Saunders Postpartum Period
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 n eed for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I develop a fever." 3. "I will turn on my side and push up with my arms to get out of bed." 4. "I will lift nothing heavier than my newborn baby for at least 2 weeks."
1 Rationale: 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. Options 2, 3, and 4 are appropriate instructions for the client after a cesarean delivery. Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Keeping in mind that the client had a cesarean delivery and noting the word immediately in the correct option will assist in directing you to this option. Review: Home care instructions for a client after cesarean delivery
The nurse is teaching a postpartum client about breast-feeding.Which instruction should the nurse include? 1. The diet should include additional fluids. 2. Prenatal vitamins should be discontinued. 3. Soap should be used to cleanse the breasts. 4. Birth control measures are unnecessary while breast-feeding.
1 Rationale: 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. Test-Taking Strategy: Note the subject, teachingfor the breastfeeding client. Remember that fluids and calories should be increased when the client is breast-feeding. Review: Breast-feeding Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning
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? 1. A temperature of 100.4 °F (38 °C) 2. An increase in the pulse rate from 88 to 102 beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg 4. An increase in the respiratory rate from 18 to 22 breaths/minute
2 Rationa le: 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. Test-Taking Strategy: Note the strategic word, early. Think about the physiological occurrences of hemorrhage and shock and the expected findings in the postpartum period. This should assist in directing you to the correct option. Review: Early signs of h emor rh age
A postpartum client is diagnosed with cystitis. The nurse should plan for which priority action in the care of the client? 1. Providing sitz baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels
2 Rationale: 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. Test-Taking Strategy: Focus on the subject, measures to treat cystitis, and note the str ategic word, priority. Remember that increased fluids are a priority intervention. Review: Interventions for a client with cystitis
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? 1. Elevate the client's legs. 2. Massage the fundus until it is firm. 3. Ask the client to turn on her left side. 4. Push on the uterus to assist in expressing clots.
2 Rationale: 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. Test-Taking Strategy: Focus on the subject, a soft and boggy uterus. Visualize the procedure and recall the therapeutic management for uterine atony. Remember that a full bladder displaces the uterus. Review: Fundal assessment
After a precipitous delivery, the nurse notes that the new mother is passive and touches her newborn infant only brieflywith her fingertips.What should the nurse do to help the woman process the delivery? 1. Encourage the mother to breast-feed soon after birth. 2. Support the mother in her reaction to the newborn infant. 3. Tell the mother that it is important to hold the newborn infant. 4. Document a complete account of the mother's reaction on the birth record.
2 Rationale: 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. Options 1, 3, and 4 do not acknowledge the client's feelings. Test-Taking Strategy: Use therapeutic communication techniques. The correct option is the only option that acknowledges the client's feelings. Review: Use of therapeutic communication techniques following delivery
On assessment of a postpartum client, the nurse notes that the uterus feels soft and boggy. The nurse should take which initial action? 1. Document the findings. 2. Elevate the client's legs. 3. Massage the fundus until it is firm. 4. Push on the uterus to assist in expressing clots
3 Rationa le: If the uterus is not contracted firmly (i.e., it is soft and boggy), the initial intervention is to massage the fundus until it is firm and to express clots thatmayhave accumulated in the uterus. Elevating the client's legs would not assist in managing uterine atony. Documenting the findings is an appropriate action, but is not the initial action. Pushing on an uncontracted uterus can invert the uterus and cause massive hemorrhage. Test-Taking Strategy: Note the str ategic word, initial, in the question. Focus on the subject, that the uterus is soft and boggy. Recalling the therapeuticmanagement for uterine atony will assist in directing you to the correct option. Review: Therapeutic management of the client with uterine atony
The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially? 1. Document the finding. 2. Encourage the client to ambulate. 3. Encourage the client to increase fluid intake. 4. Contact the health care provider (HCP) and inform the HCP of this finding.
4 Rationa le: Lochia is the discharge from the uterus in the postpartum period; it consists of blood from the vessels of the placental site and debris from the decidua. The following can be used as a guide to determine the amount of flow: scant¼less than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light¼less than 10 cm (< 4 inches) on menstrual pad in 1 hour;moderate¼ less than 15 cm (< 6 inches) on menstrualpad in 1 hour;heavy¼ saturated menstrual pad in 1 hour; and excessive¼menstrual pad saturated in 15 minutes. If the client is experiencing excessive bleeding, the nurse should contact the HCP in the event that postpartum hemorrhage is occurring. It may be appropriate to encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Test-Taking Strategy: Note the strategic word, initially. Focus on the data in the question, a saturated perineal pad in 15 minutes. Next, determine if an abnormality exists. The data and the use of guidelines to determine the amount of lochial flow will help you to determine that this is abnormal and warrants notification of the HCP. Review: Assessment of the amount of lochia
The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia
3 Rationale: 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 the other clients. In addition, there are no specific data in the client descriptions in options 1, 2, and 4 that present the risk for hemorrhage. Test-Taking Strategy: Note the strategic word, most. Focus on the subject, the client at most risk for hemorrhage. Read the client description in each option. Noting the words large and oxytocin in the correct option will direct you to this option. Review: Hemor rh age and postpar tum clien t
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.
4 Rationale: If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous CHAPTER 30 Postpartum Complications 369 line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen. Test-Taking Strategy: Note the strategic word, initial. Use the ABCs—airway-br eath in g-cir culation—to assist in directing you to the correct option. Review: Therapeutic management of a client with pulmon ary embolism Level of Cognitive Ability: Analyzing
The nurse is monitoring a postpartum client who received epidural anesthesia for delivery for the presence of a vulvar hematoma. Which assessment finding would best indicate the presence of a hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation
1 Rationale: Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in an anesthetized postpartum client with vulvar hematoma. Option 2 (heavy bruising) may be seen, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. Test-Taking Strategy: Note the str ategic wo rd , best. Also note that the client received epidural anesthesia. With this in mind, eliminate options 3 and 4. From the remaining options, use the ABCs—airway-breathing-circulation—to direct you to the correct option. Review: Signs of a vulvar h ematoma
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? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume
1 Rationale: 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. Test-Taking Strategy: Note the strategic word, priority. Use Maslow's Hierarchy of Needs theory to eliminate option 3 because this is a psychosocial, not a physiological, need. To select from the remaining options, focus on the data in the question. Review: Discomforts in the postpartum client
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. 1. Wear a supportive bra. 2. Rest during the acute phase. 3. Maintain a fluid intake of at least 3000 mL/day. 4. Continue to breast-feed if the breasts are not too sore. 5. Take the prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breast-feeding or breast pump.
1, 2, 3, 4 Rationa le: 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. Test-Taking Strategy: Focus on the subject, treatment measures for mastitis. Think about the pathophysiology associated with mastitis to answer correctly. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, increased fluid intake, breast support, and decompression of the breasts will assist in answering the question. Review: Treatment measures for mastitis
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. 1. "I should wear a bra that provides support." 2. "Drinking alcohol can affectmymilk supply." 3. "The use of caffeine can decrease my milk supply." 4. "I will start my estrogen birth control pills again as soon as I get home." 5. "I know if my breasts get engorged, I will limit my breast-feeding and supplement the baby." 6. "I plan on having bottled water available in the refrigerator so I can get additional fluids easily."
1, 2, 3, 6 Rationale: 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 other 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. Test-Taking Strategy: Focus on the subject and note the words understood the instructions. Think about the physiology associated with milk production and the complications of breastfeeding to answer correctly. Review: Postpartum instructions for a breast-feeding client
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? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting out of bed. 4. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided.
3 Rationa le: 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. Option 1 is not a helpful action in this situation and would not relieve the symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, client safety. Option 4 is inappropriate and should be eliminated first. Elevating the client's head is not a helpful intervention. To select from the remaining options, recall that safety is a primary issue. Review: Postpartum nursing interventions
The nurse is assessing a client in the fourth stage of labor and notes that the fundus is firm, but that bleeding is excessive. Which should be the initial nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position
3 Rationale: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm would not assist in controlling the bleeding. Trendelenburg's position should be avoided because it may interfere with cardiac and respiratory function.Although the nursewould record the findings, the initial nursing action would be to notify the HCP. Test-Taking Strategy: Note the str ategic word, initial. Focus on the data in the question, notingthe clinicalmanifestations identified in the question. Eliminate option 2 first because, if the uterus is firm, it would not be necessary to perform fundal massage. Knowing that Trendelenburg's position interferes with cardiac and respiratory function will assist in eliminating option 4. From the remaining options, noting the words bleeding is excessive will assist in directing you to the correct option. Review: Nursing interventions for postpar tum h emor rh age
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? 360 UNIT VI Maternity Nursing 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider (HCP). 4. Encourage increased oral intake of fluids.
3 Rationale: 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 HCP. Reassessing the client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in this situation. 362 UNIT VI Maternity Nursing Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the words larger than 1 cm. Think about the significance of lochial clots in the postpartum period to answer correctly. Review: Normal findings in the postpartum client
The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present? 1. Paleness of the calf area 2. Coolness of the calf area 3. Enlarged, hardened veins 4. Palpable dorsalis pedis pulses
3 Rationale: Thrombosis of superficial veins usually is accompanied by signs and symptoms of inflammation, including swelling, redness, tenderness, and warmth of the involved extremity. It also may be possible to palpate the enlarged, hard vein. Clients sometimes experience pain when they walk. Palpable dorsalis pedis pulses is a normal finding. Test-Taking Strategy: Eliminate option 4 first, because this is a normal and expected finding. Next, eliminate options 1 and 2 because they are compar able or alike. Review: Super ficial ven ous th rombosis
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? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids.
4 Rationa le: 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 HCP is not necessary. Test-Taking Strategy: Note the strategic word, priority, and use knowledge regarding the physiological findings in the immediate postpartum period to answer this question. Recalling that a temperature elevation often is related to the dehydrating effects of labor will direct you to the correct option. Also, increasing hydration relates to a physiological client need. Review: Normal postpartum assessment findings
The nurse is creating a plan of care for a postpartum client with a small vulvar hematoma. The nurse should include which specific action during the first 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area.
4 Rationale: A hematoma is a localized collection of blood in the tissues of the reproductive sac after delivery. Vulvar hematoma is the most common. Application of ice reduces swelling caused by hematoma formation in the vulvar area. Options 1, 2, and 3 are not interventions that are specific to the plan of care for a client with a small vulvar hematoma. Ambulation hourly increases the risk for bleeding. Client assessment every 4 hours is too infrequent. Test-Taking Strategy: Focus on the subject, a small vulvar hematoma. Think about the effect of each action in the options; this focus will assist in directing you to the correct option. Review: Nursing care of the client with a h ematoma
The nurse is caring for four 1-day postpartum clients. Which client assessment requires the need for follow-up? 1. The client with mild afterpains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both breasts 4. The client with lochia that is red and has a foulsmelling odor
4 Rationale: 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. Test-Taking Strategy: Note the strategic words, need for followup. These words indicate a n egative event query and the need to select the abnormal assessment finding. Note the words foulsmelling in the correct option. Review: Normal assessment findings in the postpartum client
The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn.Which client statement would indicate a need for further instruction? 1. "I should breast-feed every 2 to 3 hours." 2. "I should change the breast pads frequently." 3. "I should wash my hands well before breastfeeding." 4. "I should wash my nipples daily with soap and water."
4 Rationale: Mastitis is inflammation of the breast as a result of infection. It generally is caused by an organism that enters through an injured area of the nipples, such as a crack or blister. Measures to prevent the development of mastitis include changing nursing pads when they are wet and avoiding continuous pressure on the breasts. Soap is drying and could lead to cracking of the nipples, and the client should be instructed to avoid using soap on the nipples. The mother is taught about the importance of hand washing and that she should breastfeed every 2 to 3 hours. Test-Taking Strategy: Note the str ategic words, need for further instruction. These words indicate a n egative event query and the need to select the option that identifies the incorrect client statement. Recalling that the use of soap is drying to the skin and could cause cracking and provide an entry point for organisms will direct you easily to the correct option. Review: Prevention measures for mastitis
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? 1. 3 days postpartum 2. 7 days postpartum 3. On the day of birth 4. Within 2 weeks postpartum
Rationale: 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. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the subject and use general principles related to postpartum care. Eliminate options 2 and 4 first because of the length of time stated in these options. From the remaining options, eliminate option 3 because it would seem unreasonable that bowel function would return that quickly in the postpartum woman. Review: Normal gastrointestinal function in the postpartum client