Chapter 16: Nursing Management During the Postpartum Period

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "I only eat a low-fiber diet." "Sitz baths worked the last time." "I already have some pads with witch hazel at home." "My mom always used dibucaine."

"I only eat a low-fiber diet."

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "Sitz baths worked the last time." "I only eat a low-fiber diet." "I already have some pads with witch hazel at home." "My mom always used dibucaine."

"I only eat a low-fiber diet."

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much? Over 50 ml 25 to 50 ml 10 to 25 ml Under 10 ml

25 to 50 ml

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 1,000 additional calories per day 250 additional calories per day 750 additional calories per day

500 additional calories per day

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad. Vigorously massage the fundus. Immediately call the primary care provider.

Ask the client when she last changed her perineal pad.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Administer Rh immunoglobulins intramuscularly. Determine the newborn's blood type and rhesus. Ask if the client received rH immunoglobulins during the pregnancy. Determine if this is the client's first baby.

Determine the newborn's blood type and rhesus.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Determine if the client is emptying her bladder. Perform an "in and out" catheter on the client. Ask the client when she last urinated. Educate the client on how to perform Kegel exercises.

Educate the client on how to perform Kegel exercises.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action? Nothing—excessive postpartum blood loss is normal. Document the findings. Call the primary care provider. Massage the boggy fundus until it is firm.

Massage the boggy fundus until it is firm.

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? Ask family members to monitor the parents' progress. Encourage frequent clinic visits for high-risk families. Provide phone numbers for call centers for questions. Schedule home visits for high-risk families.

Schedule home visits for high-risk families.

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? Only mental health professionals can detect postpartum depression. Postpartum depression only impacts women with two or more children. Symptoms occur within a week after giving birth. Symptoms of postpartum depression can easily go undetected.

Symptoms of postpartum depression can easily go undetected.

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. Her uterus is soft to your touch. The flow contains large clots. The flow is over 500 mL.

The color of the flow is red.

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. The flow contains large clots. The flow is over 500 mL. Her uterus is soft to your touch.

The color of the flow is red.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is above expected levels. The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is normal. The urinary output is inadequate suggestive of urinary retention.

The urinary output is normal.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is normal. The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is inadequate suggestive of urinary retention. The urinary output is above expected levels.

The urinary output is normal.

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after birth? after 60 minutes every 15 minutes after 45 minutes every 30 minutes

every 15 minutes

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? whenever the couple wishes usually within a couple weeks generally within 3 to 6 weeks generally after 12 weeks

generally within 3 to 6 weeks

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? too much milk being retained an improperly positioned baby during feedings normal findings in breastfeeding mothers mastitis

mastitis

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. scant. heavy. light.

moderate.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? one fingerbreadth above the umbilicus one fingerbreadth below the umbilicus at the level of the umbilicus below the symphysis pubis

one fingerbreadth below the umbilicus

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? labor less than 3 hours placenta removed via manual extraction multiparity hemoglobin of 11.5 mg/dl (115 g/L)

placenta removed via manual extraction

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 allow visitors policies that allow rooming the infant and mother together policies that allow flexibility for cultural differences policies that discourage unwrapping and exploring the infant

policies that discourage unwrapping and exploring the infant

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 policies that allow rooming the infant and mother together policies that allow visitors policies that allow flexibility for cultural differences

policies that discourage unwrapping and exploring the infant

A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition? pulmonary embolism infection hypertension hemorrhage

pulmonary embolism

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: mitral valve collapse. upper respiratory infection. pulmonary embolism. thrombophlebitis.

pulmonary embolism.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? edema drainage temperature redness

temperature

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? hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities infection normal response to the body converting back to prepregnancy state

thromboembolic disorder of the lower extremities

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters? Determining chest and head circumference Inspecting posture, color, and respiratory effort Checking for identifying birthmarks or skin injuries Auscultating bowel sounds, and measuring urine output

Inspecting posture, color, and respiratory effort

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? "Maybe a lactation specialist can help me work through this." "Breastfeeding takes time and practice." "Some babies latch on and catch on quickly; others take a little more time." "Some women just can't breastfeed. Maybe I'm one of these women."

"Some women just can't breastfeed. Maybe I'm one of these women."

A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? A. "Talk to your 2-year-old about the baby when you're driving him to day care." B. "Have your 2-year-old stay at home while you're here in the hospital." C. "Ask your 2-year-old to pick out a special toy for his sister." D. "Expect to see your 2-year-old become more independent when the baby gets home."

C. "Ask your 2-year-old to pick out a special toy for his sister."

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Use ice packs for a week after birth. Apply ice packs for 40 minutes continuously. Ensure ice pack is changed frequently. Apply ice packs directly to the perineal area.

Ensure ice pack is changed frequently.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? hemorrhage infection atony normal involution

atony

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? showing a video of parents feeding their babies talking about how the nurse held her own newborn while on the birthing table allowing the mother to pick the best time to hold her newborn bringing the newborn into the room

bringing the newborn into the room

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? change in the temperature from the birth room fluid volume overload infection dehydration

dehydration

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 second degree third degree first degree

fourth degree

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? third degree second degree fourth degree first degree

fourth degree

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? hemorrhage pulmonary emboli infection depression

infection

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? bonding attachment being spoiled none of the above

attachment

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? A. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." B. "I'll contact your primary care provider." C. "If you don't attempt to void, I'll need to catheterize you." D. "I'll check on you in a few hours."

A. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. A. head-to-toe assessment B. pain level C. newborn's vital signs D. vital signs of mother E. head-to-toe assessment of newborn

A. head-to-toe assessment B. pain level D. vital signs of mother

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 is having a moderate amount of rubra lochia. Bowel sounds are active. The client requires assistance to ambulate in the hallway. The client is afebrile.

The fundus is located 2 fingerbreadths above the umbilicus.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: call the primary care provider or the nurse-midwife. inspect the perineum for lacerations. assess and massage the fundus. increase the flow of an IV.

assess and massage the fundus.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? infection hemorrhage normal involution atony

atony

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." "Some babies latch on and catch on quickly; others take a little more time." "Breastfeeding takes time and practice." "Maybe a lactation specialist can help me work through this."

"Some women just can't breastfeed. Maybe I'm one of these women."

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Help the mother initiate breastfeeding within 30 minutes of birth. B. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. C. Give newborns water and other foods to balance nutritional needs. D. Provide breastfeeding newborns with pacifiers. E. Encourage breastfeeding of the newborn infant on demand.

A. Help the mother initiate breastfeeding within 30 minutes of birth. B. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. E. Encourage breastfeeding of the newborn infant on demand.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Help the mother initiate breastfeeding within 30 minutes of birth. B. Provide breastfeeding newborns with pacifiers. C. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. D. Give newborns water and other foods to balance nutritional needs. E. Encourage breastfeeding of the newborn infant on demand.

A. Help the mother initiate breastfeeding within 30 minutes of birth. C. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. E. Encourage breastfeeding of the newborn infant on demand.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. A. vital signs of mother B. newborn's vital signs C. head-to-toe assessment D. pain level E. head-to-toe assessment of newborn

A. vital signs of mother C. head-to-toe assessment D. pain level

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation (dilatation) and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is: At risk for inadequate healing due to decreased nutrition. At risk for safety due to low hemoglobin. At risk for interruption of tissue integrity. At risk for postpartum depression due to inadequate rest.

At risk for postpartum depression due to inadequate rest.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? A. The client is afebrile. B. The fundus is located 2 fingerbreadths above the umbilicus. C. The client is having a moderate amount of rubra lochia. D. Bowel sounds are active. E. The client requires assistance to ambulate in the hallway.

B. The fundus is located 2 fingerbreadths above the umbilicus.

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? A. "Maybe you will feel better after you take pain medication." B. "As long as you walk more tomorrow to make up for the delay in walking today you should be fine." C. "Walking is the best way to prevent complications such as blood clots." D. "If you do not get up to walk you will not recover."

C. "Walking is the best way to prevent complications such as blood clots."

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day? 650 calories 950 calories 800 calories 500 calories

650 calories

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? A. The client is afebrile. B. The client is having a moderate amount of rubra lochia. C. The client requires assistance to ambulate in the hallway. D. Bowel sounds are active. E. The fundus is located 2 fingerbreadths above the umbilicus.

E. The fundus is located 2 fingerbreadths above the umbilicus.

A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? 99.2°F (37.3°C) 100.1°F (37.8°C) 100.8°F (38.2°C) 97.5°F (36.9°C)

100.8°F (38.2°C)

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time? Apply an ice pack to the perineal area. Instruct in the use of witch hazel compresses. Apply a glycerin-based ointment to the area. Encourage use of a sitz bath.

Apply an ice pack to the perineal area.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response? Vigorously massage the fundus. Ask the client when she last changed her perineal pad. Immediately call the primary care provider. Have the charge nurse review the assessment.

Ask the client when she last changed her perineal pad.

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? Reassess the client in 1 hour. Stop using a peri-pad. Document the lochia as scant. Massage the client's fundus.

Document the lochia as scant.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? Apply ice packs directly to the perineal area. Use ice packs for a week after birth. Apply ice packs for 40 minutes continuously. Ensure ice pack is changed frequently.

Ensure ice pack is changed frequently.

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? DVT infection nothing—it is normal hematoma

hematoma

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? transthoracic echocardiogram venogram of the right leg noninvasive arterial studies of the right leg venous duplex ultrasound of the right leg

venous duplex ultrasound of the right leg

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? normal response to the body converting back to prepregnancy state hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities infection

thromboembolic disorder of the lower extremities

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. A. women who had difficulties with breastfeeding in the past B. women on antithyroid medications C. women using street drugs D. women with more than one infant E. women on antineoplastic medications

B. women on antithyroid medications C. women using street drugs E. women on antineoplastic medications