chapter 16 PrepU

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."

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?

25 to 50 mL -Typically, the amount of lochia is described as follows: scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-mL loss; light or small: an approximately 4-in (10-cm) stain or a 10- to 25-mL loss; moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 mL; large or heavy: a pad saturated within 1 hour after changing it or over 50-mL loss.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m.

A mother is postpartum 2 hours after a cesarean birth with epidural anesthesia. The nurse notes the urine output in the Foley bedside drainage bag is 50 ml. What should the nurse do first?

Check the catheter tubing for kinks or obstruction. - The nurse should always assess the situation before attempting an intervention. If the catheter tubing is kinked or obstructed, urine may not be draining adequately; therefore, this should be the priority. Because the mother's epidural anesthesia may not totally be worn off the nurse should not ambulate the mother. The mother may also not be ready to void when the Foley is removed. The mother may need additional IV fluids but the obstetric provider would first need to be notified.

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.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Encourage breastfeeding of the newborn infant on demand. Help the mother initiate breastfeeding within 30 minutes of birth. Place baby in uninterrupted skin-to-skin contact with the mother.

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.

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.

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.

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area.

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.

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.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 100 to 200 ml with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. -Expected urinary output for a postpartum woman is at least 100 ml with each void on an hourly basis. Therefore 100 to 200 ml are a normal volume for each void.

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.

The LVN/LPN will be assessing a postpartum client for danger signs of infection after a vaginal birth. What assessment finding would the nurse assess as a possible sign of infection for this client?

fever more than 100.4° F (38° C) -A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

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

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor.

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.

pain level head-to-toe assessment vital signs of mother

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.

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

temperature

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:

the level of the umbilicus. -The uterine fundus is usually at the level of the umbilicus 1 hour after birth.

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 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.

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?

100.8°F (38.2°C) - Typically, the new mother's temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4°F (38.0°C), during the first 24 hours. However, A temperature above 100.4°F (38.0°C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported.

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.

A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply.

urinary stasis denuded endometrial arteries episiotomy -The urinary system after birth 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, such as an episiotomy. 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. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's 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.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching -Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

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.

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.

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.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

fundus boggy to the right of the umbilicus rounded mass over symphysis pubis dullness on percussion over symphysis pubis -If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

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 below the umbilicus -After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

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.

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?

bringing 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 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 if 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 contraceptives.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia -Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.