Postpartum Period
The nurse is assessing a client at her postpartum checkup 6 weeks after a vaginal delivery. The mother is bottle feeding her baby. Which client finding indicates a problem at this time? A) Firm fundus at the symphysis. B) White, thick vaginal discharge. C) Striae that are silver in color. D) Soft breasts without milk.
A) Firm fundus at the symphysis. Reason: By 4 to 6 weeks postpartum, the fundus should be deep in the pelvis and the size of a nonpregnant uterus. Subinvolution, caused by infection or retained placental fragments, is a problem associated with a uterus that is larger than expected at this time. Normal expectations include a white, thick vaginal discharge, striae that are beginning to fade to silver, and breasts that are soft without evidence of milk production (in a bottle-feeding mother).
While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. Which of the following should the nurse do next? A) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. B) Ask the client to assume a side-lying position with the knees flexed. C) Perform massage vigorously at the level of the umbilicus if the fundus feels boggy. D) Place the client on a bedpan in case the uterine palpation stimulates the client to void.
A) Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus. Reason: The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.
The nurse is caring for several mother-baby couplets. In planning the care for each of the couplets, which mother would the nurse expect to have the most severe afterbirth pains? A) G 4, P 1 client who is breastfeeding her infant. B) G 3, P 3 client who is breastfeeding her infant. C) G 2, P 2 cesarean client who is bottle-feeding her infant. D) G 3, P 3 client who is bottle-feeding her infant
B) G 3, P 3 client who is breastfeeding her infant. Reason: The major reasons for afterbirth pains are breast-feeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots. Physiologically, afterbirth pains are caused by intermittent contraction and relaxation of the uterus. These contractions are stronger in multigravidas in order to maintain a contracted uterus. The release of oxytocin when breast-feeding also stimulates uterine contractions. There is no data to suggest any of these clients has had an overdistended uterus or currently has clots within the uterus. The G 3, P 3 client who is breast-feeding has the highest parity of the clients listed, which—in addition to breast-feeding—places her most at risk for afterbirth pains. The G 2, P 2 post cesarean client may have cramping but it should be less than the G 3, P 3 client. The G 3, P 3 client who is bottle-feeding would be at risk for afterbirth pains because she has delivered several children, but her choice to bottle-feed reduces her risk of pain.
A primiparous client at 4 hours after a vaginal delivery and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the physician based on the interpretation that the assessment indicates which of the following? A) Perineal lacerations. B) Retained placental fragments. C) Cervical lacerations. D) Urine retention.
B) Retained placental fragments. Reason: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever the placenta is manually removed after delivery, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs and symptoms associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urine retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.
After being treated with heparin therapy for thrombophlebitis, a multiparous client who delivered 4 days ago is to be discharged on oral warfarin (Coumadin). After teaching the client about the medication and possible effects, which of the following client statements indicates successful teaching? A) "I can take two aspirin if I get uterine cramps." B) "Protamine sulfate should be available if I need it." C) "I should use a soft toothbrush to brush my teeth." D) "I can drink an occasional glass of wine if I desire."
C) "I should use a soft toothbrush to brush my teeth." Reason: Successful teaching is demonstrated when the client says, "I should use a soft toothbrush to brush my teeth." Heparin therapy can cause the gums to bleed, so a soft toothbrush should be used to minimize this adverse effect. Use of aspirin and other nonsteroidal anti-inflammatory medications should be avoided because of the increased risk for possible hemorrhage. Protamine sulfate is the antidote for heparin therapy. Vitamin K is the antidote for warfarin excess. Alcohol can inhibit the metabolism of oral anticoagulants and should be avoided.
A client is experiencing an early postpartum hemorrhage. Which item in the client's care plan requires revision? A) Inserting an indwelling urinary catheter B) Fundal massage C) Administration of oxytocics D) Pad count
D) Pad count Reason: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine contraction.
On the second postpartum day a gravida 6, para 5 complains of intermittent abdominal cramping. The nurse should assess for: A) endometritis. B) postpartum hemorrhage. C) subinvolution. D) after pains.
D) after pains. Reason: In a multiparous client, decreased uterine muscle tone causes alternating relaxation and contraction during uterine involution, which leads to after pains. The client's symptoms don't suggest endometritis, hemorrhage, or subinvolution.