PrepU: Chapter 22: Nursing Management of the Postpartum Woman at Risk

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Whch sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

Weak and rapid pulse

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breast-feeding.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus (S. aureus)

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

Assess the woman's fundus.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?"

The nurse is planning interventions to prevent the onset of urinary retention in a postpartum patient. Why are these interventions needed?

Decreased bladder sensation results from edema because of pressure of birth.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

A client who had a nonelective cesarean birth

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing?

Administering an enema

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema.

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus.

Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings

A nurse is a caring for a postpartum client. What instruction should the nurse provide to the client as a precautionary measure to prevent thromboembolic complications?

Avoid sitting in one position for long periods of time.

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time?

Breast-feeding can continue.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia.

A postpartum patient is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient?

Measure blood pressure.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate.

A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation?

Massage the fundus

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus.

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?

Patient is chatting on the telephone with a friend.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing.

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?

She should continue to breast-feed; mastitis will not infect the neonate.

The nurse palpates a postpartal woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The clien's bladder is distended and is causing the uterus to deviate to the right.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding?

White plaques in the mouth

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure

A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth?

postpartal hemorrhage

A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question?

Administration of an enema

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums."

The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

A new mother is diagnosed with a venous thromboembolism in her left calf. Which risk factor is associated with this problem? Select all that apply.

- cesarean birth -obesity

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

-decreased interest in life -inability to concentrate -loss of confidence

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

Applying ice

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings.

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?

Encourage to continue breast-feeding.

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination?

The client has a history of epidural anesthesia.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed

The nurse is concerned that a postpartum patient with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this patient?

Weak and rapid pulse

The nurse is caring for a woman who delivered via a cesarean delivery approximately 16 hours earlier. Which assessment finding should the nurse prioritize?

Steadily decreasing volume of urine

A client develops mastitis 3 weeks after giving birth. What part of client self-care is emphasized as most important?

Breastfeed or otherwise empty her breasts every 1 to 2 hours

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void

A postpartal woman is prescribed an antibiotic because of endometritis. Her breast-fed infant should be observed particularly for which of the following?

Signs of thrush and easy bruising

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?

impaired urinary elimination

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

Teach that adequate hydration helps clear the infection quicker.