Ch. 16 nursing mgmt during PP period
Which finding would the nurse describe as "light" or "small" lochia?
4-inch stain or a 1 to 25 ml loss Typically the amount of lochia is described as follows: Scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; Light or small: 4-inch stain or a 10 to 25 ml loss; Moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; Large or heavy: a pad is saturated within 1 hour after changing it.
Which of the following is an appropriate nursing intervention 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 physician's order and is not necessary as a prevention measure.
A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that patients empty their bladders. A full bladder can lead to which of the following complications?
Increased lochia drainage If the bladder is full in a postpartum mother, lochia drainage will be more than normal because the uterus cannot contract to suppress the bleeding. The other options do not happen if a woman has a distended bladder.
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 is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment?
• Passing gas • Active bowel sounds • Nondistended abdomen Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into
A newly delivered mother has difficulty sleeping despite her exhaustion from labor. This inability to rest is due to
• The baby's crying • Inability to get adequate pain relief • Frequent trips to the bathroom due to diuresis • Excess fatigue and overstimulation by visitors The period before labor and delivery can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.
Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after delivery make a woman more susceptible to infection?
• Urinary stasis • Denuded endometrial arteries • Episiotomy The urinary system after delivery is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation.