15. Postpartum

coagulation factors

-hypercoagulability -predisposes postpartum pt to thrombus formation and thromboembolism

thrombophlebitis symptoms (6)

-leg pain and tenderness -swelling -warmth -redness -hardened vein over the thrombosis -fever

lochia serosa

-pinkish brown -lasts 4-10 days after delivery

postpartum diuresis

-urinary output ↑ 12 hrs after delivery (>3,000 mL/day) -can last 2-3 days

postpartum hemorrhage: blood loss

-vaginal: >500 mL -c-section: >1,000 mL

A nurse is caring for a postpartum client 8hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) a. Magnesium sulfate infusion b. Distended bladder c. Oxytocin infusion d. Prolonged labor e. Small for gestational age newborn

a. Magnesium sulfate infusion b. Distended bladder d. Prolonged labor ATI

UTI pt teaching (4)

-↑ fluid intake to at least 3,000 mL/day to flush out bacteria -take acetaminophen to reduce discomfort and pain -drink cranberry and prune juice to promote urine acidification -perineal hygiene: wipe front to back

The nurse has determined that a postpartum client has physical findings consistent with uterine atony. The nurse should plan to take which action first? 1. Massage the uterus until firm. 2. Take the client's blood pressure. 3. Ask the client about the presence of pain. 4. Recheck the amount of drainage on the peripad.

1. Massage the uterus until firm. NCLEX

A nurse is assessing the fundus in a postpartum woman and notes that the uterus is soft and spongy and is not firmly contracted. The nurse should prepare to implement which interventions? (Select all that apply) 1. Massaging the uterus 2. Pushing gently on the uterus 3. Assisting the woman to urinate 4. Rechecking the uterus in 1 hour 5. Checking for a distended bladder 6. Calling the delivery room to schedule an abdominal hysterectomy

1. Massaging the uterus 3. Assisting the woman to urinate 5. Checking for a distended bladder If the uterus is soft and spongy and not firmly contracted, the initial nursing action is to massage the fundus gently until it is firm; this will express clots that may have accumulated in the uterus. If the uterus does not remain contracted as a result of massage, the problem may be a distended bladder, which lifts and displaces the uterus and prevents effective contraction of the uterine muscles. NCLEX

A client arrives at the postpartum unit after delivery of her infant. On performing an assessment, the nurse notes that the client is shaking uncontrollably. Which nursing action would be appropriate? 1. Massage the fundus. 2. Contact the health care provider. 3. Cover the client with a warm blanket. 4. Place the client in Trendelenburg's position.

3. Cover the client with a warm blanket. (postpartum chill) NCLEX

The nurse is assessing a client for signs of postpartum depression. Which observation, if noted in the new mother, would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner. 2. The mother demonstrates an interest in the surroundings. 3. The mother constantly complains of tiredness and fatigue. 4. The mother looks forward to visits from the father of the newborn.

3. The mother constantly complains of tiredness and fatigue. NCLEX

The nurse is monitoring the lochia of a client who is 2 hrs postpartum and notes that the client saturated a perineal pad in 15 min. 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 and inform the HCP of this finding

4. contact the health care provider and inform the HCP of this finding (excessive = perineal pad saturated in ≤15 min) NCLEX

Which of the following laboratory findings would most likely be considered normal in the immediate postpartum period? a. Increased white blood cell (WBC) count b. Decreased erythrocyte sedimentation rate (ESR) c. Decreased hematocrit d. Increased platelet (PLT) count

a. Increased white blood cell (WBC) count text

A nurse is assessing a postpartum client. The fundus is noted to be displaced laterally to the right, and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony? a. poor involution b. urinary retention c. hemorrhage d. infection

b. urinary retention ATI

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? a. lochia serosa vaginal drainage b. vaginal pressure c. intermittent vaginal pain d. yellow exudate vaginal drainage

b. vaginal pressure ATI

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? a. Continuous lochia flow and a flaccid uterus. b. Report of increasing pain and pressure in the perineal area. c. A slow trickle of bright vaginal bleeding and a firm fundus. d. A gush of rubra lochia when the nurse massages the uterus.

c. A slow trickle of bright vaginal bleeding and a firm fundus. ATI

Which woman is most at risk for bladder distention after a normal vaginal delivery? a. A woman who had IV fluids running during labor b. A woman who had a midline episiotomy c. A woman who had epidural anesthesia d. A woman who had an active labor lasting 12 hours

c. A woman who had epidural anesthesia text

A nurse has assessed a 4cm vaginal hematoma on a client who is 6 hours postpartum. What initial nursing intervention would be most appropriate? a. Administer anti-inflammatory medication. b. Apply hot packs. c. Insert an indwelling Foley catheter. d. Apply ice packs every 4 hours.

d. Apply ice packs every 4 hours. text

general symptoms of infection (6)

flu-like symptoms: -fever -chills -body aches -anorexia -nausea -tachycardia

flash cards

https://www.freezingblue.com/flashcards/print_preview.cgi?cardsetID=256743

endometritis

uterine infection

heart rate

-bradycardia -50-70 beats/min -6-10 days postpartum

infection risk factors: other (3)

-hx of puerperal infection -diabetes -anemia

uterine subinvolution

-when the uterus remains enlarged with continued lochial discharge -can result in postpartum hemorrhage

lochia alba

-yellowish, white, creamy -lasts 11 days - 8 weeks after delivery

The postpartum client asks the nurse about the occurrence of afterpains. The nurse informs the client that afterpains will be especially noticeable during which activity? 1. Ambulating 2. Breast-feeding 3. Taking sitz baths 4. Arriving home and activities are increased

2. Breast-feeding NCLEX

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn infant briefly with 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. Support the mother in her reaction to the newborn infant. (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.) NCLEX

The nursing student is assigned to care for a client in the postpartum unit. The coassigned nurse asks the student to identify the most objective method to assess the amount of lochial flow in the client. Which statement, if made by the student, indicates an understanding of this method? 1. "I can estimate the amount of blood loss by gauging the amount of staining on a perineal pad." 2. "I should ask the client to keep a record and document every time the perineal pad is changed." 3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." 4. "I can look at the perineal pad and gauge the amount of staining and relate it to the amount of time between pad changes."

3. "I should weigh the perineal pad before and after use and note the amount of time between each pad change." NCLEX

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 would be 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 mother's symptoms have subsided.

3. Instruct the client to request help when getting out of bed. (orthostatic hypotension is normal) NCLEX

A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1. The client is hemorrhaging. 2. The client needs to increase oral fluids. 3. The client is experiencing normal lochia discharge. 4. The client's health care provider needs to be notified of the finding.

3. The client is experiencing normal lochia discharge. NCLEX

The nurse is caring for four 1-day postpartum clients. Which client would require further nursing action? 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 foul-smelling odor

4. The client with lochia that is red and has a foul-smelling odor (foul-smelling or purulent lochia = infection) NCLEX

A nurse is caring for a 6-hour-postpartum client who is experiencing perineal discomfort. Which intervention is most appropriate for the nurse to implement? a. Application of warm compresses to the perineum b. Application of an ice pack to the perineum c. Administration of Methergine 0.2 mg d. Contacting the primary healthcare provider/CNM for new orders

b. Application of an ice pack to the perineum text

temperature

1st 24 hrs: -37.8°-39°C (100°-102.2°F) (text) -up to 38°C (100.4°F) (ATI) -because of dehydrating effects of labor

WBC count

↑ 1st week postpartum (normal WBC = 5,000-10,000 mm³)

Hgb and Hct

↓ for 3-4 days postpartum (ATI p 121)

symptoms of urinary retention (4)

-fundal height ↑ umbilicus -fundus displaced (usually to the right) -excessive lochia -tenderness over bladder area

fundal height rate of decrease

1 cm/day, 1 cm every 24 hr

The postpartum nurse is providing instructions to a client after delivery 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 delivery 4. Within 2 weeks postpartum

1. 3 days postpartum NCLEX

A nurse is reviewing discharge teaching with a client who has a urinary tract infection. Which of the following statements by the client indicates understanding of the teaching? (select all that apply.) A. "I will perform peri care and apply a perineal pad in a back‐to‐front direction." B. "I will drink cranberry and prune juices to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." D. "I will go back to breastfeeding after I have finished taking the antibiotic." E. "I will take Tylenol for any discomfort."

B. "I will drink cranberry and prune juices to make my urine more acidic." C. "I will drink large amounts of fluids to flush the bacteria from my urinary tract." E. "I will take Tylenol for any discomfort." ATI

BUBBLE HE

B: breasts U: uterus (fundal height, uterine placement, consistency) B: bowel and GI function B: bladder function L: lochia (color, odor, consistency, amount) E: episiotomy (edema, ecchymosis, approximation) H: hemorrhoids E: emotional status text p 673 ATI p 117

Which question from a postpartum client indicates a need for further teaching about managing afterpains? a. "Can I get an ice pack for my belly to help with these cramps?" b. "Should I have my mom bring me a lysine supplement? She says it might help." c. "The baby's due to nurse in about an hour. Can I have some ibuprofen?" d. "I guess we can expect this to be worse after having twins that it was with my singleton, right?"

a. "Can I get an ice pack for my belly to help with these cramps?" (heat application for afterpains) text

A 24-year-old primipara is rooming in with her new infant. Which behavior indicates a need for further assessment? a. Verbalizing concerns over the shape of the baby's head b. Reluctance to hand the baby to staff for assessment c. Allowing the baby to cry in the bassinette and learn self-soothing d. Keeping the baby constantly on her chest

c. Allowing the baby to cry in the bassinette and learn self-soothing text

During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of the umbilicus. Which of the following findings should the nurse interpret this data as being? a. evidence of a possible vaginal hematoma b. an indication of a cervical or perineal laceration c. a normal postural discharge of lochia d. abnormally excessive lochia rubra flow

c. a normal postural discharge of lochia ATI

REEDA

episiotomy assessment R: redness E: edema E: ecchymosis D: discharge, drainage A: approximation

blood pressure

orthostatic hypotension 1st 48 hrs

fundal height immediately after delivery

slightly ↑ umbilicus, at the umbilicus

postpartum hemorrhage: lochia assessment (3)

-blood clots larger than a quarter, >1 cm -perineal pad saturated in ≤15 min -bright red blood

subinvolution symptoms (5)

-boggy uterus -uterine pain on palpation -enlarged uterus -prolonged vaginal bleeding -excessive vaginal bleeding

afterpains causes (5)

-breastfeeding (oxytocin) -multipara (more common) -multiple gestation (overdistended uterus) -large baby (overdistended uterus) -use of oxytocin

lochia rubra

-bright red -lasts 1-3 days after delivery

infection risk factors: birth-related (7)

-cesarean birth -vacuum- or forceps-assisted birth -prolonged rupture of membranes -wounds from lacerations, incisions, hematomas, episiotomy -internal fetal/uterine pressure monitoring -multiple vaginal exams -retained placental fragments

afterpains

-cramplike pains due to contractions of the uterus that occur after childbirth -last 2-3 days after birth

thrombophlebitis prevention pt teaching (4)

-frequent ambulation -↑ fluid intake (prevent dehydration, sluggish circulation) -don't cross legs -avoid prolonged sitting, standing, immobility

postpartum hemorrhage symptoms (5)

-uterine atony (hypotonic or boggy) -tachycardia -hypotension -oliguria -skin: pale (pallor), cool, clammy

A postpartum care unit nurse is reviewing the records of 5 new mothers admitted to the unit. The nurse determines that which mother is most likely at risk for developing a puerperal infection? (Select all that apply.) 1. A mother who had 10 vaginal exams during labor 2. A mother with a history of previous puerperal infections 3. A mother who gave birth vaginally to a 3200-gram infant 4. A mother who experienced prolonged rupture of the membranes 5. A mother who experienced the expected outcome with delivery of the placenta

1. A mother who had 10 vaginal exams during labor 2. A mother with a history of previous puerperal infections 4. A mother who experienced prolonged rupture of the membranes (Risk factors: hx of previous puerperal infections, cesarean births, trauma, prolonged rupture of the membranes, prolonged labor, multiple vaginal exams, retained placental fragments) NCLEX

The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client had a midline 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. Client pain level NCLEX

The nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which intervention will be prescribed? 1. Administration of anticoagulants 2. Elevation of the affected extremity 3. Ambulation eight to ten times daily 4. Application of ice packs to the affected area

2. Elevation of the affected extremity (don't need anticoagulants unless the condition persists - elevation ↑ venous return) NCLEX

A nurse is caring for a client who has just delivered a newborn following a pregnancy with a placenta previa. When reviewing the plan of care, the nurse should prepare to monitor the client for which risk that is associated with placenta previa? 1. Infection 2. Hemorrhage 3. Chronic hypertension 4. Disseminated intravascular coagulation

2. Hemorrhage NCLEX

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? 1. Provide oral fluids and begin fundal massage. 2. Begin hourly pad counts and reassure the client. 3. Elevate the head of the bed and assess vital signs. 4. Assess for hypovolemia and notify the health care provider (HCP).

4. Assess for hypovolemia and notify the health care provider (HCP). NCLEX

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. Increase hydration by encouraging oral fluids. (temp up to 100.4° F (38° C) in the first 24 hrs after birth is often related to the dehydrating effects of labor - increase hydration by encouraging oral fluids) NCLEX

A nurse is caring for a client who is 1 day postpartum. The nurse is assessing for maternal adaptation and mother‐infant bonding. Which of the following behaviors by the client indicates a need for the nurse to intervene? (Select all that apply.) A. Demonstrates apathy when the infant cries B. Touches the infant and maintains close physical proximity C. Views the infant's behavior as uncooperative during diaper changing d. Identifies and relates infant's characteristics to those of family members e. Interprets the infant's behavior as meaningful and a way of expressing needs

A. Demonstrates apathy when the infant cries C. Views the infant's behavior as uncooperative during diaper changing ATI

A nurse is providing care to four clients on the postpartum unit. Which of the following clients is at greatest risk for developing a postpartum infection? A. A client who has an episiotomy that is erythematous and has extended into a third‐degree laceration B. A client who does not wash her hands between perineal care and breastfeeding C. A client who is not breastfeeding and is using measures to suppress lactation d. A client who has a cesarean incision that is well‐approximated with no drainage

B. A client who does not wash her hands between perineal care and breastfeeding ATI

A nurse in the delivery room is planning to promote maternal‐infant bonding for a client who just delivered. Which of the following is the priority action by the nurse? A. Encourage the parents to touch and explore the neonate's features. B. Limit noise and interruption in the delivery room. C. Place the neonate at the client's breast. D. Position the neonate skin‐to‐skin on the client's chest.

D. Position the neonate skin‐to‐skin on the client's chest. ATI

A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. Which of the following conditions are associated with these clinical findings? A. Postpartum fatigue B. Postpartum psychosis C. Letting‐go phase D. Postpartum blues

D. Postpartum blues ATI

A nurse concludes that the father of an infant is not showing positive signs of parent‐infant bonding. He appears very anxious and nervous when the infant's mother asks him to bring her the infant. Which of the following actions should the nurse use to promote father‐infant bonding? A. Hand the father the infant, and suggest that he change the diaper. B. Ask the father why he is so anxious and nervous. C. Tell the father that he will grow accustomed to the infant. D. Provide education about infant care when the father is present.

D. Provide education about infant care when the father is present. ATI

A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the immediate nursing action? a. Massage the fundus until firm. b. Increase the rate of the intravenous infusion. c. Notify the primary healthcare provider or nurse-midwife. d. Obtain an order to catheterize the client.

a. Massage the fundus until firm. (notify health care provider only if fundal massage is not effective) text

What suggestion should the nurse provide to the client who complains of severe afterpains? a. Stay in bed with your feet elevated. b. Assume a prone position at intervals. c. Try to nurse more frequently. d. Apply ice to your abdomen for 20 minutes.

b. Assume a prone position at intervals. text

A nurse is assessing four postpartum clients with vaginal births. Which one is most at risk for uterine atony? a. The client who had epidural anesthesia b. The client who had an oxytocin induction c. The client who had a cerclage d. The client who had a breech presentation

b. The client who had an oxytocin induction text

A nurse is caring for a couple in the birthing center. Which parent-infant behaviors should the nurse investigate further? a. The parents change diapers when needed. b. The parents complete activities silently without looking at the baby. c. The parents position the baby comfortably. d. The parents demonstrate eye-to-eye contact with the baby.

b. The parents complete activities silently without looking at the baby. text

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? a. check for a full bladder b. massage the fundus c. measure vital signs d. administer carboprost IM

b. massage the fundus ATI

postpartum chill

-uncontrollable shaking chill immediately following birth -occurs in the 1st 2 hrs puerperium -normal unless accompanied by elevated temperature

uterine atony risk factors - not related to labor/delivery (5)

-urinary retention, distended bladder -placenta previa -abruptio placentae -preeclampsia -Asian or Hispanic

postpartum hemorrhage causes (5)

-uterine atony -lacerations -episiotomy -hematoma -retained placental fragments

afterpains treatments (3)

-application of warmth to lower abdomen -mild analgesic 1 hr before breastfeeding -prone position (puts pressure on uterus)

thrombophlebitis risk factors (7)

-cesarean birth -age >35 yrs -obesity -multiparity -hx of thromboembolism -smoking -diabetes

UTI symptoms (5)

-dysuria -urinary frequency -cloudy, malodorous urine -fever -chills

UTI risk factors (5)

-epidural anesthesia -urinary catheterization -hx of UTIs -cesarean birth -frequent pelvic exams

The nurse is monitoring a postpartum client who is at risk of developing postpartum endometritis. Which finding, if noted during the first 24 hours after delivery, would support a diagnosis of postpartum endometritis? 1. Abdominal tenderness and chills 2. Increased perspiration and appetite 3. Maternal oral temperature of 100.2° F 4. Uterus two fingerbreadths below midline and firm

1. Abdominal tenderness and chills Signs and symptoms in the postpartum period heralding endometritis include delayed uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, and temperature elevations up to 104°F (37.9°C). NCLEX

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. Changes in vital signs (epidural = pt can't feel pain) NCLEX

Which instructions should a nurse provide to a client following delivery regarding care of the episiotomy site to prevent infection? (Select all that apply.) 1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 3. Change the perineum pads three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation.

1. Report a foul-smelling discharge. 2. Take a warm sitz baths three times a day. 4. Use warm water to rinse the perineum after elimination. 5. Wipe the perineum from front to back after voiding and defecation. (the perineal pad should be changed after each elimination and may be changed in between) NCLEX

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? (Select all that apply) 1. Afterpains 2. Uterine infection 3. Increased estrogen levels 4. Increased progesterone levels 5. Retained placental fragments from delivery

2. Uterine infection 5. Retained placental fragments from delivery NCLEX

The postpartum unit nurse is performing an assessment on a client who is at risk for thrombophlebitis. Which nursing action is indicated in assessing for thrombophlebitis? 1. Palpate for pedal pulses. 2. Ask the client about pain in the calf area. 3. Assess for the presence of vaginal hematoma. 4. Ask the client to ambulate and assess for the presence of pain.

2. Ask the client about pain in the calf area. NCLEX

The nurse is preparing to care for four assigned clients. Which client is at highest 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. A multiparous client who delivered a large baby after oxytocin induction (risk factors for hemorrhage include multiparity, large neonate, oxytocin) NCLEX

On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urinalysis is done, and the results indicate the presence of a urinary tract infection. The nurse instructs the new mother regarding measures to take for treatment of the infection. Which statement, if made by the mother, would indicate a need for further instructions? 1. "I need to urinate frequently throughout the day." 2. "The prescribed medication must be taken until it is finished." 3. "My fluid intake should be increased to at least 3000 mL daily." 4. "Foods and fluids that will increase urine alkalinity should be consumed."

4. "Foods and fluids that will increase urine alkalinity should be consumed." (consume foods/fluids that ↑ urine acidity) NCLEX

The nursing instructor is reviewing the plan of care with a student regarding care of a postpartum client. The instructor asks the nursing student about the taking-in phase according to Rubin's phases of regeneration and the client behaviors that are most likely to occur during this phase. Which response made by the student indicates an understanding of this phase? (Select all that apply) 1. "The client would be independent." 2. "The client initiates activities on her own." 3. "The client participates in mothering tasks." 4. "The client may complain of lack of sleep and fatigue." 5. "The client is self-focused and talks to others about labor."

4. "The client may complain of lack of sleep and fatigue." 5. "The client is self-focused and talks to others about labor." NCLEX

The nurse is preparing to care for a client in the immediate postpartum period who has just delivered a healthy newborn. How often should the nurse plan to take the client's vital signs? 1. Hourly for the first 2 hours and then every 4 hours 2. 30 minutes during the first hour and then every hour for the next 2 hours 3. 5 minutes for the first 30 minutes and then every hour for the next 4 hours 4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours

4. 15 minutes during the first hour and then every 30 minutes for the next 2 hours During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. NCLEX

A nurse has just received an intershift report. After reviewing the client assignment and the appropriate medical records, the nurse determines that which client is most at risk for developing postdelivery endometritis? 1. A primigravida with a normal spontaneous vaginal delivery 2. A gravida II who delivered vaginally following an 18-hour labor 3. A client experiencing an elective cesarean delivery at 38 weeks' gestation 4. An adolescent experiencing an emergency cesarean delivery for fetal distress

4. An adolescent experiencing an emergency cesarean delivery for fetal distress (Cesarean delivery is the primary risk factor for uterine infection, especially after emergency procedures.) NCLEX

A nurse is caring for a postpartum client who delivered her third infant 2 days ago. The nurse recognizes that which of the following findings are suggestive of postpartum depression? (select all that apply.) A. Fatigue B. Insomnia C. Euphoria D. Flat affect E. Delusions

A. Fatigue B. Insomnia D. Flat affect ATI

A nurse is assigned to care for four postpartum clients. Which client would be LEAST likely to request relief for afterpains? a. Gravida 1, para 1 with a 16-hour labor b. Gravida 2, para 1 with hydramnios c. Gravida 5, para 4 with twins d. Gravida 3, para 2 who is breastfeeding

a. Gravida 1, para 1 with a 16-hour labor (multiparity = ↑ risk for afterpains) text

postpartum hemorrhage: nursing interventions (5)

-massage fundus -assess for source of bleeding -supplemental oxygen -IV fluids -elevate legs (↑ venous return)

A postpartum unit nurse is caring for a stable client 12 hours after delivering a healthy newborn. At this time in the postpartum period, what is the recommended frequency for the nurse to assess the client's vital signs? 1. Every hour 2. Every 4 hours 3. Every 24 hours 4. Every 30 minutes

2. Every 4 hours During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. NCLEX

The nurse is caring for a client in the postpartum period immediately after delivery. The nurse performs an assessment on the client and prepares to assess uterine involution by taking which action? 1. Monitoring the vital signs 2. Palpating the uterine fundus 3. Auscultating the bowel sounds 4. Assessing the amount of drainage on the peripad

2. Palpating the uterine fundus NCLEX

The nurse is assessing a client in the 4th stage of labor and notes that the fundus is firm, but that the bleeding is excessive. Which should be the initial nursing action? 1. record the findings 2. massage the fundus 3. notify the health care provider 4. place the client in Trendelenburg's position

3. notify the health care provider (if bleeding is excessive, the cause may be laceration of the cervix or birth canal - massaging a firm fundus would not help with bleeding) NCLEX

The nurse is teaching a new mother how to care for her newborn. The nurse notes that the client is very fearful and reluctant to handle the newborn and notes that this is the client's first child. Which nursing intervention is least appropriate in assisting the promotion of mother-infant interaction and bonding? 1. Accepting the client's feelings 2. Acknowledging the client's apprehension 3. Assisting the client with giving the baths to allow her to become more at ease 4. Leaving the infant with the client so that she will be required to provide the care

4. Leaving the infant with the client so that she will be required to provide the care NCLEX

Regarding neurologic conditions, which of the following is true of headaches during the postpartum period? a. Headaches are the most common neurologic symptoms demonstrated by postpartum clients. b. Spinal anesthesia is not associated with a risk for headache. c. Migraine headaches are more common during pregnancy. d. Hypertension is not associated with headaches.

a. Headaches are the most common neurologic symptoms demonstrated by postpartum clients. text

cystitis

bladder infection

postpartum diaphoresis

-mostly at night -caused by ↓ estrogen

postpartum chill causes (4)

-nervous system response -vasomotor changes -shift in fluid -the work of labor

postpartum hemorrhage: medications (4)

-oxytocin -methylergonovine -misoprostol -carboprost

symptoms of endometritis (4)

-pelvic pain -abdominal/uterine tenderness -malodorous or purulent lochia -dark, profuse lochia

factors that slow uterine involution (7)

-prolonged labor, dystocia -anesthesia -full bladder -retained placental fragments -infection -uterine overdistention -multiparity

atony risk factors - related to labor/delivery (8)

-prolonged labor, dystocia -precipitous labor -oxytocin -magnesium sulfate -anesthesia and analgesia -forceps- or vacuum-assisted birth -cesarean birth -uterine overdistention (twins, polyhydramnios, large baby)

postpartum chill nursing interventions (2)

-reassure pt that chills are common and will only last a short while -provide warm blankets and fluids

lochia scale

-scant: <2.5 cm (1") -light: 2.5-10 cm (1-4") -moderate: 10-15 cm (4-6") -heavy: pad saturated in 1 hr -excessive: pad saturated in ≤15 min

Which clients would be at most risk for development of postpartum thromboembolic disorders? (Select all that apply.) 1. A 39-year-old woman who reports that she smokes 2. A 24-year-old woman with a thin frame who is a vegetarian 3. A 26-year-old woman with a family history of thrombophlebitis 4. A 37-year-old woman in her fourth pregnancy who is overweight 5. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis

1. A 39-year-old woman who reports that she smokes 4. A 37-year-old woman in her fourth pregnancy who is overweight 5. A 22-year-old woman in a first pregnancy who states that oral contraceptives taken in the past have caused thrombophlebitis (risk factors: smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than 3 pregnancies, and women who have had a cesarean birth) NCLEX

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 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. An increase in the pulse rate from 88 to 102 beats/minute (↑ pulse is an early sign of excessive blood loss because the heart pumps faster to compensate for ↓ blood volume. A slight ↑ in temp is normal. BP ↓ as the blood volume ↓, but a ↓ BP would not be the earliest sign of hemorrhage.) NCLEX

The nurse is preparing to perform a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment? 1. Ask the client to turn on her side. 2. Ask the client to urinate and empty her bladder. 3. Massage the fundus gently before determining the level of the fundus. 4. Ask the client to lie flat on her back, with her knees and legs flat and straight.

2. Ask the client to urinate and empty her bladder. NCLEX

A postpartum client is diagnosed with cystitis. The nurse should plan for which priority nursing 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. Encouraging fluid intake (flush bacteria out of bladder) NCLEX

The nurse is developing a plan of care for a client recovering from a cesarean delivery. Which action should the nurse encourage the client to do to prevent thrombophlebitis? 1. Elevate her legs. 2. Remain on bed rest. 3. Ambulate frequently. 4. Apply warm, moist packs to the legs.

3. Ambulate frequently. NCLEX

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 would 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. Enlarged, hardened veins NCLEX

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 1 hour. How should the nurse document this finding? 1. Scant 2. Light 3. Heavy 4. Excessive

3. Heavy (heavy = saturated pad in 1 hr) NCLEX

A client with known cardiac disease has been admitted to the postpartum care unit after an uneventful delivery. The unit nurse instructs the client to use the call button for assistance whenever she needs to get out of bed or wishes to care for her infant. Which postpartum complication is the nurse most concerned about for this client? 1. Postpartum infection 2. Maternal attachment 3. Maternal overexertion 4. Postpartum newborn-mother bonding

3. Maternal overexertion (stress on cardiac functioning) NCLEX

When performing a postpartum assessment on a client, a 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? 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider. 4. Encourage increased oral intake of fluids.

3. Notify the health care provider. (Normally, a few small clots may be noted in the lochia in the first 1-2 days after birth from pooling of blood in the vagina. Clots > 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.) NCLEX

The nurse is developing 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. Assess vital signs every 4 hours. 2. Measure fundal height every 4 hours. 3. Prepare an ice pack for application to the area. 4. Inform the health care provider of assessment findings.

3. Prepare an ice pack for application to the area. NCLEX

The nurse is monitoring a postpartum client in the fourth stage of labor. Which finding, if noted by the nurse, would indicate a complication related to a laceration of the birth canal? 1. Presence of dark red lochia 2. Palpation of the uterus as a firm contracted ball 3. The saturation of more than one peripad per hour 4. Palpation of the fundus at the level of the umbilicus

3. The saturation of more than one peripad per hour NCLEX

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. Administer oxygen, 8 to 10 L/minute, by face mask. (pulmonary embolism - oxygen to ↓ hypoxia) NCLEX

The postpartum unit nurse has provided information regarding performing a sitz bath to a new mother after a vaginal delivery. The client demonstrates understanding of the purpose of the sitz bath by stating that the sitz bath will promote which action? 1. Numb the tissue. 2. Stimulate a bowel movement. 3. Reduce the edema and swelling. 4. Assist in healing and provide comfort.

4. Assist in healing and provide comfort. NCLEX

Which nursing intervention would be most appropriate for a postpartum client with a diagnosis of endometritis to facilitate participation in newborn care? 1. Limit fluid intake. 2. Maintain the client in a supine position. 3. Ask family members to care for the newborn. 4. Encourage the client to take pain medication as prescribed.

4. Encourage the client to take pain medication as prescribed. NCLEX

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum her systolic blood pressure has dropped 20 points, her diastolic blood pressure has dropped 10 points, and her pulse is 120 beats/min. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, what is the nurse's next action? 1. Reassure the client. 2. Monitor fundal height. 3. Apply perineal pressure. 4. Prepare the client for surgery.

4. Prepare the client for surgery. A hematoma is a localized collection of blood into the tissues of the reproductive sac after delivery. A vulvar hematoma is the most common type. The use of an epidural, prolonged second-stage labor, and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 mL of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action is to prepare the client for surgery to stop the bleeding. NCLEX

The nurse in the postpartum unit is observing the mother-infant bonding process in a client. Which observation, if made by the nurse, indicates the potential for a maladaptive interaction? 1. The mother is observed talking to the newborn. 2. The mother performs cord care for the newborn. 3. The mother verbalizes discomfort with the new role of motherhood. 4. The mother requests that the nurse feed the newborn because she is feeling fatigued.

4. The mother requests that the nurse feed the newborn because she is feeling fatigued. (Expressing discomfort with the new role of motherhood is a normal, expected process, and it is important for the mother to verbalize concerns.) NCLEX

A pregnant client is admitted in labor. The nursing assessment reveals that the client's hemoglobin and hematocrit levels are low, indicating anemia. What should the nurse observe for following the client's labor? 1. anxiety 2. hot flashes 3. low self-esteem 4. postpartum infection

4. postpartum infection NCLEX

A nurse on the postpartum unit is performing a physical assessment of a client who is being admitted with a suspected deep‐vein thrombosis (DVT). Which of the following clinical findings should the nurse expect? (select all that apply.) A. Calf tenderness to palpation B. Mottling of the affected extremity C. Elevated temperature D. Area of warmth E. Report of nausea

A. Calf tenderness to palpation C. Elevated temperature D. Area of warmth ATI

A nurse is discussing risks factors for urinary tract infections with a newly licensed nurse. Which of the following conditions should the nurse include in the teaching? (select all that apply). A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs E. Vaginal birth

A. Epidural anesthesia B. Urinary bladder catheterization C. Frequent pelvic examinations D. History of UTIs ATI

A nurse is caring for a client who is postpartum. The nurse should identify which of the following findings as an early indicator of hypovolemia caused by hemorrhage? A. Increasing pulse and decreasing blood pressure B. Dizziness and increasing respiratory rate C. Cool, clammy skin, and pale mucous membranes D. Altered mental status and level of consciousness

A. Increasing pulse and decreasing blood pressure (other choices are later signs - tachycardia and hypotension are 1st symptoms of hypovolemic shock) ATI

A nurse educator on the postpartum unit is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in the teaching? (select all that apply.) A. Precipitous delivery B. Obesity C. Inversion of the uterus D. Oligohydramnios E. Retained placental fragments

A. Precipitous delivery C. Inversion of the uterus E. Retained placental fragments ATI

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following antepartum complications should the nurse understand is a risk factor for this condition? A. Preeclampsia B. Thrombophlebitis C. Placenta previa D. Hyperemesis gravidarum

A. Preeclampsia ATI

A nurse is caring for a client who is 2 days postpartum. The client states, "My 4‐year old son was toilet trained and now he is frequently wetting himself." Which of the following statements should the nurse provide to the client? A. "Your son was probably not ready for toilet training and should wear training pants." B. "Your son is showing an adverse sibling response." C."Your son may need counseling." D."You should try sending your son to preschool to resolve the behavior."

B. "Your son is showing an adverse sibling response." ATI

A nurse on the postpartum unit is caring for four clients. Which of the following clients should the nurse recognize as the greatest risk for development of a postpartum infection? A. A client who experienced a precipitous labor less than 3 hr in duration B. A client who had premature rupture of membranes and prolonged labor C. A client who delivered a large for gestational age infant D. A client who had a boggy uterus that was not well‐contracted

B. A client who had premature rupture of membranes and prolonged labor ATI

A nurse is caring for a client who has postpartum psychosis. Which of the following actions is the nurse's priority? A. Reinforce the need to take antipsychotics as prescribed. B. Ask the client if she has thoughts of harming herself or her infant. C. Monitor the infant for indications of failure to thrive. D. Review the client's medical record for a history of bipolar disorder.

B. Ask the client if she has thoughts of harming herself or her infant. ATI

A nurse is assessing a client who has postpartum depression. The nurse should expect which of the following findings? (select all that apply.) A. Paranoia that her infant will be harmed B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a mother

B. Concerns about lack of income to pay bills C. Anxiety about assuming a new role as a mother D. Rapid decline in estrogen and progesterone E. Feeling of inadequacy with the new role as a mother ATI

A client in the early postpartum period is very excited and talkative. She is repeatedly telling the nurse every detail of her labor and birth. Because the client will not stop talking, the nurse is having difficulty completing the postpartum assessments. Which of the following action should the nurse take? a. Come back later when the client is more cooperative. B. Give the client time to express her feelings. C. Tell the client she needs to be quiet so the assessment can be completed. D. redirect the client's focus so that she will become quiet.

B. Give the client time to express her feelings. ATI

A nurse on the postpartum unit is planning care for a client who has thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? A. Apply cold compresses to the affected extremity. B. Massage the affected extremity. C. Allow the client to ambulate. D. Measure leg circumferences.

D. Measure leg circumferences. ATI

Obesity places women at increased risk for which postpartum complication? a. Thrombophlebitis b. Uterine atony c. Postpartum depression d. Low milk production

a. Thrombophlebitis text

A nurse is caring for a client who is 1 hr postpartum following a vaginal birth and experiencing uncontrollable shaking. The nurse should understand that the shaking is due to which of the following factors? (select all that apply.) a. change in body fluids b. metabolic effort of labor c. diaphoresis d. decrease in body temperature e. decrease in prolactin levels

a. change in body fluids b. metabolic effort of labor (postpartum chill) ATI

A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is bright red and contains small clots. Which of the following findings should the nurse document? a. moderate lochia rubra b. excessive blood loss c. light lochia rubra d. scant lochia serosa

a. moderate lochia rubra -moderate: >10 cm -normal finding 2nd day postpartum ATI

The nurse is assisting a mother with perineal care on the postpartum floor. The birth record indicates she had a second-degree, midline episiotomy the day before. The mother asks, "When will this stop hurting?" What is the nurse's best response? a. "The pain should be gone by tomorrow." b. "It might be painful for several weeks." c. "Episiotomy usually results some degree of permanent discomfort." d. "You might have an infection. It's not normal to still be experiencing pain."

b. "It might be painful for several weeks." text

Which women are at increased risk of developing endometritis after giving birth? (Select all that apply.) a. A woman giving birth to her first child b. A woman who had a cesarean delivery c. A woman who had an intrauterine pressure device used during labor d. A woman who had a forceps-assisted vaginal birth e. A woman who has a grand multiparity

b. A woman who had a cesarean delivery c. A woman who had an intrauterine pressure device used during labor d. A woman who had a forceps-assisted vaginal birth text

The nurse caring for a postpartum client with an episiotomy notes that the client complains of rectal pressure and increasing perineal pain. What is the priority assessment for the nurse to make at this time? a. Assess bowel status for timing of last bowel movement. b. Assess for a vaginal hematoma. c. Assess the approximation of sutures. d. Assess for incomplete bladder emptying.

b. Assess for a vaginal hematoma. text

A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree perineal laceration. The client's temperature is 37.8C (100F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? a. Notify the provider about the elevated temperature. b. Assist the client to empty her bladder. c. Administer a bisacodyl suppository. d. Massage the client's fundus.

b. Assist the client to empty her bladder. (uterus to the right = bladder distention, assist pt to bathroom to prevent atony) ATI

A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. What would be the most appropriate initial nursing action? a. Assess activity pattern. b. Monitor vital signs. c. Ask the client to empty her bladder. d. Administer analgesics.

c. Ask the client to empty her bladder. text

The nurse assesses an 8-hour-postpartum client. Findings include lochia rubra, with a firm fundus at the level of the umbilicus. What nursing action is indicated? a. Massage the fundus to prevent early postpartum hemorrhage. b. Administer Methergine to stop the bleeding. c. Call the primary healthcare provider/CNM and prepare for a pelvic exam. d. Document findings and continue to monitor.

d. Document findings and continue to monitor. text

The nurse is talking with a mother during a routine follow-up call on postpartum day 3. The mother reports waking up with the baby every 2 hours; nipple tenderness with latch that resolves during the course of the feeding; seeing small, dime-sized blood clots on her pad when waking in the morning; and a nagging cramp in her right leg, which she attributes to her position while giving birth. Which report from the mother does the nurse need to assess further? a. Her report of nipple tenderness b. Her report of the baby's frequent night waking c. Her description of the blood clots d. Her report of leg cramps

d. Her report of leg cramps (unilateral leg pain is a sign of thrombosis) text

The nurse is reviewing laboratory values and flowsheet data for her client on postpartum day 1. Which of the following would the nurse point out to the nurse-midwife or primary healthcare provider? a. WBC count of 25,000/mm3 b. Urine output of 3000 ml in 24 hours c. Decrease in hematocrit from 32% to 31% d. Maternal heart rate of 120 bpm

d. Maternal heart rate of 120 bpm -bradycardia is expected in the postpartum period -normal WBC = 5,000-10,000 mm³ text

A 24-hour-postpartum client who had a cesarean birth with general anesthesia complains of abdominal discomfort and gas pains. What is the most appropriate nursing intervention? a. Administer analgesic medication to the client. b. Encourage the client to drink hot tea. c. Offer carbonated beverages to the client. d. Position the client on the left side.

d. Position the client on the left side. (positioning the pt on the left side allows for the gas to rise from the descending colon to the sigmoid colon so it may be expelled) text

The nurse is at the bedside during the recovery period immediately after a vaginal birth at term. The pregnancy, labor, and birth were uncomplicated. The mother experiences a visible, full body tremor, and states, "Oh no! I can't stop shaking! What's wrong with me?" What are the most appropriate nursing actions? a. Overhead page the nurse-midwife or primary healthcare provider and notify the charge nurse. b. Increase the rate of IV fluid and postpartum Pitocin. c. Recline the head of the bed and elevate the foot. d. Reassure the client and cover her with warm blankets.

d. Reassure the client and cover her with warm blankets. text

Immediately after delivery, the nurse performs a fundal assessment on the new mother. Which of the following findings is considered to be normal? a. The top of fundus is in the midline and at the level of the umbilicus. b. The top of fundus is in the midline and one fingerbreadth below the umbilicus. c. The top of fundus remains in the midline and descends about one fingerbreadth per day. d. The top of fundus is in the midline about midway between the symphysis pubis and umbilicus.

d. The top of fundus is in the midline about midway between the symphysis pubis and umbilicus. text

hallmark symptom of postpartum infection

fever >38°C (100.4°F) for 2 or more consecutive days