EXAM 2 POSTPARTUM

After a vaginal delivery, a postpartum client complains of perineal discomfort when sitting. To promote comfort, the nurse should provide which instruction?

"Contract your buttocks before sitting or rising."

Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth?

1 hour

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:

BP

A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for:

Hematuria, ecchymosis, and epistaxis

Which description of postpartum restoration or healing times is accurate?

Rugae reappear within 3 to 4 weeks. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.

A hypotonic uterus can be managed with

massage and oxytocin

Few alterations in vital signs are seen after birth under normal circumstances.

true

Which statement regarding postpartum depression (PPD) is essential for the nurse to be aware of when attempting to formulate a plan of care?

. PPD can easily go undetected.

On completing a fundal assessment, the nurse notes the fundus is situated on the client's left abdomen. Which of the following actions is appropriate? 1. Ask the client to empty her bladder 2. Straight catheterize the client immediately 3. Call the client's health provider for direction 4. Straight catheterize the client for half of her uterine volume

1. Ask the client to empty her bladder A full bladder may displace the uterine fundus to the left or right side of the abdomen. Catheterization is unnecessary invasive if the woman can void on her own.

After receiving methylergonovine (Methergine) I.M. for postpartum hemorrhage, a client is prescribed methylergonovine 0.4 mg by mouth every 6 hours. The pharmacy sends 0.2 mg tablets. How many tablets must the nurse administer with each dose?

2

On which of the postpartum days can the client expect lochia serosa? 1. Days 3 and 4 PP 2. Days 3 to 10 PP 3. Days 10-14 PP 4. Days 14 to 42 PP

2. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP.

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? 1. Retained placental fragments 2. Urinary tract infection 3. Cervical laceration 4. Uterine atony

3. Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. UTI won't cause vaginal bleeding, although hematuria may be present.

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?

Activated partial thromboplastin time

BUBBLE H

Breast Uterus Bladder/ Bowel Lochia/ Legs Episiotomy and perineum Hematoma/ hemorrhage (emotional status)

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? Retained placental fragments Urinary tract infection Cervical laceration Uterine atony

Cervical laceration

. Postbirth uterine/vaginal discharge, called lochia:

D. should smell like normal menstrual flow unless an infection is present.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs:

Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate?

Increase hydration by encouraging oral fluids

A client is at the end of her 1st postpartum day. When assessing her uterus, the nurse expects to find the top of the fundus at the midline and at which position?

One fingerbreadth below the umbilicus

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?

Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed

Which of the following physiological responses is considered normal in the early postpartum period? Urinary urgency and dysuria Rapid diuresis Decrease in blood pressure Increase motility of the GI system

Rapid diuresis

What type of milk is present in the breasts 7 to 10 days PP?

Transitional milk

Postbirth uterine discharge (lochia),

initially is bright red (lochia rubra) and may contain small clots. For the first 2 hours after birth, the amount of uterine discharge should be about that of a heavy menstrual period. After that time, the lochial flow should steadily decrease.

Hypercoagulability, vessel damage, and immobility predispose the woman to

thromboembolism.

Which postpartum infection is most often contracted by first-time mothers who are breastfeeding?

. Mastitis: is infection in a breast, usually confined to a milk duct. Most women who suffer this are first-timers who are breastfeeding. -Endometritis is the most common postpartum infection. Incidence is higher after a cesarean birth and not limited to first-time mothers. -Wound infections are also a common postpartum complication. Sites of infection include both a cesarean incision and the episiotomy or repaired laceration. The gravidity of the mother and her feeding choice are not factors in the development of a wound infection. - UTIs occur in 2% to 4% of all postpartum women. Risk factors include catheterizations, frequent vaginal examinations, and epidural anesthesia.

. Two hours after giving birth, a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm, at the umbilicus, and midline. Her lochia is moderate rubra with no clots. The nurse would suspect:

. hematoma formation.

The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to

. palpate the uterus and massage it if it is boggy Once the nurse has applied firm massage of the uterine fundus, the primary health care provider should be notified or the nurse can delegate this task to another staff member. This intervention is appropriate after assessment and immediate steps have been taken to control the bleeding. The initial management of excessive postpartum bleeding is firm massage of the uterine fundus. Vital signs will need to be ascertained after fundal massage has been applied.

Which measure would be least effective in preventing postpartum hemorrhage? massaging the fundus every hour for 24 hours

Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.

the most common and most serious type of excessive obstetric blood loss.

PPH Causes of PPH are uterine atony, retained placenta, lacerations of the genital tract, hematomas, inversion of the uterus, and subinvolution of the uterus.

With regard to afterbirth pains, nurses should be aware that these pains are:

more noticeable in births in which the uterus was overdistended.

The physician prescribes phytonadione (AquaMEPHYTON), 0.5 mg I.M., for a neonate born 30 minutes ago. The nurse has a solution containing 2 mg/ml. How many milliliters of solution should the nurse administer to achieve this dose?

.25

Vascular abnormalities, spider angiomas, palmar erythema, and epulis regress with rapid decline in estrogens Spider nevi persist indefinitely for some Hair growth slows during the postpartum period Some women experience significant hair loss

.

When working with parents who have some form of sensory impairment, nurses should consider which information when writing a plan of care? (Select all that apply.) A. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals B. Visually impaired mothers cannot overcome the infant's need for eye-to-eye contact C. The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities D. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information E. Childbirth education and other materials are available in Braille.

A. One of the major difficulties visually impaired parents experience is the skepticism of health care professionals C. The best approach for the nurse is to assess the parents' capabilities rather than focusing on their disabilities D. Technologic advances, including the Internet, can provide deaf parents with a full range of parenting activities and information E. Childbirth education and other materials are available in Braille.

. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1-day postpartum. Expected findings include:

-little if any change Breasts are essentially unchanged for the first 24 hours after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs after the milk comes in 72 to 96 hours after birth. Engorgement occurs at day 3 or 4 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used. Colostrum, or early milk, a clear, yellow fluid, may be expressed from the breasts during the first 24 hours.

A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician prescribes bethanechol (Urecholine), 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond?

"It stimulates the smooth muscle of the bladder."

Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process

-

Select all of the physiological maternal changes that occur during the PP period. -Cervical involution ceases immediately -Vaginal distention decreases slowly -Fundus begins to descend into the pelvis after 24 hours -Cardiac output decreases with resultant tachycardia in the -first 24 hours -Digestive processes slow immediately.

-Cervical involution ceases immediately --Fundus begins to descend into the pelvis after 24 hours

21) A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. Take the prescribed antibiotics until the soreness subsides. Wear supportive bra Avoid decompression of the breasts by breastfeeding or breast pump Rest during the acute phase Continue to breastfeed if the breasts are not too sore.

-Wear supportive bra -Rest during the acute phase -Continue to breastfeed if the breasts are not too sore.

The priority nursing intervention for a woman who suffered a perineal laceration is to:

. establish hemostasis. Bleeding should be stopped first. After bleeding has been controlled, the care of the woman with lacerations of the perineum includes analgesia administration, hot or cold applications, and stool softeners. Stool softeners may be used to assist the woman in reestablishing bowel habits without straining and putting stress on the suture lines.

Select all of the physiological maternal changes that occur during the PP period. 1.Cervical involution ceases immediately 2.Vaginal distention decreases slowly 3.Fundus begins to descend into the pelvis after 24 hours 4.Cardiac output decreases with resultant tachycardia in the first 24 hours 5.Digestive processes slow immediately.

1 and 3. In the PP period, cervical healing occurs rapidly and cervical involution occurs. After 1 week the muscle begins to regenerate and the cervix feels firm and the external os is the width of a pencil. Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution. Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period. Soon after childbirth, digestion begins to begin to be active and the new mother is usually hungry because of the energy expended during labor.

Kidney function returns to normal within

1 month after birth. Marked diuresis, decreased bladder sensitivity, and overdistention of the bladder can lead to problems with urinary elimination.

(SELECT ALL THAT APPLY) The nurse is collecting data on client who is 1 day postpartum. The nurse expects which normal findings?

1) Lochia Rubra, (4) Heart rate of 50 to 70 beats/minute

Which of the following behaviors characterizes the PP mother in the taking in phase? 1. Passive and dependant 2. Striving for independence and autonomy 3. Curious and interested in care of the baby 4. Exhibiting maximum readiness for new learning

1. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs. The taking hold phase usually lasts from days 3-10 PP. During this stage, the mother strives for independence and autonomy; she also becomes curious and interested in the care of the baby and is most ready to learn.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially? 1. Massage the fundus until it is firm 2. Elevate the mothers legs 3. Push on the uterus to assist in expressing clots 4. Encourage the mother to void

1. If the uterus is not contracted firmly, the first intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Elevating the client's legs and encouraging the client to void will not assist in managing uterine atony. If the uterus does not remain contracted as a result of the uterine massage, the problem may be distended bladder and the nurse should assist the mother to urinate, but this would not be the initial action.

Parents can facilitate the adjustment of their other children to a new baby by: Having the children choose or make a gift to give to the new baby upon its arrival home Emphasizing activities that keep the new baby and other children together Having the mother carry the new baby into the home so she can show the other children the new baby Reducing stress on other children by limiting their involvement in the care of the new baby

1. Special time should be set aside just for the other children without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability without overwhelming them.

Which of the following factors might result in a decreased supply of breast milk in a PP mother? 1. Supplemental feedings with formula 2. Maternal diet high in vitamin C 3. An alcoholic drink 4. Frequent feedings

1. Supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the mother's nipples affects hormonal levels and milk production.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: 1. Assess for hypovolemia and notify the health care provider 2. Begin hourly pad counts and reassure the client 3. Begin fundal massage and start oxygen by mask 4. Elevate the head of the bed and assess vital signs

1. Symptoms of hypovolemia include cool, clammy, pale skin, sensations of anxiety or impending doom, restlessness, and thirst. When these symptoms are present, the nurse should further assess for hypovolemia and notify the health care provider.

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? 1. Peripheral vascular disease 2. Hypothyroidism 3. Hypotension 4. Type 1 diabetes

1. These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

Which of the following findings would be expected when assessing the postpartum client? 1. Fundus 1 cm above the umbilicus 1 hour postpartum 2. Fundus 1 cm above the umbilicus on postpartum day 3 3. Fundus palpable in the abdomen at 2 weeks postpartum 4. Fundus slightly to the right; 2 cm above umbilicus on postpartum day 2

1. Within the first 12 hours postpartum, the fundus usually is approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by PP day 3. The fundus shouldn't be palpated in the abdomen after day 10.

The nurse determines that a postpartum client's perineal pad weighs 100 g. The nurse should document this client's blood loss as:

100 ml

The uterus involutes rapidly after birth and returns to the true pelvis within

2 weeks

Hct drop with blood loss

2% for each 500cc of blood loss

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. 1. Take the prescribed antibiotics until the soreness subsides. 2. Wear supportive bra 3. Avoid decompression of the breasts by breastfeeding or breast pump 4. Rest during the acute phase 5. Continue to breastfeed if the breasts are not too sore.

2, 4, and 5. Mastitis are an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3L/ day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breastfeeding or pumping is important to empty the breast and prevent formation of an abscess.

A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return: 1. On the day of the delivery 2. 3 days PP 3. 7 days PP 4. within 2 weeks PP

2. After birth, the nurse should auscultate the woman's abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.

nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? 1. A temperature of 100.4*F 2. An increase in the pulse from 88 to 102 BPM 3. An increase in the respiratory rate from 18 to 22 breaths per minute 4. A blood pressure change from 130/88 to 124/80 mm Hg

2. During the 4th stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. The blood pressure will fall as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. A slight rise in temperature is normal. The respiratory rate is increased slightly.

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman's vital signs: 1. Every 30 minutes during the first hour and then every hour for the next two hours. 2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours. 3. Every hour for the first 2 hours and then every 4 hours 4. Every 5 minutes for the first 30 minutes and then every hour for the next 4 hours.

2. Every 15 minutes during the first hour and then every 30 minutes for the next two hours.

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the: 1. Amount of lochia 2. Blood pressure 3. Deep tendon reflexes 4. Uterine tone

2. Methergine and pitocin are agents that are used to prevent or control postpartum hemorrhage by contracting the uterus. They cause continuous uterine contractions and may elevate blood pressure. A priority nursing intervention is to check blood pressure. The physician should be notified if hypertension is present.

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate? 1. Document the findings 2. Notify the physician 3. Reassess the client in 2 hours 4. Encourage increased intake of fluids

2. Normally, one may find a few small clots in the first 1 to 2 days after birth from pooling of blood in the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: -Foster an active role in the baby's care -Provide time for the mother to reflect on the events of and her behavior during childbirth -Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now -Promote maternal independence by encouraging her to meet her own hygiene and comfort needs

2. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach.

A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Enlarged, hardened veins 3. Coolness of the calf area 4. Palpable dorsalis pedis pulses

2. Thrombosis of the superficial veins is usually accompanied by signs and symptoms of inflammation. These include swelling of the involved extremity and redness, tenderness, and warmth.

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate? 1.Obtain hemoglobin and hematocrit levels 2.Instruct the mother to request help when getting out of bed 3.Elevate the mother's legs 4.Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings of light-headedness and dizziness have subsided.

2.Instruct the mother to request help when getting out of bed Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client's safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Obtaining an H/H requires a physicians order.

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? 1. Prothrombin time 2. Internationalized normalized ratio 3. Activated partial thromboplastin time 4. Platelet count

3. Anticoagulation therapy may be used to prevent the extension of thrombus by delaying the clotting time of the blood. Activated partial thromboplastin time should be monitored, and a heparin dose should be adjusted to maintain a therapeutic level of 1.5 to 2.5 times the control. The prothrombin time and the INR are used to monitor coagulation time when warfarin (Coumadin) is used.

A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? 1.Complaints of a tearing sensation 2.Complaints of intense pain 3.Changes in vital signs 4.Signs of heavy bruising

3. Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma. Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following? 1. Ask the client to turn on her side 2. Ask the client to lie flat on her back with the knees and legs flat and straight. 3. Ask the mother to urinate and empty her bladder 4. Massage the fundus gently before determining the level of the fundus

3. Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following? 1. Massage the fundus 2. Place the mother in the Trendelenburg's position 3. Notify the physician 4. Record the findings

3. If the bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm will not assist in controlling the bleeding. Trendelenburg's position is to be avoided because it may interfere with cardiac function.

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum? 1. Lower than during her pregnancy 2. Higher than during her pregnancy 3. Lower than before she became pregnant 4. Higher than before she became pregnant

3. Lower than before she became pregnant PP insulin requirements are usually significantly lower than prepregnancy requirements. Occasionally, clients may require little to no insulin during the first 24 to 48 hours postpartum

A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains? 1. Bottle-feeding 2. Diabetes 3. Multiple gestation 4. Primiparity

3. Multiple gestation, breastfeeding, multiparity, and conditions that cause overdistention of the uterus will increase the intensity of after-pains. Bottle-feeding and diabetes aren't directly associated with increasing severity of afterpains unless the client has delivered a macrosomic infant.

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: -Express a strong need to review events and her behavior during the process of labor and birth -Exhibit a reduced attention span, limiting readiness to learn -Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn -Have reestablished her role as a spouse/partner

3. One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage as described in response 3. This stage lasts for as long as 4 to 5 weeks after birth. Responses 1 and 2 are characteristic of the taking-in stage, which lasts for the first few days after birth. Response 4 reflects the letting-go stage, which indicates that psychosocial recovery is complete.

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? 1. Applying ice 2. Applying a breast binder 3. Teaching how to express her breasts in a warm shower 4. Administering bromocriptine (Parlodel)

3. Teaching how to express her breasts in a warm shower Teaching the client how to express her breasts in a warm shower aids with let-down and will give temporary relief. Ice can promote comfort by vasoconstriction, numbing, and discouraging further letdown of milk. ** bromocriptine -(parlodel) will block release of prolactin - which would stop breastfeeding.

A PP client is being treated for DVT. The nurse understands that the client's response to treatment will be evaluated by regularly assessing the client for: 1. Dysuria, ecchymosis, and vertigo 2. Epistaxis, hematuria, and dysuria 3. Hematuria, ecchymosis, and epistaxis 4. Hematuria, ecchymosis, and vertigo

3. The treatment for DVT is anticoagulant therapy. The nurse assesses for bleeding, which is an adverse effect of anticoagulants. This includes hematuria, ecchymosis, and epistaxis. Dysuria and vertigo are not associated specifically with bleeding.

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: 1. Monitor fundal height 2. Apply perineal pressure 3. Prepare the client for surgery. 4. Reassure the client

3. The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.

A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for: 1. One peripad per day 2. Two peripads per day 3. Three peripads per day 4. Eight peripads per day

4. Eight peripads per day The normal amount of lochia may vary with the individual but should never exceed 6 to 8 peripads per day. The average number of peripads is 6 per day

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching? 1. "I need to take antibiotics, and I should begin to feel better in 24-48 hours." 2. "I can use analgesics to assist in alleviating some of the discomfort." 3. "I need to wear a supportive bra to relieve the discomfort." 4. "I need to stop breastfeeding until this condition resolves."

4. In most cases, the mother can continue to breast feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24-48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

a postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother's temperature is 100.2*F. Which of the following actions would be most appropriate? 1. Retake the temperature in 15 minutes 2. Notify the physician 3. Document the findings 4. Increase hydration by encouraging oral fluids

4. Increase hydration by encouraging oral fluids

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? 1. Cervical laceration 2. Clotting deficiency 3. Perineal laceration 4. Uterine subinvolution

4. Late postpartum bleeding is often the result of subinvolution of the uterus. Retained products of conception or infection often cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may also have an immediate PP hemorrhage if the deficiency isn't corrected at the time of delivery.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: -Tell the woman she can rest after she feeds her baby -Recognize this as a behavior of the taking-hold stage -Record the behavior as ineffective maternal-newborn attachment -Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

4. Response 1 does not take into consideration the need for the new mother to be nurtured and have her needs met during the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: Uses soap and warm water to wash the vulva and perineum Washes from symphysis pubis back to episiotomy Changes her perineal pad every 2 - 3 hours Uses the peribottle to rinse upward into her vagina

4. Responses 1, 2, and 3 are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? 1. The vaccine is safe in clients with egg allergies 2. Breast-feeding isn't compatible with the vaccine 3. Transient arthralgia and rash are common adverse effects 4. The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

4. The client must understand that she must not become pregnant for 3 months after the vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs so an allergic reaction may occur in clients with egg allergies. The virus is not transmitted into the breast milk, so clients may continue to breastfeed after the vaccination. Transient arthralgia and rash are common adverse effects of the vaccine

What type of milk is present in the breasts 7 to 10 days PP? 1. Colostrum 2. Hind milk 3. Mature milk 4. Transitional milk

4. Transitional milk comes after colostrum and usually lasts until 2 weeks PP

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? 1.Assess vital signs every 4 hours 2.Inform health care provider of assessment findings 3.Measure fundal height every 4 hours 4.Prepare an ice pack for application to the area.

4.Prepare an ice pack for application to the area Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.

The client has just given birth to her first child, a healthy, full-term baby girl. The client is Rho(D)-negative and her baby is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours

A breast-feeding client is diagnosed with mastitis. Which nursing intervention would be most helpful to her

Advising her to massage the affected area gently while breast-feeding

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss? A temperature of 100.4*F An increase in the pulse from 88 to 102 BPM An increase in the respiratory rate from 18 to 22 breaths per minute A blood pressure change from 130/88 to 124/80 mm Hg

An increase in the pulse from 88 to 102 BPM

client has small vulvar hematoma

Application of ice will reduce swelling caused by hematoma formation in the vulvar area.

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:

Assess for hypovolemia and notify the health care provider

when performing a postpartum check, the nurse should: A) Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum B) Assist the woman into a supine position with her arms above her head and her legs extended for the examination of her abdomen C) Instruct the woman to avoid urinating just before the examination since a full bladder will facilitate fundal palpation D) Wash hands and put on sterile gloves before beginning the check

Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate. Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.

-

Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.

Blood volume

Changes in blood volume depend on several factors Blood loss during childbirth Amount of extravascular water mobilized and excreted Pregnancy-induced hypervolemia allow most women to tolerate blood loss during child

which of the postpartum days can the client expect lochia serosa?

DAYS 3-10 PP

Abdomen

During first 2 weeks abdominal wall remains relaxed Woman has still-pregnant appearance Return to prepregnancy state takes 6 weeks Depends on previous tone, proper exercise, and amount of adipose tissue

Which postpartum conditions are considered medical emergencies that require immediate treatment?

Inversion of the uterus and hypovolemic shock

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum?

Lower than before she became pregnant

client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?

MULTIPLE GESTATION

The nurse examines a woman one hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: Place her on a bedpan to empty her bladder Massage her fundus Call the physician Administer Methergine 0.2 mg IM which has been ordered prn

Massage her fundus 2. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm, followed by 3 and 4, especially if the fundus does not become or remain firm with massage. There is no indication of a distended bladder since the fundus is midline and below the umbilicus.

Which measure would be least effective in preventing postpartum hemorrhage? Administer Methergine 0.2 mg every 6 hours for 4 doses as ordered Encourage the woman to void every 2 hours Massage the fundus every hour for the first 24 hours following birth Teach the woman the importance of rest and nutrition to enhance healing

Massage the fundus every hour for the first 24 hours following birth The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Responses 1, 2, and 4 are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.

After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer's solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because: She had a precipitate birth This was an extramural birth Retained placental fragments must be expelled Multigravida's are at increased risk for uterine atony.

Multigravida's are at increased risk for uterine atony. Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.

Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum? Postural hypotension Temperature of 100.4°F Bradycardia — pulse rate of 55 BPM Pain in left calf with dorsiflexion of left foot

Pain in left calf with dorsiflexion of left foot Responses 1 and 3 are expected related to circulatory changes after birth. A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake. The findings in response 4 indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client's medical history? Peripheral vascular disease Hypothyroidism Hypotension Type 1 diabetes

Peripheral vascular disease These medications are avoided in clients with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. These conditions are worsened by the vasoconstriction effects of these medications.

The nurse observes several interactions between a postpartum woman and her new son. What behavior, if exhibited by this woman, does the nurse identify as a possible maladaptive behavior regarding parent-infant attachment?

Seldom makes eye contact with her son

• Postpartum infection is a major cause of maternal morbidity and mortality throughout the world, and endometritis is the most common postpartum infection. • Postpartum UTIs are common because of trauma experienced during labor

Structural disorders of the uterus and vagina related to pelvic relaxation are often the delayed but direct result of childbearing. These can include uterine displacement and prolapse, cystocele and rectocele, genital fistulas, and urinary incontinence

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts? Applying ice Applying a breast binder Teaching how to express her breasts in a warm shower Administering bromocriptine (Parlodel)

Teaching how to express her breasts in a warm shower

During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?

The client appears interested in learning about neonatal care. The third to tenth days of PP care are the "taking-hold" phase, in which the new mother strives for independence and is eager for her neonate.

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:

The expected weight loss immediately following delivery is 11 to 13 lbs Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 lbs.

In follow-up appointments or visits with parents and their new baby, it may be useful if the nurse can identify parental behaviors that can either facilitate or inhibit attachment. What is a facilitating behavior?

The parents hover around the infant, directing attention to and pointing at the infant.

have reestablished her role as a spouse/partner.

This reflects the letting-go stage, which indicates that psychosocial recovery is complete.

A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm, moist compress over the painful area.

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage? Cervical laceration Clotting deficiency Perineal laceration Uterine subinvolution

Uterine subinvolution

Hemorrhagic (hypovolemic) shock is

an emergency situation in which the perfusion of body organs can become severely compromised and death can ensue

Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health?

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?

ask mother to urinate and empty bladder

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary health care provider?

blurred vision/headache

nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma

changes in vital signs

Leukocytosis in postpartum

common 15000-20000

changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications?

decrease

A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?

enlarged hardened veins

Subinvolution

is the failure of the uterus to return to a nonpregnant state. The most common causes of subinvolution are: -retained placental fragments -infection

Postpartum period

is the interval between birth and return of reproductive organs to their nonpregnant state Referred to as puerperium or fourth stage of pregnancy Traditionally lasts 6 weeks, although this varies among women

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?

notify physician

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?

notify the physician

behaviors characterizes the PP mother in the taking in phase?

passive and dependent

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to:

prepare for surgery

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be:

red and moderate

Postpartum estrogen deprivation is

responsible for the thinness of the vaginal mucosa and the absence of rugae. The greatly distended, smooth-walled vagina gradually decreases in size and regains tone, although it never completely returns to its prepregnancy state.

To provide optimum care for the postpartum woman, the nurse understands that the most common causes of subinvolution are: -postpartum hemorrhage and infection. -multiple gestation and postpartum hemorrhage. -uterine tetany and overproduction of oxytocin. -retained placental fragments and infection.

retained placental fragments and infection

During the first formula feeding, a client has difficulty getting her neonate to take the artificial nipple into his mouth. To resolve this problem, the nurse should suggest that the mother:

stroke neonates lips gently with nipple of bottle

Which finding would lead the nurse to suspect that a client has developed hypovolemic shock caused by postpartum hemorrhage?

urine output less than 25 ml/hour

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage? Hypertension Cervical and vaginal tears Urine retention Endometritis

urine retention

client's neonate was delivered by cesarean. Which management strategy should be implemented regarding breast-feeding after this type of delivery?

use the football hold

Uterus

Involution process is the return of the uterus to a nonpregnant state following birth Progresses rapidly Fundus descends 1 to 2 cm every 24 hours 2 weeks after childbirth the uterus is no longer palpable Returns to a nonpregnant state by 6 weeks Subinvolution is the failure of uterus to return to nonpregnant state Contractions Postpartum hemostasis achieved by compression of intramyometrial blood vessels as uterine muscle contracts Hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions -Afterpains -Placental site -Lochia: postbirth uterine discharge -Lochia rubra Blood and decidual and trophoblastic debris Duration of 3 to 4 days Lochia: postbirth uterine discharge -Lochia serosa Old blood, serum, leukocytes, and debris Duration of 22 to 27 days -Lochia alba Leukocytes, decidua, epithelial cells, mucus, serum, and bacteria Continues 2 to 6 weeks after birth

Reversal of pregnancy adaptations

Joints are completely stabilized by 6 to 8 weeks after birth New mother may notice permanent increase in shoe size

describes the anticipated actions in the taking-hold phase of the maternal attachment process?

Kissing, embracing, and caring for the infant

The nurse is discharging a 34-year-old multipara client who, after 16 hours of labor, delivered an 8-lb, 14-oz (4,032-g) baby vaginally. The nurse notes that the mother is rubella-immune with Rh-positive blood. Which client outcome takes priority for this client?

The client will verbalize the importance of reporting changes in lochia flow.

As part of the postpartum follow-up, the nurse calls a new mother at home a few days after discharge. The client answers the telephone, begins to cry, and tells the nurse that she has feelings of inadequacy and isn't coping with the demands of motherhood. Based on this information, which of the following assessments would the nurse make?

This is expected behavior for a client 3 to 7 days postpartum.

A client is taking a progestin-only oral contraceptive, or minipill. Progestin use may increase the client's risk of:

tubal or ectopic pregnancy.

Mood disorders account for most mental health disorders in the postpartum period. • Suicidal thoughts or attempts are among the most serious symptoms of PPD. • Antidepressant medications are the usual treatment for PPD; however, specific precautions are needed for breastfeeding women

Anxiety disorders include generalized anxiety disorder, obsessive-compulsive disorder, panic disorder and panic attacks, specific phobias, social anxiety disorder, and post-traumatic stress disorder. Common characteristics of these disorders are irrational fear, worry, and tension; physical symptoms such as trembling, nausea and vomiting, dizziness, dyspnea, and insomnia areoften seen. • Treatment of postpartum onset of panic disorder requires a combination of medication, education, supportive measures, and psychotherapy

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. Sherese is concerned about having her first bowel movement. "I have hemorrhoids and stitches-it is going to be awful until I heal. Maybe I should hold back from having a BM for a few days until I feel a little less sore. Besides, I am sure that will prevent my stitches from ripping apart if I wait until I begin to heal." How should the nurse respond?

Emphasize that holding back will only dry the stool, making it harder to pass. Reassure Sherese that the sutures are secure and are unlikely to rip apart, especially if she avoids straining with constipated stool. Discuss measures to enhance bowel elimination such as increased dietary roughage, fluids, moderate activity, and local perineal measures to relieve discomfort and reduce the need for and use of systemic analgesics that can have a constipating effect. Administer a stool softener and/or mild laxative if ordered by a primary health care provider. Administer topical medications to hemorrhoids as indicated to help with shrinking tissue. Discuss relief measures to soothe the perineum and anus after the bowel movement such as perineal cleansing, sitz bath, and application of a topical preparation.

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. During a postpartum assessment at 1 1/2 hours after birth, Sherese's fundus was no longer firm and her lochial flow had increased in amount, saturating her pad in less than 1 hour. State in order of priority the actions that the nurse should take in response to these assessment findings.

Immediate response should be to massage the fundus until firm, and then to express clots that may be present; check Sherese's bladder for distension because a full bladder can inhibit uterine contraction. Check the primary health care provider's orders to determine if oxytocics such as Pitocin and/or Methergine should be administered; administer as indicated following appropriate guidelines. Change Sherese's pad, taking note of the time to aid in determining the quantity of lochia and if it is increasing or decreasing (e.g., if the pad becomes saturated in 1 hour or less, the flow is considered to be profuse). Notify Sherese's primary health care provider to report the findings, actions taken, and the results. Increase the frequency of postpartum assessments; document all findings, actions, and responses.

Although the administration of this prostaglandin is known to promote contraction of the uterus during postpartum hemorrhage, it is not effective for the client who presents with a bleeding disorder.

Hemabate

The cervix is soft immediately after birth. The ectocervix (portion of the cervix that protrudes into the vagina) appears bruised and has some small lacerations—optimal conditions for .....?

the development of infection.

What statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth?

"My first menstrual cycle will be heavier than normal and will return to my prepregnant volume within three or four cycles."

The nurse is instructing the client on breast-feeding. Which instructions should she include to help the mother prevent mastitis?

(2) Change the breast pads frequently., (3) Expose your nipples to air part of each day., (4) Wash your hands before handling your breast and breast-feeding., (6) Release the baby's grasp on the nipple before removing him from the breast.

Bladder distention would result in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony would result in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

,

With regard to the condition and reconditioning of the urinary system after childbirth, nurses should be aware that:

-fluid loss through perspiration and increased urinary output account for a weight loss of more than 2 kg during the puerperium. Kidney function usually returns to normal in about a month. Diastasis recti abdominis is the separation of muscles in the abdominal wall; it has no effect on the voiding reflex. Excess fluid loss through other means occurs as well. Bladder tone usually is restored 5 to 7 days after childbirth.

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects:

. hematoma formation

Nursing care management for mothers and fathers suffering grief from the loss of their baby includes: (Select all that apply.) A. using therapeutic communication and caring techniques. B. listening as parents tell their story of loss and grief. C. avoiding asking any questions about the loss of parents. D. giving advice from personal experiences. E. insisting parents name the baby in order to be remembered.

A. using therapeutic communication and caring techniques. B. listening as parents tell their story of loss and grief.

One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?

Administer the drug with meals or milk.

Urine components

Postpartal diuresis Within 12 hours women begin to diurese Profuse diaphoresis often occurs at night for first 2 to 3 days Urethra and bladder Excessive bleeding can occur because of displacement of the uterus if bladder is full

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. Sherese complains of perineal pain. She tells the nurse that she does not know what hurts worse, her episiotomy or her hemorrhoids. State the nursing diagnosis reflective of Sherese's complaint, one expected outcome, and appropriate relief measures.

Acute pain related to presence of a midline episiotomy and hemorrhoids Sherese will experience a reduction in pain following implementation of perineal relief measures. Appropriate relief measures include: - Fully assess Sherese's pain experience (character, location, severity) before taking action; determine if Sherese is allergic to any analgesics or topical medications. - Consider nonpharmacologic and local measures for pain relief because the pain is of perineal origin: -- Ice packs for the first 12 to 24 hours -- Sitz bath (after 24 hours) -- Perineal cleansing with soap and water, rinsing with peri (squeeze) bottle -- Maternal positioning to reduce pressure on perineum (e.g., side-lying) -- Topicals such as Tucks, Epifoam, Hurricaine gel, and Dermoplast spray - Inspect hemorrhoids, noting size and vascularity because this will influence plan-of-care options. - Consider pharmacologic relief measures if the pain is moderate to severe and/or the other measures are ineffective; be sure to determine safety of any medication for the lactating woman. - Emphasize to Sherese that pain relief is important so that she can rest and get ready to care for her baby. Evaluate effectiveness of any relief measures used. Use measures to enhance bowel elimination and prevent constipation.

Placental hormones

Expulsion of placenta results in dramatic decreases of placental-produced hormones Decreases in chorionic somatomammotropin (hCS), estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy Estrogen and progesterone levels drop markedly Pituitary hormones and ovarian function Lactating and nonlactating women differ in timing of first ovulation and menstruation 70% of nonbreastfeeding mothers menstruate within first 12 weeks In breastfeeding women, return of ovulation depends on breastfeeding patterns In nonlactating women, ovulation occurs as early as 27 days after birth

When helping a woman cope with postpartum blues, the nurse should offer what appropriate suggestions? (Select all that apply.) A. The father should take over care of the baby, because postpartum blues are exclusively a female problem. B. Get plenty of rest. C. Plan to get out of the house occasionally. D. Asking for help will not foster independence. E. Use La Leche League or community mental health centers.

B. Get plenty of rest. C. Plan to get out of the house occasionally. E. Use La Leche League or community mental health centers.

The maternity nurse promoting parental-infant attachment should incorporate which appropriate cultural beliefs into the plan of care? (Select all that apply.) A. Asian mothers are encouraged to return to work as soon as possible. B. Jordanian mothers have a 40-day lying-in after birth. C. Japanese mothers rest for the first 2 months after childbirth. D. Encourage Hispanics to eat plenty of fish and pork to increase vitamin intake. E. Encourage Vietnamese mothers to cuddle with the newborn.

B. Jordanian mothers have a 40-day lying-in after birth. C. Japanese mothers rest for the first 2 months after childbirth.

Thromboembolic conditions that are of concern during the postpartum period include (Select all that apply.) A. Amniotic fluid embolism (AFE) B. Superficial venous thrombosis C. Deep vein thrombosis D. Pulmonary embolism E. Disseminate intravascular coagulation (DIC)

B. Superficial venous thrombosis C. Deep vein thrombosis D. Pulmonary embolism A superficial venous thrombosis includes involvement of the superficial saphenous venous system. With deep vein thrombosis the involvement varies but can extend from the foot to the iliofemoral region. A pulmonary embolism is a complication of deep vein thrombosis occurring when part of a blood clot dislodges and is carried to the pulmonary artery, where it occludes the vessel and obstructs blood flow to the lungs. An AFE occurs during the intrapartum period when amniotic fluid containing particles of debris enters the maternal circulation. Although AFE is rare, the mortality rate is as high as 80%. DIC is an imbalance between the body's clotting and fibrinolytic systems. It's a pathologic form of clotting that consumes large amounts of clotting factors.

Herbal remedies have been used with some success to control PPH after initial management. Some herbs have homeostatic actions, whereas others work as oxytocic agents to contract the uterus. What herbal remedy is a commonly used oxytocic agent?

Blue cohosh *oxytocic agents that promote uterine contraction : Blue cohosh, cotton root bark, motherwort, and shepherd's purse *homeostatic remedies: -Witch hazel -Lady's mantel -Yarrow

A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? (Select all that apply.) A. Do not perform Kegel exercises to decrease pelvic floor muscle healing time. B. If breastfeeding, sexual interest may be delayed. C. Fatigue may affect interest in sexual activity. D. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. E. Water-soluble lubrication may increase comfort. F. The female-on-top position may be more comfortable than other positions.

C. Fatigue may affect interest in sexual activity. D. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. E. Water-soluble lubrication may increase comfort. F. The female-on-top position may be more comfortable than other positions.

After completing a postpartum assessment on woman who delivered 20 hours ago, the nurse should report which assessment findings to the health care provider? (Select all that apply.)

Pulse 110 beats/min Temperature 38° C During the first 24 hours postpartum, temperature may increase to 38° C (100.4° F) Pulse, remains elevated for the first hour or so after childbirth. It then begins to decrease to a nonpregnant rate. A rapid pulse may indicate hypovolemia. Respiratory rate is normal. Blood pressure is altered slightly if at all postpartum.

Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? (Select all that apply.) A. Postural hypotension B. Temperature of 100.4° F C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot E. Lochia rubra with foul odor

D. Pain in left calf with dorsiflexion of left foot E. Lochia rubra with foul odor

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. Sherese tells the nurse that one reason she chose to breast-feed is that she hates to use birth control and breast-feeding means that she will not have to use any until she weans her baby at about 10 months. How should the nurse respond to Sherese's comments?

Emphasize that breast-feeding is not a form of contraception because return of ovulation is unpredictable even for a woman who is breast-feeding; ovulation is delayed the longest for women who are complete breast-feeders (i.e., no bottle feeding or solid foods are used); for some women ovulation occurs before the first menstrual period after birth. Discuss safe methods to use: - Hormonally based contraceptives such as low-dose oral contraceptives, Norplant, and Depoprovera are used by some couples limitedly during postpartum because estrogen and progesterone can interfere with lactation unless it is well established; after 6 weeks, Progestin-only hormone contraception may have the least effect on lactation. - Barrier methods are safe and effective: -- Spermicide and condom can be used; spermicide may also act as an effective lubricant because vaginal dryness related to estrogen deprivation is common during lactation. -- A diaphragm may be used after 6 weeks when proper fitting can take place. - A copper IUD may be used and inserted in the early postpartum period; instruction must emphasize monogamy and scrupulous genital hygiene.

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. Outline the assessment components that should be given priority when monitoring the progress of Sherese's physiologic recovery during the fourth stage of labor.

Hemorrhage is the major concern during the fourth stage of labor; efforts are directed toward prevention, as well as early detection and intervention. Assessment should focus on: - Vital signs including blood pressure, pulse, respirations, and temperature - Fundus: consistency and location - Llochia: amount, characteristics, presence of clots - Perineum including condition of episiotomy or lacerations - REEDA (redness, edema, ecchymosis, drainage, approximation) - Swelling, excessive pain and pressure (possible hematoma formation), and condition of hemorrhoids - Condition of bladder including ability to void, presence of distension - Postepidural anesthesia recovery (return of sensation to legs and bladder) Assessments should be made on a frequent basis and documented fully and promptly: - Suggested frequency: every 15 minutes for the first hour, then if stable every 30 minutes for the next hour; continued frequency should be dependent on Sherese's physical recovery following birth - Findings should be compared with expected norms and with Sherese's previous findings; use of flow sheets facilitates comparison - Documentation should include assessment findings, action taken if findings are abnormal, and results of actions taken

immune system

Mildly suppressed during pregnancy, the immune system returns to its prepregnant state Rebound of the immune system can cause "flare-ups" of some conditions Lupus erythematosus Multiple sclerosis

Chloasma of pregnancy usually disappears at end of pregnancy

Persists in 30% of women

Vagina and perineum

Postpartum estrogen deprivation responsible for thinness of vaginal mucosa and absence of rugae Vaginal rugae reappear within 3 weeks Thickening of vaginal mucosa occurs with return of ovarian function Dryness and coital discomfort, dyspareunia, may persist until return of ovarian function Introitus is erythematous and edematous Episiotomies heal within 2 to 3 weeks May take 4 to 6 weeks to heal completely Hemorrhoids (anal varicosities) are common and decrease within 6 weeks of childbirth Pelvic muscular support Supportive tissues of pelvic floor torn or stretched during childbirth Require up to 6 months to regain tone Kegel exercises encourage healing

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. Sherese and her husband Kyle are worried about how they will manage when they go home with their new baby at 48 hours after birth. "We never even babysat when we were kids or helped take care of younger siblings." What can the nurse do to help Sherese and Kyle take care of their new baby effectively? Sherese also expresses concern about what will happen to the baby when she returns to work as a legal secretary in 6 weeks.

Promote parenting skills: - Help couple to get acquainted with their newborn by pointing out behaviors and characteristics when performing a newborn assessment in Sherese's room. - Arrange for classes and videos that demonstrate newborn care skills to be available before discharge. - Provide time for supervised practice of newborn care skills; offer positive reinforcement to enhance self-confidence. - Provide written materials and videos to take home and/or make suggestions for purchase. Discuss effective coping strategies: - Manage time appropriately by setting priorities that emphasize adequate rest and nutrition. - Mobilize support system to help. - Negotiate parental role functions—share responsibilities for newborn care, as well as essential household tasks. - Maintain open lines of communication; freely communicate concerns, feelings, fears, and frustrations to one another. - Arrange for time alone together. - Begin to plan for return to work now by determining how the baby will be cared for, arranging for a breast pump to be used while at work, etc. Implement discharge planning strategies: - Establish warm lines and follow-up phone calls. - Refer to parenting classes, new parent support groups, lactation consultant, and breast-feeding support groups like La Leche League. - Arrange for a home visit. - Make plans for the newborn's health care to begin after discharge.

Cardiac output

Remains increased for 48 hours after birth Increased stroke volume is caused by the return of blood to the maternal systemic circulation Stroke volume, end-diastolic volume, and systemic vascular resistance remain elevated for 12 weeks after delivery Vital signs Blood components Hematocrit and hemoglobin White blood cell count Coagulation factors Varicosities Total or nearly total regression of varicosities is expected after childbirth

Cervix

Soft immediately after birth During the next 12 to 18 hours the cervix shortens, becomes firm, and regains prepregnant form External os regains its prepregnancy appearance Cervical os, dilated to 10 cm during labor, closes gradually

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. During a home health care visit 4 days after birth, Sherese and Kyle ask the nurse about postpartum blues. They relate to the nurse that Sherese has been "feeling down" since coming home from the hospital 2 days ago. What approach should the nurse take in responding to this couple's concern?

Review the phases of maternal postpartum adjustment with Sherese and Kyle and discuss measures that would be helpful to facilitate progress through each state: - Taking-in: The first few days after birth is characterized by dependency; Sherese will seek to have her needs met with regard to comfort, rest, and nutrition, and she will need to review her childbirth experience. - Taking-hold: Lasting up to 4 to 5 weeks, this phase is characterized by vacillation between the need for dependence and independence; Sherese will seek to care for herself and her newborn and will need instruction and help to accomplish this. - Letting-go: This is the stage of interdependence when Sherese will give up the role of pregnant woman and take on the role of mother; she will reestablish her role as spouse to Kyle, career role as a legal secretary, and roles with support group such as daughter, sister, and friend; Sherese will need help in planning her return to work and sharing the care of her infant with others so that she can resume her roles. Describe the postpartum blues in terms of what they are and why they happen. - Why: hormonal changes, effect of fatigue and discomfort, changing relationships, role strain with added responsibilities for newborn care, frustrations/diminished confidence taking on the role of mother - When: 2 to 3 days after birth and again at about 1 month postpartum; duration is 3 to 7 days - What: irritability, moodiness, restlessness, crying spells, sleepiness, anxiety, and withdrawal Discuss strategies to help Sherese cope with postpartum blues in an effective manner; include Kyle in the discussion because he is affected by Sherese's emotions and is important in helping her to cope. - Recognize that the blues are normal and of limited duration. - Take care of self with proper rest, nutrition, and time away from baby and responsibilities with friends and with Kyle. - Keep lines of communication open with each other and with a support group. - Initiate time management that recognizes the importance of setting priorities and sharing responsibilities with each other and with a support group. - Provide Sherese with positive reinforcement for her efforts. - Use community resources for support and information: parenting groups and classes, lactation consultant, etc. - Prepare early for Sherese's return to work. - Contact your health care provider for follow-up if blues persist for more than 2 weeks.

Sherese, a primigravida, gave birth to a full-term, 7-lb 8-oz boy 30 minutes ago. Her placenta was intact and normal in appearance and size. Currently, her fundus is firm, at the umbilicus, and midline; her lochia is moderate rubra with no odor and a few small clots. A midline episiotomy was performed during the birth process. Sherese has several large hemorrhoids that first developed late in the third trimester and increased in size as a result of her bearing-down efforts. Epidural anesthesia was used during labor and birth. Sherese plans to breast-feed her baby. State the priority nursing diagnosis for Sherese during the fourth stage of labor; cite one expected outcome for the nursing diagnosis you identified.

The priority nursing diagnosis for the fourth stage of labor is: risk for deficient fluid volume related to blood loss associated with vaginal birth; this diagnosis reflects the major postpartum complication during the first 24 hours following birth, which is postpartum hemorrhage. It most commonly results from uterine atony. An expected outcome would be that Sherese will exhibit a firm uterus and moderate lochial flow.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:

take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

Breasts

become fuller and heavier, estimate when milk comes in (72 to 96 hours after birth) Nonbreastfeeding mothers: Engorgement resolves spontaneously, and discomfort decreases within 24 to 36 hours

Although subinvolution of the uterus and ITP are serious conditions, they do not always require immediate treatment. ITP can be safely managed with

corticosteroids or IV immunoglobulin.

Despite popular belief, there is a rare type of hemophilia that affects women of childbearing age. von Willebrand disease is the most common of the hereditary bleeding disorders and can affect males and females alike. It results from a factor VIII deficiency and platelet dysfunction. Although factor VIII levels increase naturally during pregnancy, there is an increased risk for postpartum hemorrhage from birth until 4 weeks postpartum as levels of von Willebrand factor (vWf) and factor VIII decrease. The treatment that should be considered first for the client with von Willebrand disease who experiences a postpartum hemorrhage is:

desmopressin This hormone can be administered orally, nasally, and intravenously. This medication promotes the release of factor VIII and vWf from storage. Cryoprecipitate may be used; however, because of the risk of possible donor viruses, other modalities are considered safer. Treatment with plasma products, such as factor VIII and vWf, are an acceptable option for this client. Because of the repeated exposure to donor blood products and possible viruses, this is not the initial treatment of choice.

Common nursing interventions in the postpartum period include the following:

evaluating and treating the boggy uterus and the full urinary bladder; providing for nonpharmacologic and pharmacologic relief of pain and discomfort associated with the episiotomy, lacerations, afterbirth pains, or breastfeeding; and instituting measures to promote or suppress lactation.

A woman gave birth to a 7-lb, 3-oz boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:

excessive uterine bleeding.

Excessive blood loss after childbirth can have several causes; however, the most common is:

failure of the uterine muscle to contract firmly.

Postpartum headaches may be caused by

gestational hypertension, stress, and leakage of cerebrospinal fluid into extradural space during placement of spinal anesthesia

Parents can facilitate the adjustment of their other children to a new baby by:

having the children choose or make a gift to give to the new baby on its arrival home.

A client is receiving oxytocin (Pitocin) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions?

hypertension and tachycardia

When bleeding is continuous and there is no identifiable source, coagulopathy can be the cause. The woman's coagulation status must be assessed quickly and continuously. Causes of coagulopathies can include pregnancy complications such as

idiopathic or immune thrombocytopenic purpura (ITP), von Willebrand disease (vWD), or DIC

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:

massage her fundus. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

Postpartum women experience an increased risk for urinary tract infection. A prevention measure the nurse could teach the postpartum woman would be to:

perform perineal care on a regular basis. Urine is acidified with cranberry juice. The woman should drink at least 3 L of fluid each day. The woman should empty her bladder every 2 hours to prevent stasis of urine. Keeping the perineum clean will help prevent a urinary tract infection.

Early ambulation is associated with a reduced incidence of venous thromboembolism (VTE); it also promotes the return of strength. Free movement is encouraged once anesthesia wears off unless an opioid analgesic has been administered.

true

• Pregnancy-induced hypervolemia, combined with several postpartum physiologic changes, allows the woman to tolerate considerable blood loss at birth.

true

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for FURTHER INSTRUCTION if the woman:

uses the peribottle to rinse upward into her vagina.

The breasts of a bottle-feeding woman are engorged. The nurse should tell her to:

wear a snug, supportive bra.

The rapid decrease in estrogen and progesterone levels after expulsion of the placenta is responsible for triggering many of the anatomic and physiologic changes in the puerperium.

• Assessment of lochia and fundal height is essential to monitor the progress of normal involution and to identify potential problems.

• The return of ovulation and menses is determined in part by whether the woman breastfeeds her infant

• During the first 24 hours after birth, there is little, if any, change in the breast tissue. The breasts gradually become fuller and heavier as the colostrum transitions to mature milk by about 72 to 96 hours after birth

taking in phase

- express a strong need to review events and her behavior during the process of labor and birth. - exhibit a reduced attention span, limiting readiness to learn.

s/s of postpartum infection

-Fever, chills -Pain or redness of wounds -Purulent wound drainage or wound edges not approximated -Tachycardia -Uterine subinvolution -Abnormal duration of lochia, foul odor -Elevated white blood cell count -Frequency or urgency of urination, dysuria, or hematuria -Suprapubic pain -Localized area of warmth, redness or tenderness in breasts -Body aches, general malaise

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

assist the woman to empty her bladder. A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

massage the woman's fundus. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

. When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically:

vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. *taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth*