chapter 19 nursing of the family during postpartum care

At the time of discharge Contraception is an important aspect of patient care. It should be discussed with the patient at the time of discharge. The patient may start to ovulate as early as 1 month postpartum; therefore contraception methods should be explained to the patient at discharge. Waiting for the patient's follow-up visit or for a month or more to educate the patient about contraception may be too late, and the patient may conceive again.

A postpartum patient is being prepared for discharge and is instructed to visit the clinic after 6 weeks for follow-up. When should the nurse discuss contraceptive options with the patient?

Oxytocin (Pitocin) Oxytocin is the most common drug ordered to increase the uterine tone and control uterine atony. Nonopioid analgesics such as ibuprofen are used for pain management in postpartum breastfeeding women because they do not reduce maternal or infant alertness. Magnesium sulfate is used to treat preeclampsia.

The nurse is caring for a patient with uterine atony. The nurse massages the patient's uterine fundus. The uterus remains boggy even after the blood clots are expelled. What medication would be most beneficial for the patient?

A woman who had epidural anesthesia Every woman is at risk for bladder distention after delivery. Therefore the nurse must assess the patient's voiding patterns after childbirth. The biggest risk factor is epidural anesthesia, which affects the sensory nerves. It occurs because the woman is unaware of the need to empty her bladder. Nerve blocks may also affect the motor nerves, making micturition difficult. A midline episiotomy will not promote urinary retention. Intravenous fluids may cause more urine to be produced but would not worsen retention of urine. A labor that lasts 12 hours would not increase the risk of bladder distention

A nursing student asks the nurse, "Which woman is at greatest risk of bladder distention after a normal vaginal delivery?" Which is the best response by the nurse?

continue prenatal vitamins The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean.

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient?

Inform the primary health care provider (PHP) about the patient's condition immediately Have the patient remain in bed with reddened limb elevated on pillows A patient who has had a cesarean birth and has remained in the bed for more than 8 hours is at risk of venous thromboembolism. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the leg, the nurse should notify the PHP immediately. Meanwhile, the patient should remain in bed with the affected limb elevated on pillows. Applying heat increases discomfort because the affected limb is already warm. Applying antiinflammatory ointment to the leg at the reddened site would not be useful because the redness is caused by embolism, not inflammation.

A patient who has had a cesarean birth has been on bed rest for 8 hours after surgery and has warmth and redness in the left lower limb. Which interventions taken by the nurse would be most beneficial to the patient? Select all that apply.

Place hydrogel pads to the breasts between feedings Hydrogel pads can be applied if the patient has sore nipples between feedings. This will increase comfort during breastfeeding. Application of ice packs between feedings reduces breast engorgement. To reduce breast irritation, the nurse advises the patient to wear breast shells. Cold cabbage leaves applied to the breasts for 15 to 20 minutes between feedings can reduce breast engorgement by reducing tissue swelling and facilitating the flow of milk.

The nurse is caring for a 2-day postpartum patient who is breastfeeding. The patient reports sore nipples. Which intervention would be beneficial to the patient?

To strengthen the perineal muscles Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles.

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises?

Dark red with a fleshy odor Lochia rubra is observed within 1 to 3 days. It is dark red and has a fleshy odor. If the lochia has a foul odor, it indicates that the patient has an infection. The lochia is yellowish white in color 10 days after delivery. Therefore the nurse would find dark red lochia with a fleshy odor in a postpartum patient 24 hours after delivery.

While assessing a postpartum patient 24 hours after delivery, the nurse checks the lochia and finds that the patient is free of infection. Which observation related to the lochia led the nurse to make such a conclusion?

Massaging the fundus every hour for the first 24 hours following birth The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.

Which measure is least effective in preventing postpartum hemorrhage?

Fatigue may affect interest in sexual activity Sexual activity can usually be safely resumed by 2 to 4 weeks after birth Water-soluble lubrication may increase comfort The female-on-top position may be more comfortable than other positions The amount of psychological energy expended by the mother in child care activities may lead to fatigue and decreased interest in sexual activity. A patient can safely resume sexual activity (intercourse) by the second to fourth week after birth. A water-soluble gel or jelly is recommended for lubrication. A position in which the mother has control of the depth of insertion of the penis, such as the female-on-top position may be more comfortable than other positions.

A postpartum patient preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? Select all that apply.

Encourage the patient to use a rocking chair A patient who complains of abdominal discomfort and gas pains should be encouraged to use a rocking chair because it stimulates the passage of flatus and relieves discomfort. The patient should not be encouraged to drink coffee because the caffeine present in it intensifies the pain by increasing bowel movements. Analgesic medication does not relieve gas, but the administration of antigas or antiflatulent medications may help relieve gas. Offering soups and beverages may cause more discomfort and gas in the patient.

The nurse is caring for a 24-hour-postpartum patient who had a cesarean birth with general anesthesia. The patient complains of abdominal discomfort and gas pains. What would be the most suitable nursing intervention in this situation?

Postpartum hemorrhage A loss of 600 mL of blood within 24 hours indicates that the patient has postpartum hemorrhage. Because the patient's uterus feels soft and relaxed, it indicates that the patient has uterine atony, which leads to excessive blood loss. Mastitis is inflammation of the mammary glands that disrupts normal lactation and usually develops 1 to 4 weeks after labor. Puerperal infection is characterized by fever. Venous thromboembolism is caused by deep vein thrombosis. It occurs later in the postpartum period, 10 to 14 days after delivery.

The nurse is caring for a patient during the fourth stage of labor. After assessment, the nurse finds that the patient has lost 600 mL of blood. The nurse also finds that the patient's uterus is soft and relaxed. Which postpartum complication has the patient developed?

Periodic crying and insomnia After the baby is born, many new mothers have the "postpartum blues" or "baby blues." Periodic crying and insomnia are characteristics of postpartum blues. It is transient and resolves on its own. It is caused by a number of factors including changes in hormone levels and adjustment to motherhood. Symptoms that last for more than 2 weeks could indicate postpartum depression and warrant treatment. Panic attacks and suicidal thoughts are characteristics of postpartum psychosis; anger toward self and infant and obsessive thoughts and hallucinations are characteristics of postpartum depression.

The nurse is caring for a patient who has just given birth. What findings in the patient would indicate that she has postpartum blues?

Nipples with cracks and fissures Cracks and fissures in the nipples indicate problems with latching. This is a potential complication and should be reported to the PHP. Lochia alba, a white vaginal discharge, is a normal finding 10 days after childbirth. Breastfeeding mothers often experience vaginal dryness related to high prolactin levels and low estrogen levels. Dizziness while changing positions indicate that the patient has orthostatic hypotension. Orthostatic hypotension for 48 hours is a normal finding in a postpartum patient.

The nurse is giving discharge instructions to a patient. Which finding does the nurse instruct the patient to report to the primary health care provider (PHP)?

Apply an ice pack to limit edema during the first 12 to 24 hours Applying a covered ice pack to the perineum from front to back during first 24 hours decreases edema and increases comfort. Using two or more perineal pads would be helpful in absorbing the heavy menstrual flow but will not reduce the pain or promote perineal healing. Sitz baths and Kegel exercises are important measures to provide pain relief and comfort to the patient with a fourth-degree laceration. Therefore the nurse should not advise the patient to avoid taking sitz baths and performing perineal (Kegel) exercises.

While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient?

Advise the patient to wear a breast binder for the first 72 hours after giving birth Suppression of lactation is recommended in cases of neonatal death. To suppress lactation, the nurse should advise the patient to wear a breast binder continuously for the first 72 hours after delivery. Running warm water over the breast stimulates lactation. Mild analgesics can be administered to reduce breast engorgement, but they are not used to suppress lactation. Administration of oral or intravenous fluids may stimulate lactation

What intervention does the nurse perform to suppress lactation in a patient who had a stillbirth?

Take stool softeners regularly The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean

A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient?

Failure of the uterine muscle to contract firmly Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause

Excessive blood loss after childbirth can have several causes; however, which is the most common?

Venous thromboembolism (VTE Homans' sign is an assessment test used to determine whether the patient has VTE. Presence of Homans' sign indicates that the patient may have VTE. Uterine atony can be assessed by palpating the uterine fundus. Hypotensive shock can be assessed by checking the patient's vitals. Mastitis can be assessed by the examining the patient's breasts.

On reviewing the medical reports of a postpartum patient, the nurse finds that the patient has Homans' sign. What does the nurse interpret from this finding?

Uses the peribottle to rinse upward into her vagina The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix. Using soap and warm water to wash is appropriate. Washing from the symphysis pubis back to the episiotomy is appropriate. Changing the perineal pad every 2 to 3 hours is appropriate.

Perineal care is an important infection control measure. When evaluating a postpartum patient's perineal care technique, the nurse recognizes the need for additional instruction if the patient does what?

thromboembolism Thromboembolism is a postpartum complication caused by hormonal imbalances, stress of childbirth, and long periods of immobility. This complication can be prevented by encouraging early ambulation

The nurse helps a postpartum patient ambulate around the patient's bed. What complication is the nurse trying to prevent?

Provide education about newborn care when the father is present To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to demonstrate the process.

The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding?

Provide oxygen Notify the physician Increase intravenous fluids. The patient is exhibiting signs of hypovolemic shock. Appropriate interventions include providing oxygen, notifying the physician, and increasing intravenous fluids

The nurse performs an assessment on a woman who is four hours postpartum. The woman appears grayish and is anxious. Her blood pressure is 82/44 mm Hg and her heart rate is 128 bpm. Which interventions should the nurse implement? Select all that apply

300 mcg of intramuscular Rh immune globulin If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization.

The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient?

Limit visitors and activities The mother should sleep when the baby sleeps accept help with housework The patient's responses indicate that she is experiencing postpartum fatigue. It is important to save energy during this period and sleep when the baby sleeps. The nurse should advise the patient and her partner to limit visitors and activities. Fatigue may increase further if the patient provides care and feeding for the newborn and performs other household responsibilities such as preparing meals and doing laundry. Therefore, she should accept help from other family members for household work for at least first 6 weeks after childbirth. The patient is lactating and needs proper nutrition. Therefore the nurse should not ask the patient to skip meals. Because the patient does not report having pain, the nurse need not suggest the use of pain medications.

A postpartum patient tells the nurse, "It has been several weeks since I had my baby, and I'm still tired all the time." What advice should the nurse provide to the patient in this situation? Select all that apply.

document the findings and continue to monitor. Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation?

"I should use soap and a full bottle of water to wash my perineum." "I should wash from symphysis pubis back to anus." I should change the perineal pad for every 2 to 3 hours." The nurse should inform the patient that the tap water should be heated to 38o C. Washing with warm water will make the patient feel comfortable and provide relief from pain. The patient should wash the perineum with mild soap and squeeze a bottle full of water at least once daily to maintain hygiene and prevent infections. Cleansing from symphysis pubis to anal area ensures proper cleaning and prevents infection. Changing the perineal pad for every 2 to 3 hours helps prevent infections.

The nurse has taught perineal care techniques to a postpartum patient to prevent infections. After the teaching session, the nurse asks the patient to repeat the measures that should be followed to prevent infection. how should the patient wash?

Monitoring blood pressure Monitoring skin condition Administering oxytocin Administering blood or blood products Uterine atony results from failure of the uterine muscle to contract firmly. Skin color changes to ash or gray in a patient who has uterine atony, so the nurse should monitor the patient's skin condition because it is a sensitive means of identifying hypovolemic shock. Administering uterotonic medications such as oxytocin helps increase the uterine tone and thereby control excess bleeding. Administering blood or blood products replaces blood loss. Monitoring blood pressure does not help in controlling blood loss. Analgesics can be administered to patients who feel pain during urinating, but this does not help prevent bleeding.

The nurse is caring for a patient who has postpartum hemorrhage resulting from uterine atony. Which interventions would help identify and care for hypovolemic shock? Select all that apply.

Measure the patient's fluid intake and output Encourage the patient to void urine frequently. The patient has impaired urinary elimination due to pain caused by the episiotomy wound. The nurse should encourage the patient to void frequently to prevent uterine atony. A full or distended bladder increases the risk of uterine atony and may lead to postpartum hemorrhage. The nurse should measure the patient's fluid intake and urine output to assess the fluid electrolyte balance. The patient should also be advised to take adequate oral fluids. If these measures are unsuccessful, only then should the nurse insert a sterile catheter to drain the urine. If the patient does not pass urine, it will further increase the risk of uterine atony.

The nurse is caring for a patient who has undergone a vaginal delivery and has an episiotomy wound. During assessment, the nurse finds that the patient has impaired urinary elimination. Which interventions taken by the nurse would be most beneficial for the patient? Select all that apply.

Complete the child care activities silently, without looking at the baby The psychosocial assessment includes evaluating adaptation to parenthood, as evidenced by the parents' reactions to the baby and interactions with the new baby. Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning baby comfortably, and maintaining eye-to-eye contact are appropriate behaviors that increase parent-infant attachment.

The nurse is caring for a postpartum patient who gave birth recently. The nurse is evaluating the parent's behavior toward the new baby. Which parent-infant behaviors should the nurse investigate further?

Laxatives Opioid analgesics decrease intestinal motility, which results in constipation. To decrease constipation, the PHP includes laxatives in the patient's treatment regimen. Enemas and rectal suppositories should not be administered to the patient with fourth-degree perineal lacerations because they are very uncomfortable and may cause hemorrhage or damage to the suture line. Prostaglandins may suppress the immune system and can also predispose the patient to the various infections.

The nurse is caring for a postpartum patient with fourth-degree perineal lacerations who has been prescribed opioid analgesics. After 2 days, the nurse informs the primary health care provider (PHP) that the patient has constipation. Which medication does the nurse expect to be included in the patient's treatment regimen

An infection is present. Lochia is vaginal discharge that can be observed after childbirth; it contains blood and mucus. Usually, lochia appears to be dark red during the first 3 days after delivery and has fleshy odor. The presence of foul odor indicates that the patient has an infection. Foul-smelling lochia does not indicate that the patient is healing well. The presence of a moderate amount of lochia would indicate that the patient is healing well. An increase in body temperature would indicate that the patient is dehydrated. Excessive bleeding would indicate internal hemorrhage.

The nurse is caring for a postpartum patient. One day after delivery, the nurse assesses the lochia of the patient and finds that it is red and has a foul-smelling odor. What does the nurse conclude from this assessment?

An increase in pulse from 88 to 102 beats/min During the postpartum period, maternal blood pressure, pulse, and respiration should be checked every 15 minutes during the first hour. A rising pulse is an early sign of excessive blood loss because the heart pumps faster to increase the supply of blood. A body temperature of 100.4° F is a normal finding. A respiratory rate of 22 breaths/min indicates that the patient has no internal bleeding. A blood pressure of 120/80 mm Hg does not indicate that the patient has hemorrhage.

The nurse is monitoring a postpartum patient for signs of hemorrhage. Which observation would indicate excessive blood loss?

You should use proper contraception for 1 month after the vaccination The patient must not become pregnant for 1 month after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient?

You should use proper contraception for 1 month after the vaccination. The patient must not become pregnant for 1 month after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient?

Breastfed infants should be taken for a pediatric health checkup 3 to 5 days after birth, or 48 to 72 hours after hospital discharge, and again at approximately 2 weeks of age. Breastfed infants should be taken for a pediatric health checkup 3 to 5 days after birth, or 48 to 72 hours after hospital discharge, and again at approximately 2 weeks of age. The nurse should not administer analgesic medications before discharge because the patient is unlikely to be in pain at this time. The nurse can give the patient's hospital documents to her partner after discharge when the assessment findings have been documented and discharge teaching are provided. If the nurse removes the identification band before thoroughly checking the infant and the mother, it may lead to confusion in the identification of the infant

The nurse is reviewing the discharge orders with a postpartum patient. Which action does the nurse implement before discharging the patient?

Hemoglobin The hemoglobin laboratory test evaluates blood loss during or after delivery.

Which laboratory value will the nurse evaluate on the first postpartum day to assess blood loss during delivery?

Apply ice packs in the perineum if the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient.

A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation

Apply ice packs on the breasts Use a breast binder Wear a well-fitted support bra Patients who choose not to breastfeed may experience breast engorgement and related discomfort. The nurse should instruct the patient to wear a well-fitted support bra or use a breast binder to support the breasts, which can relieve discomfort. Applying ice packs with a 15-minutes-on, 45-minutes-off schedule also helps relieve breast engorgement and reduce discomfort

A postpartum patient has chosen not to breastfeed. What instructions should the nurse provide to the patient to prevent discomfort caused by breast engorgement? Select all that apply.

I will get my vaginal diaphragm refitted next week Because we are Catholics, we are going to use the rhythm method I will not use oral contraceptives while I am breastfeeding." Breastfeeding is not a reliable means of contraception, even if menses has not yet resumed. The patient is correct in having her diaphragm refitted after pregnancy and childbirth. The rhythm method is not an effective method of contraception, but if the couple chooses this based on their cultural belief, the nurse should explain the method to them. Oral contraceptive pills are not a good form of birth control as the patient is lactating, and the patient should use other methods of birth control.

At 3 months postpartum, a lactating patient informs the nurse that her menses has not yet resumed. The patient also discusses contraception with the nurse, stating that she does not want to become pregnant again for the next 3 years. The nurse educates the patient about contraceptive methods. Which statement given by the patient indicates they understand?

Massage her fundus A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. The health care provider can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

The nurse examines a patient 1 hour after birth. The patient's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. What is the nurse's initial action?

I might feel like laughing one minute and crying the next. Mood swings are a common symptom of postpartum blues. The patient may have continuous mood swings and may feel like laughing one minute and crying the next. The patient can call the support line whenever she feels depressed or anxious. The patient should consult the PHP if the symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication.

The nurse has taught a postpartum patient about postpartum blues. Which statement given by the patient indicates effective teaching?

Scanty bleeding If the area of saturated pad is less than 2.5 cm, it indicates that the patient had scanty bleeding. If it is less than 10 cm, then the patient had light bleeding. If the pad is saturated within 2 hours, the patient had heavy bleeding. If it is 10 cm or more, the patient had moderate bleeding

The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5 cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding?

Rotating ankles in a circular motion Alternate flexion and extension of the legs Applying sequential compression devices (SCDs Precautions should be taken to prevent venous thromboembolism in a woman who is on bedrest. These precautions include exercises to promote circulation in the legs, including rotating the ankles in a circular motion and alternating flexion and extension of the legs. SCDs are applied to the legs to promote circulation. A woman on magnesium sulfate is not safe to ambulate

The nurse is caring for a woman who is prescribed postpartum magnesium sulfate therapy. Which nursing interventions should be included in the plan of care? Select all that apply.

"You must return for a second dose in 4 to 8 weeks. Use contraception for 1 month to avoid pregnancy After receiving the first dose of Varivax, the patient must take the second dose 4 to 8 weeks later. The patient must use contraception for 1 month after being vaccinated to avoid pregnancy because the vaccine has teratogenic effects

The primary health care provider (PHP) has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine? Select all that apply.

Assist the woman to empty her bladder The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action is to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. This is not an expected finding, and emptying the bladder is required.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. What should the nurse do?

Temperature of 100.8º F Pulse rate of 100 beats/min A temperature of 100.8° F indicates fever and is a sign of infection in a postpartum patient. A pulse rate of 100 beats/min, or tachycardia, also indicates fever.

Which assessment findings in a postpartum patient indicate the presence of infection? Select all that apply.

Lochia rubra with foul odor Pain in left calf with dorsiflexion of left foot Pain in the left calf with dorsiflexion of the left foot indicates a positive Homans' sign and is suggestive of thrombophlebitis and should be investigated. Lochia with odor may indicate infection. Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period.

Which findings are a source of concern if noted during assessment of a woman who is 12 hours postpartum? Select all that apply.