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.

A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse emphasize when teaching the patient about this treatment approach?

Sitz baths increase the blood supply to the perineal area. Moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. Sitz baths do not cause postpartal infections. Sitz baths do not cause perineal vasoconstriction and decreased bleeding. Every use of a sitz bath is therapeutic.

Identification of appropriate psychological adaptations to the postpartum period is necessary to detect maladaptive behaviors. Which behavior would indicate the need for further assessment of a new mother's adaptation?

Staring off into the distance while holding the newborn Showing detachment such as staring into space while holding the newborn is a maladaptive behavior. These behaviors need further observation and discussion with the mother to determine her level of attachment to the infant.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.

A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis. The nurse would also expect to assess an elevation in which of the following?

Temperature Additional assessment findings would include an elevation in the client's temperature. Elevation in blood pressure, heart rate, and respiratory rate are not associated findings with endometritis.

The nurse is checking the lochia of a new mother at her 2-week checkup. The mother reports that the lochia is a small amount, pale yellow with occasional tinges of brown. She also reports that it has fleshy odor to it. How would the nurse evaluate these findings?

The color and amount of the lochia is normal and there are no concerns. Lochia normally progresses through three stages: lochia rubra, lochia serosa and lochia alba. Lochia rubra lasts approximately 3 to 4 days and is bloody in appearance. Lochia serosa is brownish-pink in color, less in quantity and occurs during days 4 to 10 following delivery. Lochia alba, which this client has, is white to pale yellow in color and small in volume and occurs around week 2 after delivery. The fleshy odor is normal for lochia.

When assessing the postpartum client 2 hours after giving birth, which finding indicates the need for further action?

The fundus is firm and deviated sharply to the right side of the abdomen. In the immediate postpartum period, the fundus is regularly assessed. The fundus must be firm. A boggy fundus indicates uterine atony and will result in blood loss. The fundus is to be midline in the abdomen. A deviation to the side may indicate a full bladder. In the immediate hours after birth, the fundus may be found at one fingerbreadth above or below the umbilicus.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. Expected urinary output for a postpartum woman is at least 150 mL with each void on an hourly basis. Therefore 150 to 200 mL is a normal volume for each void.

The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor?

discomfort due to hemorrhoids The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation.

When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement?

estrogen Decreased levels of estrogen are associated with breast engorgement and with the diuresis that occurs postpartum. Progesterone and hCG are not involved with breast engorgement. Prolactin levels remain elevated in the lactating woman for milk synthesis and secretion, but decrease within 2 weeks for the woman who is not breast-feeding.

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?

lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartum period.

A postpartum client comes to the clinic for her 6-week postpartum check up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

slit-like. After birth, the external cervical os is no longer shaped like a circle but instead appears as a jagged slit-like opening, often described as a "fish mouth."

A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation?

suggest proper exercise This client developed diastasis recti, a condition in which the abdominal muscles separate during the pregnancy, leaving part of the abdominal wall without muscular support. Exercise can improve muscle tone when this condition occurs. Application of warm compresses, application of moist heat, and massaging the muscles gently will not correct this situation.

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.

A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?

uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.

The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?

uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?

"It takes about 3 days after birth for milk to begin forming." The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy, since midway through pregnancy she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day postpartum, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?

"It varies, but you can estimate it returning in about 7 to 9 weeks." For the nonlactating woman, menstruation resumes 7 to 9 weeks after giving birth, with the first cycle being anovulatory. For the lactating woman, menses can return anytime from 2 to 18 months after birth.

The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?

The health care provider needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.

One thing a new mother does is to adapt to the new baby psychologically. The woman takes on her new role as mother by going through a series of four developmental stages. What is one of them?

Achieving a maternal identity The woman adapts to her new role as mother through a series of four developmental stages:1. Beginning attachment and preparation for the infant during pregnancy2. Increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period3. Moving toward a new normal in the first several months4. Achieving a maternal identity around 4 months

A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?

Apply ice. Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?

Ask her questions and observe her caring for the baby. The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone Muscle clenching perineal exercises help to improve pelvic floor tone, strengthen perineal muscles, and promote healing, ultimately helping to prevent urinary incontinence later in life. Kegel exercises have no effect on lochia, involution, or pain.

A postpartum patient is prescribed docusate sodium (Colace) as treatment for constipation. What should the nurse include when teaching the patient about this medication? Select all that apply.

Be sure to engage in activity to aid in intestinal motility. This medication works the best when a high-fiber diet is consumed. Take each dose of the medication with a full glass of water or juice. Docusate sodium (Colace) is used in the postpartal period to prevent constipation. It works by lowering the surface tension of feces, allowing water and lipids to penetrate the stool and soften it. The nurse should instruct the patient to engage in activity to promote intestinal motility, consume a diet high in fiber, and take each dose of the medication with a full glass of water or juice. This medication has abdominal pain and diarrhea as potential adverse effects. This medication is not taken after every meal but rather one dose per day.

The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.

Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful Normal findings for a breast exam in a Day 2 postpartum mother should include non-painful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.

The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation?

lochia rubra Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.

The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?

perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.

The nurse is preparing discharge training for a G2P2 client who will breast-feed her infant. The client mentions she wants more children but wants to wait a couple years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals?

when she resumes sexual activity She should use mechanical means of birth control as soon as she resumes sexual activity. She can ovulate even though she is not having a normal menstrual cycle. She needs to take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or as soon as she stops breast-feeding is not affording her protection from getting pregnant.

A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?

white blood cell count 14,000/mm3 (14 ×109/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.

While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?

yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.

The nurse is assessing the fundus of a patient on postpartum day 2. What should the nurse expect when palpating the fundus?

Fundus two fingerbreadths below umbilicus and firm Because uterine contraction begins immediately after placental delivery, the fundus of the uterus is palpable through the abdominal wall, halfway between the umbilicus and the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the level of the umbilicus, where it remains for approximately the next 24 hours. From then on, it decreases one fingerbreadth or centimeter per day and will be palpable 1 cm below the umbilicus. For the second postpartal day, the uterus will be two fingerbreadths or centimeters below the umbilicus. The fundus should not be palpated 4 cm above the symphysis pubis, 4 cm below the umbilicus, or two fingerbreadths above the symphysis pubis on the second postpartum day. The fundus should not be hard.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago?

Gently massage the fundus until it tones up After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.

A mother's chart notes that she is non-immune on her rubella status. The nurse explains what this means to the client. Which statement by the mother indicates that more teaching is needed?

"I need to have three shots to get my rubella levels up." If a mother is non-immune to rubella, she will receive a rubella immunization prior to being discharged from the hospital. She will have titers drawn 6 to 8 weeks later to determine if she developed immunity to rubella. If she remains non-immune, she will receive a re-vaccination. There will only be two shots potentially, not three.

A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?

"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.

A nursing instructor teaching students how to check the client's uterus postpartum realizes that further instruction is needed when one of the students says:

"One to two hours after birth the fundus is typically at the level of the umbilicus." One to two hours after birth, the fundus is typically between the umbilicus and symphysis pubis. At 6 to 12 hours after birth, the fundus usually is at the level of the umbilicus. Normally the fundus progresses downward at at rate of one fingerbreadth per day after birth.

A client who is breastfeeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

"The baby's sucking releases a hormone that causes the uterus to contract." The woman is describing afterpains, which are usually stronger during breastfeeding because oxytocin released by the sucking reflex strengthens uterine contractions. Afterpains are associated with uterine involution, but the woman's description strongly correlates with the hormonal events of breastfeeding. All women experience afterpains, but they are more acute in multiparous women secondary to repeated stretching of the uterine muscles.

A Chinese mother delivers her newborn and is ready to go home. The grandmother is present and will remain with the mother for 1 month. The grandmother tells the nurse that the mother will not be allowed to leave the house for the first month after delivery. How should the nurse respond to this statement?

Accept the grandmother's statement and do discharge teaching accordingly. In many cultures, new mothers are not allowed to leave the home for at least 1 month to allow her opportunity to rest and keep her healthy. In the Chinese, Middle Eastern and Indian cultures, this is common practice. The nurse should not try to talk the grandmother out of her beliefs on caring for both her daughter and the newborn. Asking the grandmother why she is doing this is challenging and unprofessional.

The night shift LPN is checking on a woman who had a cesarean delivery with spinal morphine injection anesthesia early that morning. The nurse counts a respiratory rate of 8 per minute. What should the nurse do first?

Administer naloxone per the preprinted orders. Have naloxone readily available. The anesthesiologist orders naloxone administration if the respiratory rate falls below 10 to 12 per minute.

A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?

Administer pain medications. "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.

The nurse is doing discharge teaching with the parents of a baby. It is their second child. The nurse explains about sibling regression and offers ways to deal with regressive behavior. What is this called?

Anticipatory guidance Anticipatory guidance is helpful when siblings are involved. Explain to the parents that it is normal for the older sibling to regress in the first few days after the birth of the baby. Tell them it helps if they do not focus undue attention on regressive behaviors, such as a return to bedwetting, sucking the thumb, or clinging to a favorite toy or blanket. It is particularly important for the parents not to criticize or belittle the older child for regressive behaviors.

A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); BP 120/70 mm Hg; heart rate 80 bpm. and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?

BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.

A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?

Demonstrating how to do cord care on the newborn When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.

A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client?

Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.

A gravida 4 para 4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is having what feels like labor pains again off and on. What would be the nurse's response?

Explain to her that women who have had several babies prior to this delivery often experience afterpains, which is where the uterus is contracting and relaxing at intervals. Afterpains occur most commonly in multipara mothers and occur when the uterus contracts and relaxes at intervals. Breast-feeding also can cause afterpains, increasing both the duration and the intensity of the pains. Ambulation will not affect the incidence of afterpains; afterpains are a very common postpartum event so there is no need to call the doctor.

The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?

Harm to self When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed.

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client?

Her bladder for distension Bladder distension can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.

What two elements play the biggest role in becoming a mother after delivery of her newborn?

Love and attachment to the child and engagement with the child A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.

A new mother exhibits signs of feeling abandoned shortly before being released from the hospital. The mother gave birth to a healthy newborn 2 days ago. Which nursing intervention would be most appropriate in this case?

Mention to the mother how it is common to feel "left out" when all of the attention shifts from the pregnant mother to the newborn Many mothers, if given the opportunity, admit to feeling abandoned and less important after giving birth than they did during pregnancy or labor. Only hours before, after all, they were the center of attention, with everyone asking about their health and well-being. Now, suddenly, the baby is everyone's chief interest. You can help a woman move past these feelings by verbalizing the problem: "How things have changed! Everyone's asking about the baby today and not about you, aren't they?" These are reassuring words for a woman and help her realize, although uncomfortable, the feeling she is experiencing is normal. Commenting on a newborn's good points would be more appropriate if the mother is experiencing disappointment with the child. An explanation of how hormonal changes contribute to overwhelming sadness would be more appropriate in the case of postpartal blues. Referral to a psychologist would be more appropriate for a case of postpartal depression.

During the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply.

Needing assistance with changing her peripad Telling the nurse about her delivery experience. Asking the nurse to take the newborn away so she can rest. In the early postpartum period, the new mother is focused upon herself and concerned about her needs. She is very dependent, having difficulty making decisions and requesting help with self-care. She relives the delivery experience and wants to share it with others. This period may last several hours or several days.

When assessing a postpartum mother, the nurse asks the client how many peripads she has used over the last 4 hours. The mother responds that she has changed her pad 2 to 3 times per hour when they were saturated. What action should the nurse take?

Notify the RN of the finding. If a mother reports that she is saturating more than one peripad per hour, the RN needs to be notified because this is too much bleeding. Having the mother massage the fundus after demonstrating how to do it is a good idea but her excessive bleeding is a much higher priority at this time.

A nurse is providing discharge instructions to a postpartum client. Which symptom is a possible complication that the nurse should educate the client about?

Notify the health care provider of increased lochia and bright red bleeding. Once the lochia has changed to pink, a change back to bright red may indicate a problem or complication. Palpating the funds to make it soft is not appropriate. The other occurrences are normal and would not need to be reported to the health care provider.

A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first?

Notify the health care provider of the findings. If the nurse notes abnormal findings on her exam—such as depressed respiratory status like this client is presenting—the nurse will immediately notify a health care provider. Having a peer come in to confirm your findings is always fine but this does not preclude notification of the physician. Asking the charge nurse to look in on the client later indicates there is no urgency to the situation, which there is.

A 17-year-old woman is living with a 21-year-old man. The man often comes home drunk and then becomes jealous. He refers to the woman as lazy, stupid, and useless and makes accusations about her talking with people while he is working to support her. He rarely hits her. Given this history, the nurse recognizes this client is at risk for which condition associated with pregnancy?

Postpartum depression Intimate partner violence during pregnancy is a risk for the development of postpartum depression. In fact, risk for postpartum depression increases by two to three times. Molar pregnancy, gestational diabetes, and postterm pregnancy are not related to lack of social support or situational factors.

A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?

She did her perineal care independently. During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.

A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?

Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier. New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with.

The nurse is reviewing the health records of several clients who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage?

a client diagnosed with placenta succenturiate Placental succenturiate is a concern for maternal hemorrhage if the accessory lobes of the placenta are retained after delivery. The other conditions are not associated with a higher than usual concern for hemorrhage, although all postpartum clients are observed for hemorrhage.

A primipara client gave birth vaginally to a healthy newborn girl 12 hours ago. The nurse palpates the client's fundus. Which finding would the nurse identify as expected?

at the level of the umbilicus During the first 12 hours postpartum, the fundus of the uterus is located at the level of the umbilicus. Over the first few days after birth, the uterus typically descends from the level of the umbilicus at a rate of 1 cm (one fingerbreadth) per day. By 3 days, the fundus lies two to three fingerbreadths below the umbilicus (or slightly higher in multiparous women). By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

bleeding Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.

When the nurse is assessing a postpartum client approximately 6 hours after birth, which finding would warrant further investigation?

blood pressure 90/50 mm Hg In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of the compensatory increase in heart rate. Thus, a decrease in blood pressure and cardiac output are not expected changes during the postpartum period. Early identification is essential to ensure prompt intervention. Deep red, fleshy-smelling lochia is a normal finding 6 hours postpartum. Voiding in small amounts such as less than 150 cc would indicate a problem, but 350 cc would be appropriate. Profuse sweating also is normal during the postpartum period.

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

cannot be palpated By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.

A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior?

identifies imperfections in the newborn's appearance Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.

The nurse is developing a teaching plan for a client who has decided to bottle-feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?

instructing her to apply ice packs to both breasts every other hour If the woman is not breastfeeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

less than after a vaginal birth. Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.

The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?

moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.

The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?

rise in hematocrit Hemoglobin and erythrocyte values vary during the early postpartum period, but they should approximate or exceed prelabor values within 2 to 6 weeks. As the woman excretes extracellular fluid, hemoconcentration occurs, with a concomitant rise in hematocrit. Puerperal bradycardia, with rates of 50 to 70 beats per minute, is common during the first 6 to 10 days postpartum. Blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks' gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.

When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?

"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.

A newly delivered mother asks the nurse "What can I do to help my womb to get back to a normal size more quickly?" The nurse's best response would be:

"If you are breast-feeding, that will help make your uterus contract and get smaller." There are several things that a new mother can do to assist in uterine involution. The most well known one is breast-feeding the infant. Whenever a new mother breast-feeds her infant, it stimulates the release of oxytocin, which stimulates the uterus to contract. The mother is also advised to eat a well-balanced diet and ambulate early in the postpartum period.

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?

"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 combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.

A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan?

Ensure early and frequent parent-newborn interactions. Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and their partners to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. Eye contact and interacting with the newborn during feeding helps to promote attachment and bonding.

A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?

Ensure the baby empties the breasts at each feeding Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.

The nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize?

Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 ml of blood lost during the delivery process, the hemoglobin should decrease by 1 g/dl (10 g/L) and the hematocrit by 2%. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 ml to 500 m and for a cesarean delivery approximately 500 mL to 1000 ml. The loss of hemoglobin from 14 gm/dl (140 g/L) to 9 gm/dl (90 g/L) is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 ml of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.