Chapter 15: Postpartum Adaptations
The nurse is providing discharge education for a new mother regarding constipation. Which statement by the mother indicates that she understands what the nurse explained to her?
"I will increase my intake of fruits and vegetables in my diet. I love to eat them anyhow." Explanation: The objective of preventing constipation is to increase the mother's intake of fruits, vegetables, and fiber. The offered meal is comprised of low fiber foods. The mother is discouraged from suppressing the urge to pass stool, although the mother is often frightened it will hurt. Bulk-forming medications such as psyllium are excellent to help the mother not become constipated. There is no problem with the medication interfering with breastfeeding.
The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding?
A process of developing an attachment and becoming acquainted with each other Explanation: Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.
A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?
Empty the breasts frequently. Explanation: The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?
Harm to self Explanation: When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed.
Healthy bonding behaviors are important to note when the nurse is assessing the new family. What statement or action would the nurse consider a warning sign that the mother and infant were not attaching as they should?
Mother states she wanted a boy this time, not another girl. Explanation: It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals of poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn.
The nurse is observing a set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive?
The mother is reluctant to touch the newborn for fear of hurting her. Explanation: New parents are often nervous and unsure of themselves but bonding behaviors normally follow a pattern. Initially, the parents gently touch the newborn with their fingers, and then go to the extremities to inspect them. Making comments about the newborn's similarities in appearance to the parents is also commonly seen. Holding of the newborn in the en face position, where the parent is directly looking at the newborn, is seen in most families. A reluctance to touch the newborn is counterproductive for bonding since bonding relies on the interaction between the parent and the child.
Which body system is most vulnerable to infection during the postpartum period?
Urinary Explanation: The urinary system must handle an increased workload in the early postpartum period and the renal system is altered by hydronephrosis, a normal change with pregnancy. The hydronephrosis and urinary stasis often lead to urinary tract infections.
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding Explanation: During the postpartum period, many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartum blues. The 38-year-old mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.
A young mother is at the office for her 6-week visit. She is still experiencing mild lochia alba and is concerned that she has an infection. Which finding would the nurse interpret as supporting this suspicion?
foul odor Explanation: At 3 to 6 weeks, the lochia alba is in the final stage. The discharge is creamy white or light brown and consists of leukocytes, decidual tissue, and reduced fluid content. Lochia at any stage should have a fleshy smell; an offensive odor usually indicates an infection.
The postpartum client is reporting her left calf hurts and it is making it difficult for her to walk. The nurse predicts which factor is contributing to this situation after finding an area of warmth and redness?
increased coagulation factors Explanation: The woman is showing signs of thromboembolism or deep vein thrombosis, which is a risk for the postpartum client due to the increased hypercoagulable state that occurs during the pregnancy. This hypercoagulable state is the result of increased coagulation factors that the body uses as a protective device; however, it also increases the risk of blood clots in the lower extremities. Increased white blood cell count would be suspicious for an infection. Decreased red blood cell count would be expected due to the loss of blood; however, if it continues, the client should be evaluated for anemia. The stirrups should not cause an injury.
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Explanation: Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?
perineum Explanation: Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?
postpartum baby blues Explanation: Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.
The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest?
promoting skin-to-skin contact (kangaroo care) on the chest Explanation: Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.
A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?
urinary tract infection Explanation: Urinary frequency and burning suggest a urinary tract infection. Uterine atony and subinvolution could cause increased blood loss and prolonged lochia. Loss of pelvic muscle tone causes stress incontinence, which results in an inability to hold urine.
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage?
uterine atony Explanation: Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?
"After birth it is easier to develop an infection in the urinary system; we need to see you today." Explanation: The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
"I can't wait for these stretch marks to disappear after I give birth." Explanation: Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.
A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?
"It sounded like you had quite a time getting here. Would you like to continue your story?" Explanation: The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.
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 woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be:
"Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy." Explanation: Diaphoresis often occurs in postpartum women as a way to get rid of both excess water and waste through the skin. It is not uncommon for a woman to wake up drenched in sweat during the first few days following delivery. This is a normal finding and is not a cause for concern.
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 woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort." Explanation: Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. -Lochia rubra -Fundal height level of one fingerbreadth above the umbilicus -Episiotomy appears edematous -Temperature of 101.8°F (38.8°C) -White blood cell count of 28,000/mm3
-Fundal height level of one fingerbreadth above the umbilicus -Temperature of 101.8°F (38.8°C) Explanation: The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.
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 client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema?
Apply ice. Explanation: Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. Explanation: The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.
A new mother is in the second developmental stage of becoming a mother and is becoming independent in her actions. Which action by the nurse would best foster this stage?
Demonstrating how to do cord care on the newborn Explanation: When a mother enters the independent period of the second stage of becoming a mother, the nurse can assist her best by supporting her and praising her when she cares for the newborn. By demonstrating cord care to her, it empowers her to do the cord care the next time it is needed. The nurse's job is to not take over but to assist the mother in caring for her newborn.
The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation?
Encourage fiber-rich foods. Explanation: Encouraging fiber-rich foods will help with prevention of constipation. The client needs plenty of water, needs to ambulate, and should take stool softeners (not a stimulant laxative) if ordered by the health care provider. Increasing the coffee intake will not assist with preventing constipation. The client should get plenty of rest but it should be balanced with activity to help stimulate peristalsis of the GI tract.
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 nurse has received the results of a client's postpartum hemoglobin and hematocrit. Review of the client's history reveals a prepartum hemoglobin of 14 g/dl (140 g/L) and hematocrit of 42% (0.42). Which result should the nurse prioritize?
Hemoglobin 9 g/dl (90 g/L) and hematocrit 32% (0.32) in a woman who has given birth by cesarean Explanation: First, the nurse needs to determine the amount of blood loss during the delivery. For every 250 ml of blood lost during the delivery process, the hemoglobin should decrease by 1 g/dl (10 g/L) and the hematocrit by 2%. The acceptable amount of blood loss during a normal vaginal delivery is approximately 300 ml to 500 m and for a cesarean delivery approximately 500 mL to 1000 ml. The loss of hemoglobin from 14 gm/dl (140 g/L) to 9 gm/dl (90 g/L) is 5 and for the hematocrit from 42% to 32% is 10. This would indicate the client lost approximately 1250 ml of blood during the cesarean delivery (5 x 250 = 1250); this is too much and should be reported to the health care provider immediately. The other choices would be considered to be within normal range.
A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any client experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?
Kegel exercises Explanation: The nurse should recommend that the client practice Kegel exercises to improve pelvic floor tone, strengthen the perineal muscles, and promote healing. Sitz baths are useful in promoting local comfort in a client who had an episiotomy during the birth. Abdominal crunches would not be advised during the initial postpartum period and would not help tone the pelvic floor as much as Kegel exercises.
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?
Maintain correct posture and positioning. Explanation: The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.
A postpartum client reports stress incontinence. What information should the nurse suggest to the client to overcome stress incontinence?
Perform Kegel exercises. Explanation: The nurse should ask the client to perform the Kegel exercises in which the client needs to alternately contract and relax the perineal muscles. Aerobic exercises will not help to strengthen perineal muscles. Reduced fluid intake and frequent emptying of the bladder will not help the client overcome stress incontinence.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next?
Perform urinary catheterization. Explanation: Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The health care provider would be notified if no other interventions help the client.
A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. What should the nurse do next?
Tell the client to take an NSAID orally. Explanation: The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Explanation: Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.
Which reason explains why women should be encouraged to perform Kegel exercises after birth?
They promote blood flow, enabling healing and muscle strengthening. Explanation: Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.
What is the primary rationale for monitoring a new mother every 15 minutes for the first hour after delivery?
To check for postpartum hemorrhage Explanation: If a new mother is going to hemorrhage, it will usually occur within the first hour following delivery. Therefore, the nurse checks on the client every 15 minutes, noting fundal firmness and position, amount and character of lochia and checking for bladder distention. There are no anticipated elevations in the mother's blood pressure, nor should the mother's milk come in this early.
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra. Explanation: The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as:
attachment. Explanation: When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smooths the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?
bleeding Explanation: Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis Explanation: Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.
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.
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
hemorrhage Explanation: The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.
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 woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?
inability of infant to empty breasts Explanation: For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
A nurse is assessing a breastfeeding client in the third week postpartum. During the physical examination, the nurse observes that the rugae in the vagina have not reappeared. Which factor would the nurse identify as the possible cause of delayed return of rugae?
low circulating estrogen level Explanation: The nurse should identify low circulating estrogen levels as the possible cause of delayed return of rugae. Low circulating progesterone levels initiate lactation. High circulating prolactin levels increase secretion of milk. Oxytocin is responsible for stimulating contractions of the uterus.
During the birth, the primary care provider performed an episiotomy. The client is now reporting discomfort. To reduce this discomfort and increase hygiene to the perineum, the nurse would encourage the client to use which intervention?
peribottle and warm water Explanation: Local comfort measures for the perineum after an episiotomy or laceration include ice packs, pouring warm water over the area via a peribottle, witch hazel pads, anesthetic sprays, and sitz baths.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition?
postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breastfeeding, the nurse would identify which hormone that is responsible for milk production?
prolactin Explanation: Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.
The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?
rise in hematocrit Explanation: Hemoglobin and erythrocyte values vary during the early postpartum period, but they should approximate or exceed prelabor values within 2 to 6 weeks. As the woman excretes extracellular fluid, hemoconcentration occurs, with a concomitant rise in hematocrit. Puerperal bradycardia, with rates of 50 to 70 beats per minute, is common during the first 6 to 10 days postpartum. Blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks' gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
showing increased confidence when caring for the newborn Explanation: Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.
