306 Ricci PrepU Chapter 16: Nursing Management During the Postpartum Period 1
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?
2 weeks Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?
continue to monitor the woman's temperature every 4 hours; this finding is normal A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?
delayed hemorrhage Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.
A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?
first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?
hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:
moderate Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it.
A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?
negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors.
A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?
percussion reveals dullness A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.
When palpating for fundal height on a postpartum woman, which technique is preferable?
placing one hand at the base of the urterus, and one on the fundus Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?
policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.
Client teaching is conducted throughout a client's hospitalization and is reinforced before discharge. Which self-care items are to be reinforced before discharge? Select all that apply.
resumption of intercourse activity signs and symptoms of infection The correct answers give information on managing changes in her new role as a mother. The assumption cannot be made that her prepregnancy diet is still appropriate, and the formula choice should be discussed with her pediatrician.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?
the fundus is located 2 fingerbreadths above the umbilicus The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?
thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
Which factor puts a client on her first postpartum day at risk for hemorrhage?
uterine atony Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention?
uterus is boggy A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual.
A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action?
walk with the nurse the length of her room Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.
During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?
schedule home visits for high risk families To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.
Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:
"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
Atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.
Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.
The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?
document the lochia as scant "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?
educate the client on how to perform Kegel exercises Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.
Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?
encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.
A nurse is assessing a postpartum client. Which measure is appropriate?
instruct the client to empty her bladder before examination An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.
A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?
long term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:
maintaining previous house hold routines to prevent infection The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.
A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?
massage the boggy fundus until it is firm The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.
A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?
placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage.
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?
sitz bath increased blood supply to the perineal area Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.
Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means? Select all that apply.
stasis altered coagulation localized vascular damage Three factors predispose women to thromboembolic disorders during pregnancy: stasis (compression of the large veins because of gravid uterus), altered coagulation (state of pregnancy), and localized vascular damage (may occur during birthing process). All these increase the risk of clot formation.
A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?
wash her perineal with her daily shower A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?
wash her perineum with her daily shower A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?
Continue to monitor the woman's temperature every 4 hours; this finding is normal. A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
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 birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.
It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at:
between the umbilicus and symphis pubis The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?
brining the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next?
determine the newborns blood type and rhesus The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within *72 hours after birth*; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?
generally 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.
During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?
places a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus.
At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:
postpartum depression Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother.
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?
resume intercourse is bright red bleeding stops The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptive pills (OCPs).
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?
thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony?
boggy or relaxed uterus A boggy or relaxed uterus is a sign of uterine atony. This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foul-smelling urine and purulent drainage are signs of infections but are not related to uterine atony. The firm fundus is normal and is not a sign of uterine atony.
A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?
fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.
The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which action would the nurse include in the discussion as possible strategies for the new mothers to do? Select all that apply.
performing Kegel exercises avoiding smoking losing weight if obese Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoiding smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 ml to 2,000 ml.
The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care?
symptoms of post partum depression can easily go undetected The plan of care should acknowledge that symptoms of postpartum depression are often missed and go undetected (and therefore untreated). Postpartum blues occur within the first week after birth. Postpartum depression can develop after any pregnancy and can be assessed by providers in a variety of settings.
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:
the level of the umbilicus Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.
A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?
the color of the flow is red A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?
"It might take up to a week for your bowels to return to their normal pattern" Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern.
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?
inspecting posture, color, and respiratory effort The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age.
The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?
"Walking is the best way to prevent complications such as blood clots" The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.
In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.
women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?
"Some women just can't breastfeed. Maybe I'm one of these women" The statement about some women not being able to breastfeed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breastfeeding takes time and practice and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breastfeed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation.
A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?
offer suggestions based on observation to correct positioning or latching The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?
dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.
On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?
500 additional calories per day The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next?
determine the newborns blood type and rhesus The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding?
Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience. The nurse should reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience; this information will help to reduce the feelings of frustration and uncertainty about their ability to breastfeed. The nurse should also explain that breastfeeding is a learned skill for both parties. It would not be correct to say that breastfeeding is a mechanical procedure. In fact, the nurse should encourage the mother to cuddle and caress the newborn while feeding. The nurse should allow sufficient time to the mother and child to enjoy each other in an unhurried atmosphere. The nurse should teach the mother to burp the newborn frequently. Different positions, such as cradle and football holds and side-lying positions, should be shown to the mother.
A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply.
Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels. One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Appropriate interventions include: checking blood pressure first before ambulating the client; elevating the head of the bed for a few minutes before ambulating the client; having the client sit on the side of the bed for a few moments before getting up; helping the client to stand up, and staying with her; ambulating alongside the client and providing support if needed; and frequently asking the client how her head feels. Having her sit in the chair after getting out of bed would be inappropriate because the client's blood pressure may already have dropped.
A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply.
Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow. An infection of the breast during lactation is termed mastitis. Mastitis can interfere with lactation, and sometimes an infant will refuse to nurse on the affected side. The women's medical provider must be notified to initiate antibiotic treatment. Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of maternal mastitis.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
When assessing the episiotomy site of a postpartum client who delivered 3 hours ago, the nurse would document which findings as expected? Select all that apply.
edema slight bruising During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.