chap 15 Postpartum adaptations
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum Explanation: A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra. Explanation: The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming." Explanation: The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy, since midway through pregnancy she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day postpartum, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding Explanation: Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading?
sitting on the side of the bed for 2 minutes Explanation: To get the most accurate reading on a 1-day postpartum client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Explanation: Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.
A nurse is providing care to a postpartum woman who is breastfeeding her 1-day old neonate. While observing the interaction, the woman says to the nurse, "I have noticed some tingling in both of my breasts just before my baby starts to feed and then for a bit during the feeding. What is happening?" Which response by the nurse would be appropriate?
"What you are feeling is the normal let-down reflex when milk is released." Explanation: Typically, during the first 2 days after birth, the breasts are soft and nontender. The woman may also report a tingling sensation in both breasts, which is the "let-down reflex" that occurs immediately before or during breastfeeding. This tingling is not a sign of infection or blockage of the milk ducts. Engorgement is a postnatal physiologic painful condition in which distension and swelling of the breast tissue occurs as a result of an increase in blood and lymph supply as a precursor to lactation. Breast engorgement usually peaks in 3 to 5 days postpartum and usually subsides within the following 24 to 36 hours.
A nurse is making a home visit to a new mother who gave birth vaginally 5 days ago. The woman tells the nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. The woman asks the nurse about the average weight loss for 5 days postpartum. Which information would the nurse incorporate into the response?
19 lb Explanation: The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb.
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Bladder distention Explanation: Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours. Explanation: The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution Explanation: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack. Explanation: The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.
The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?
The health care provider needs to be notified of the latest lab values. Explanation: If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased. Explanation: Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.
The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor?
discomfort due to hemorrhoids Explanation: The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation.
The nurse is caring for a client is who 24-hours post-delivery of an infant. Which assessment does the nurse predict the health care provider will prioritize for the mother at this time?
hemoglobin and hematocrit Explanation: The health care provider will order hemoglobin and hematocrit (H&H) levels to assess the woman for potential anemia. A decreased result may indicate the woman has suffered post-delivery hemorrhage and is also common with cesarean deliveries. The maternal blood type will be determined before the delivery. The H&H may be ordered as part of the complete blood count or may be ordered separately. The complete blood count may be ordered to evaluate for infection if the client has a fever. The iron level may be ordered at a later date if the H&H continues to remain low after a few days, but is not a priority within the first 24 hours after delivery.
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?
hypovolemia Explanation: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis Explanation: The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
