Nursing Management During the Postpartum Period
Which of the following would the nurse include when teaching the parents of a newborn who have a 2-year-old boy at home? a) "Ask your 2-year-old to pick out a special toy for his sister." b) "Talk to your 2-year-old about the baby when you're driving him to day care." c) "Have your 2-year-old stay at home while you're here in the hospital." d) "Expect to see your 2-year-old become more independent when the baby gets home."
"Ask your 2-year-old to pick out a special toy for his sister." Explanation: The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.
After teaching a postpartum woman about postpartum blues, which statement indicates effective teaching? a) "I might feel like laughing one minute and crying the next." b) "I should call this support line only if I hear voices." c) "If the symptoms last more than a few days, I need to call my doctor." d) "I'll need to take medication to treat the anxiety and sadness."
"I might feel like laughing one minute and crying the next." Explanation: Emotional lability is typical of postpartum blues. Further evaluation is necessary if symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication. Support lines can be used whenever the woman feels down.
A mother just delivered 3 hours ago. The nurse enters the room to continue hourly assessments and finds the patient on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? a) "You have a beautiful baby, why worry about that now?" b) "If you plan to breastfeed, you need to calm down." c) "It sounded like you had quite a time getting here. Would you like to continue your story?" d) "I need to assess your fundus now."
"It sounded like you had quite a time getting here. Would you like to continue your story?" Explanation: The mother is going through the taking-in phase of relating events during her pregnancy and delivery. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.
A G1 P1001 mother is just home after delivering her first child 5 days ago. Her delivery was complicated by an emergency cesarean delivery resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this patient care issue is a) At risk for inadequate healing due to decreased nutrition b) At risk for interruption of tissue integrity c) At risk for safety due to low hemoglobin d) At risk for postpartum depression due to inadequate rest
At risk for postpartum depression due to inadequate rest Explanation: This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.
Which of the following findings would lead you to suspect that a woman is developing a postpartum complication? a) An absence of lochia b) Red-colored lochia for the first 24 hours c) Lochia that is the color of menstrual blood d) Lochia appearing pinkish-brown on the fourth day
An absence of lochia Explanation: Women should have a lochia flow following childbirth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.
When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? a) Ask the client when she last changed her perineal pad. b) Immediately call the primary care provider. c) Vigorously massage the fundus. d) Have the charge nurse review the assessment.
Ask the client when she last changed her perineal pad. Explanation: If the morning assessment is done relatively yearly, it's possible that the client hasn't yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, wouldn't be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse wouldn't want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.
Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to a) Assess and massage the fundus b) Increase the flow of an IV c) Inspect the perineum for lacerations d) Call the physician or the nurse-midwife
Assess and massage the fundus Explanation: This woman is a multigravida who delivered a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
Elevation of a patient's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? a) When the elevated temperature exceeds 100.4° F b) After any period of decreased intake c) During the first 24 hours after delivery owing to dehydration from exertion d) When the white blood cell count is less than 10,000/mm³
During the first 24 hours after delivery owing to dehydration from exertion Explanation: Rapid breathing during labor and delivery and limited oral intake can cause a self-limited period of dehydration that is resolved after delivery by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.
A mother delivered 90 minutes ago and has just arrived to her room on the postpartum unit. Her initial set of vital signs reveals blood pressure of 138/86. Her blood pressure during labor never rose above 128/74. What is a possible explanation for this increase in blood pressure? a) She is having an allergic reaction to Pitocin. b) Her stroke volume has increased after delivery of the placenta, and a physiologic response in blood pressure is evident. c) Her stroke volume should decrease after delivery; this reflects a pathologic adjustment of her blood pressure. d) The patient is excited to have a chance to sleep after the labor and delivery experience.
Her stroke volume has increased after delivery of the placenta, and a physiologic response in blood pressure is evident. Explanation: When stroke volume increases after delivery of the placenta, the increase in blood volume can cause increased blood pressure. Blood pressure will stabilize as diuresis reduces the circulating blood volume.
A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient? a) The patient needs to walk to the bathroom more often. b) The patient will have to call for the nurse's help more often. c) Increased intake will rehydrate the patient and decrease her skin temperature. d) Increased intake will increase the patient's output and therefore will provide an opportunity for more frequent perineal self-care.
Increased intake will rehydrate the patient and decrease her skin temperature. Explanation: The perception of increased skin temperature a short time post delivery is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature. Information is insufficient to suggest the presence of infection. Goals of more frequent perineal care and ambulation, as well as reinforcement of patient teaching, are not appropriate in this situation.
Inspection of a woman's perineal pad reveals a 5-inch stain. The nurse documents this amount as which of the following? a) Scant b) Moderate c) Light d) Heavy
Moderate Explanation: Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.
Which of the following factors in a postpartum woman's history would lead the nurse to watch the woman closely for an infection? a) Hemoglobin of 11.5 mg/dL b) Placenta removed via manual extraction c) Labor of 12 hours d) Multiparity
Placenta removed via manual extraction Explanation: Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum hemorrhage.
You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits? a) The flow contains large clots. b) The color of the flow is red. c) Her uterus is soft to your touch. d) The flow is over 500 mL.
The color of the flow is red. Explanation: A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.
A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100 degrees F. Which action would be most appropriate? a) Continue to monitor the woman's temperature every 4 hours; this finding is normal. b) Obtain a urine culture; the woman most likely has a urinary tract infection. c) Inspect the perineum for hematoma formation. d) Notify the health care provider about this elevation; this finding reflects infection.
Continue to monitor the woman's temperature every 4 hours; this finding is normal. Explanation: A temperature of 100.4 degrees F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the physician, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum), because this finding is normal
A woman gave birth vaginally approximately 12 hours ago and her temperature is now 100 degrees F. Which action would be most appropriate? a) Continue to monitor the woman's temperature every 4 hours; this finding is normal. b) Obtain a urine culture; the woman most likely has a urinary tract infection. c) Inspect the perineum for hematoma formation. d) Notify the health care provider about this elevation; this finding reflects infection.
Continue to monitor the woman's temperature every 4 hours; this finding is normal. Explanation: A temperature of 100.4 degrees F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the physician, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum), because this finding is normal.
Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? a) Lochia is less than usual b) Uterus is firm c) Bladder is nonpalpable d) Percussion reveals dullness
Percussion reveals dullness Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at: a) Between the umbilicus and symphysis pubis b) The level of the umbilicus c) 2 cm below the umbilicus d) 1 cm below the umbilicus
The level of the umbilicus Explanation: Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
Choice Multiple question - Select all answer choices that apply. Given that the first 24 hours after delivery is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply. a) Fundus one fingerbreadth above umbilicus b) Moderate saturation of peripad every 3 hours c) Inverted nipples following breastfeeding d) Hypotonic bowel sounds e) Urination of 50 mL every hour
• Fundus one fingerbreadth above umbilicus • Moderate saturation of peripad every 3 hours Explanation: A fundus can rise to slightly above or below the umbilicus in the first 24 hours, and moderate saturation of 2/3 of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and 50 mL urine is inadequate given the occurrence of diuresis.
A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." Which response by the nurse would be least helpful? a) "Some babies latch on and catch on quickly; others take a little more time." b) "Some women just can't breast-feed. Maybe you're one of these women." c) "Breast-feeding takes time. Let's see what's happening." d) "Let me contact our lactation specialist and together maybe we can work through this."
"Some women just can't breast-feed. Maybe you're one of these women." Explanation: This response ignores the woman's feelings and displays a negative attitude, indicating that the woman is at fault for the current situation. The woman needs reassurance that she can breast-feed and accomplish the task. She needs to understand that although breast-feeding is a natural process, it takes time and practice. By offering to observe her breast-feeding, the nurse offers support and can provide the woman with some practical suggestions as necessary. The statement that some babies need more time would reduce her frustration and uncertainty about her ability to breast-feed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.
A woman who delivered 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, he notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this patient? a) The patient will have to call for the nurse's help more often. b) Increased intake will rehydrate the patient and decrease her skin temperature. c) The patient needs to walk to the bathroom more often. d) Increased intake will increase the patient's output and therefore will provide an opportunity for more frequent perineal self-care.
Increased intake will rehydrate the patient and decrease her skin temperature. Explanation: The perception of increased skin temperature a short time post delivery is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature. Information is insufficient to suggest the presence of infection. Goals of more frequent perineal care and ambulation, as well as reinforcement of patient teaching, are not appropriate in this situation.
Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT a) Discuss methods that the woman will use to prevent infection b) List signs of infection that she will report to her health care provider c) The patient will show no signs of infection d) Maintain previous household routines to prevent infection
Maintain previous household routines to prevent infection Explanation: The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.
A patient delivered 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the patient was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the physician and the nurse-midwife to her concern that the patient may be experiencing a) Pulmonary embolism b) Thrombophlebitis c) Upper respiratory infection d) Mitral valve collapse
Pulmonary embolism Explanation: These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.
Choice Multiple question - Select all answer choices that apply. Patient teaching is conducted throughout a patient's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? a) Resumption of prepregnancy diet b) Signs and symptoms of infection c) Infant formula selection d) Resumption of intercourse e) Activity
• Resumption of intercourse • Activity • Signs and symptoms of infection Explanation: The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her prepregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.