Maternity-Post-Partum
The nurse has provided discharge instructions to a client who delivered a healthy newborn by cesarean delivery. Which statement made by the client indicates a need for further instruction? "I will begin abdominal exercises immediately." "I will notify my obstetrician if I develop a fever." "I will turn on my side and push up with my arms to get out of bed." "I will lift nothing heavier than my newborn baby for at least 2 weeks."
1 A cesarean delivery requires an incision made through the abdominal wall and into the uterus. Abdominal exercises should not start immediately after abdominal surgery; the client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision.
The nurse is providing instructions to a pregnant client with human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? "You will need to bottle-feed your newborn." "You will need to feed your newborn by nasogastric tube feeding." "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."
1 Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV will most likely be advised not to breast-feed; however, PHCPs recommendations regarding breast-feeding are always followed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? Providing sitz baths Encouraging fluid intake Placing ice on the perineum Monitoring hemoglobin and hematocrit levels
2 Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day if not contraindicated. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage.
The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate? Raise the head of the client's bed. Obtain hemoglobin and hematocrit levels. Instruct the client to request help when getting out of bed. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
3 Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to focus interventions on the client's safety. The nurse should advise the client to get help the first few times she gets out of bed.
On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? "I need to urinate frequently throughout the day." "The prescribed medication must be taken until it is finished." "My fluid intake should be increased to at least 3000 mL daily." "Foods and fluids that will increase urine alkalinity should be consumed."
4 A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client should also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? The client with mild afterpains The client with a pulse rate of 60 beats per minute The client with colostrum discharge from both breasts The client with lochia that is red and has a foul-smelling odor
4 Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client.
The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action should the nurse take? Provide oral fluids and begin fundal massage. Begin hourly pad counts and reassure the client. Elevate the head of the bed and assess vital signs. Assess for hypovolemia and notify the primary health care provider (PHCP).
4 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 PHCP. Providing oral fluids and beginning fundal massage and beginning hourly pad counts and reassuring the client will delay necessary treatment. Also, the question gives no indication of the cause of the hypovolemia or that the client is hemorrhaging and that fundal massage is needed. The head of the bed is not elevated in a hypovolemic condition.
The postpartum nurse is taking the vital signs of a client who delivered a healthy newborn 4 hours ago. The nurse notes that the client's temperature is 100.2° F. What is the priority nursing action? Document the findings. Notify the obstetrician. Retake the temperature in 15 minutes. Increase hydration by encouraging oral fluids
4 The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4° F (38° C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase hydration. Taking the temperature in another 15 minutes is an unnecessary action. Contacting the obstetrician is not necessary.
The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function? 3 days postpartum 7 days postpartum On the day of birth Within 2 weeks postpartum
1 After birth, the nurse should auscultate the client's abdomen in all 4 quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days postpartum. Surgery, anesthesia, and the use of opioids and pain control agents also contribute to the longer period of altered bowel functions.
The nurse is teaching a postpartum client about breast-feeding. Which instruction should the nurse include? The diet should include additional fluids. Prenatal vitamins should be discontinued. Soap should be used to cleanse the breasts. Birth control measures are unnecessary while breast-feeding.
1 The diet for a breast-feeding client should include additional fluids. Prenatal vitamins should be taken as prescribed, and soap should not be used on the breasts because it tends to remove natural oils, which increases the chance of cracked nipples. >>Breast-feeding is not a method of contraception, so birth control measures should be resumed<<
The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client? Client pain level Inadequate urinary output Client perception of body changes Potential for imbalanced body fluid volume
1 The priority nursing consideration for a client who delivered 2 hours ago and who has an episiotomy and hemorrhoids is client pain level. Most clients have some degree of discomfort during the immediate postpartum period. There are no data in the question that indicate inadequate urinary output, the presence of client perception of body changes, and potential for imbalanced body fluid volume.
A stillborn baby was delivered in the birthing suite a few hours ago. After the delivery, the family remained together, holding and touching the baby. Which statement by the nurse would assist the family in their period of grief? "What can I do for you?" "Now you have an angel in heaven." "Don't worry, there is nothing you could have done to prevent this from happening." "We will see to it that you have an early discharge so that you don't have to be reminded of this experience."
1 When a loss or death occurs, the nurse should ensure that parents have been honestly told about the situation by their primary health care provider or others on the health care team. It is important for the nurse to be with the parents at this time and to use therapeutic communication techniques. The nurse must also consider cultural and religious/ spiritual practices and beliefs
The nurse is providing postpartum instructions to a client who will be breast-feeding her newborn. The nurse determines that the client has understood the instructions if she makes which statements? Select all that apply. "I should wear a bra that provides support." "Drinking alcohol can affect my milk supply." "The use of caffeine can decrease my milk supply." "I will start my estrogen birth control pills again as soon as I get home." "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
1, 2, 3, 6 The postpartum client should wear a bra that is well fitted and supportive. Common causes of decreased milk supply include formula use; inadequate rest or diet; smoking by the mother or others in the home; and use of caffeine, alcohol, or medications. Breast-feeding clients should increase their daily fluid intake; having bottled water available indicates that the postpartum client understands the importance of increasing fluids. If engorgement occurs, the client should not limit breast-feeding but should breast-feed frequently. Oral contraceptives containing estrogen are not recommended for breast-feeding mothers.
The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. Wear a supportive bra. Rest during the acute phase. Maintain a fluid intake of at least 3000 mL/day. Continue to breast-feed if the breasts are not too sore. Take the prescribed antibiotics until the soreness subsides. Avoid decompression of the breasts by breast-feeding or breast pump.
1,2,3,4 Mastitis is an inflammation of the lactating breast as a result of infection. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day (if not contraindicated), 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 breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? A temperature of 100.4° F (38° C) An increase in the pulse rate from 88 to 102 beats per minute A blood pressure change from 130/88 to 124/80 mm Hg An increase in the respiratory rate from 18 to 22 breaths per minute
2 During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. An increasing pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for reduced blood volume. A slight increase in temperature is normal. The blood pressure decreases as the blood volume diminishes, but a decreased blood pressure would not be the earliest sign of hemorrhage. The respiratory rate is slightly increased from normal.
The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate? Elevate the client's legs. Massage the fundus until it is firm. Ask the client to turn on her left side. Push on the uterus to assist in expressing clots.
2 If the uterus is not contracted firmly, the initial intervention is to massage the fundus until it is firm and to express clots that may have accumulated in the uterus. Elevating the client's legs and positioning the client on the side would not assist in managing uterine atony. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage.
The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? Infection Hemorrhage Chronic hypertension Disseminated intravascular coagulation
2 In placenta previa, the placenta is implanted in the lower uterine segment. The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding.
When performing a postpartum 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 nursing action is most appropriate? Document the findings. Notify the obstetrician (OB). Reassess the client in 2 hours. Encourage increased oral intake of fluids.
2 Normally, a few small clots may be noted in the lochia 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 appropriate action is to notify the OB. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation.
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only briefly with her fingertips. What should the nurse do to help the woman process the delivery? Encourage the mother to breast-feed soon after birth. Support the mother in her reaction to the newborn infant. Tell the mother that it is important to hold the newborn infant. Document a complete account of the mother's reaction on the birth record.
2 Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe feelings of disbelief that their labor progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant.
A rubella titer result of a 1-day postpartum client is less than 1:8, and a rubella virus vaccine is prescribed to be administered before discharge. The nurse provides which information to the client about the vaccine? Select all that apply. Breast-feeding needs to be stopped for 3 months. Pregnancy needs to be avoided for 1 to 3 months. The vaccine is administered by the subcutaneous route. Exposure to immunosuppressed individuals needs to be avoided. A hypersensitivity reaction can occur if the client has an allergy to eggs. The area of the injection needs to be covered with a sterile gauze for 1 week.
2, 3, 4, 5 Rubella vaccine is administered to women who have not had rubella or women who are not serologically immune. The vaccine may be administered in the immediate postpartum period to prevent the possibility of contracting rubella in future pregnancies. -The live attenuated rubella virus is not communicable in breast milk; breast-feeding does not need to be stopped. -The client is counseled not to become pregnant for 1 to 3 months after immunization or as specified by the obstetrician because of a possible risk to a fetus from the live virus vaccine; the client must be using effective birth control at the time of the immunization. -The client should avoid contact with immunosuppressed individuals because of their low immunity toward live viruses and because the virus is shed in the urine and other body fluids. -The vaccine is administered by the subcutaneous route. A hypersensitivity reaction can occur if the client has an allergy to eggs because the vaccine is made from duck eggs. There is no useful or necessary reason for covering the area of the injection with a sterile gauze.
The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, indicates a complication related to a laceration of the birth canal? Presence of dark red lochia Palpation of the uterus as a firm, contracted ball The saturation of more than 1 peripad per hour Palpation of the fundus at the level of the umbilicus
3 Saturation of more than 1 peripad per hour is considered excessive even in the early postpartum period. In the first 24 hours after birth, the uterus will feel like a firmly contracted ball, roughly the size of a large grapefruit. One easily can locate the uterus at the level of the umbilicus. Lochia should be dark red and moderate in amount.
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? A primiparous client who delivered 4 hours ago A multiparous client who delivered 6 hours ago A multiparous client who delivered a large baby after oxytocin induction A primiparous client who delivered 6 hours ago and had epidural anesthesia
3 The causes of postpartum hemorrhage include uterine atony; laceration of the vagina; hematoma development in the cervix, perineum, or labia; and retained placental fragments. -Predisposing factors for hemorrhage include a previous history of postpartum hemorrhage, placenta previa, abruptio placentae, overdistention of the uterus from polyhydramnios, multiple gestation, a large neonate, infection, multiparity, dystocia or labor that is prolonged, operative delivery such as a cesarean or forceps delivery, and intrauterine manipulation. -The multiparous client who delivered a large fetus after oxytocin induction has more risk factors associated with postpartum hemorrhage than do other clients.
The nurse evaluates the ability of a hepatitis B-positive mother to provide safe bottle-feeding to her newborn during postpartum hospitalization. Which maternal action best exemplifies the mother's knowledge of potential disease transmission to the newborn? The mother requests that the window be closed before feeding. The mother holds the newborn properly during feeding and burping. The mother tests the temperature of the formula before initiating feeding. The mother washes and dries her hands before and after self-care of the perineum and asks for a pair of gloves before feeding.
4 Hepatitis B virus is highly contagious and is transmitted by direct contact with blood and body fluids of infected persons. The rationale for identifying childbearing clients with this disease is to provide adequate protection of the fetus and the newborn, to minimize transmission to other individuals, and to reduce maternal complications. The correct option provides the best evaluation of maternal understanding of disease transmission