Chapter 19: Postpartum Woman at Risk

A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? Assess vital signs. Assess the fundus. Notify the health care provider. Begin an IV infusion of Ringer's lactate solution.

Assess the fundus.

Eight days after birth the woman notices a return to red lochia. What condition does the nurse anticipate this patient is experiencing? Retained placental fragments Perineal hematoma rupture Genital tract infection Disseminate intravascular coagulopathy

Retained placental fragments

A postpartum client is receiving antibiotics for endometritis. What should the nurse instruct the client to observe in the infant with breastfeeding? jaundice irritability decreased sleep levels white plaques in the mouth

white plaques in the mouth

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 300 mL 500 mL 750 mL 1000 mL

500 mL

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? Avoid iron replacement therapy. Avoid over-the-counter (OTC) salicylates. Wear knee-high stockings when possible. Shortness of breath is a common adverse effect of the medication.

Avoid over-the-counter (OTC) salicylates.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness Degree of responsiveness, respiratory rate, fundus location Height, level of orientation, support systems

Blood pressure, pulse, reports of dizziness

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? "Postpartum blues usually resolves by the 4th or 5th postpartum day." "Postpartum psychosis usually appears soon after the woman comes home." "Postpartum depression develops gradually, appearing within the first 6 weeks." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

"Postpartum depression develops gradually, appearing within the first 6 weeks."

The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed? "I will change my perineal pad regularly to remove the infected drainage." "I will take frequent walks around my home to promote drainage." "When I am sleeping or lying in bed, I should lie flat on my back." "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor."

"When I am sleeping or lying in bed, I should lie flat on my back."

The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage? A cervical laceration Uterine atony Retained placental fragments Disseminated intravascular coagulation

A cervical laceration

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. Immediately call the health care provider. Have the charge nurse review the assessment. Ask the client when she last changed her perineal pad.

Ask the client when she last changed her perineal pad.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Bend her knee, and palpate her calf for pain. Ask her to raise her foot and draw a circle. Blanch a toe, and count the seconds it takes to color again. Assess for pedal edema.

Assess for pedal edema.

The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of bowel function Assessment of the lung fields Assessment of the perineal pad Assessment of laboratory data

Assessment of the perineal pad

The nurse is admitting a postpartum client from five days ago with diagnosis of perineal infection. What nursing intervention is most helpful to decrease pain levels from an 8 out of 10 to a 3 out of 10? Administer topical or oral corticosteroids as prescribed. Assist the client with sitz baths. House the client in a negative-pressure isolation room. Provide the client with a high-calorie, high-fat diet.

Assist the client with sitz baths

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? Content, lochia, place Location, shape, and content Consistency, shape, and location Consistency, location, and place

Consistency, shape, and location

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Oxytocin Magnesium sulfate Domperidone Calcium gluconate

Oxytocin

A postpartum client is diagnosed with a vaginal laceration. What intervention will the nurse provide to the client at this time? Monitor vital signs every 30 minutes. Insert an indwelling urinary catheter. Provide stool softeners as prescribed. Weigh vaginal packing to estimate blood loss.

Insert an indwelling urinary catheter.

A client with a perineal hematoma undergoes an incision and drainage. Which intervention would be most appropriate after this procedure? Administer prescribed magnesium sulfate. Monitor the client's fluid status. Check client's clotting study results. Pack the area to promote hemostasis and drainage.

Pack the area to promote hemostasis and drainage.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Avoid frequent breastfeeding. Perform handwashing before breastfeeding. Apply cold compresses to the breast.

Perform handwashing before breastfeeding.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond? Use of breast pumps Pierced nipple Complete emptying of the breast Frequent feeding

Pierced nipple

A client with postpartum hematoma is admitted to a local health care facility. Which of the following would the nurse assess as a characteristic of this condition? Rectal pressure Non-palpable fundus Profuse bleeding Alterations in abdominal examination

Rectal pressure

A postpartum client calls the nurse to her room and states that she knows something awful is going to happen to her. What should the nurse do? Report this immediately to the health care provider. Tell her she is being silly; nothing is going to happen to her. Ask if she would like to see the social worker. Call a code.

Report this immediately to the health care provider.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? Escherichia coli group B streptococcus (GBS) Staphylococcus aureus Streptococcus pyogenes (group A strep)

Staphylococcus aureus

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness.

Symptoms include fever, chills, malaise, and localized breast tenderness.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? The uterine placement is normal. The uterus is filling up with blood. The bladder is distended. There is an infection inside the uterus.

The bladder is distended.

Which situation should concern the nurse treating a postpartum client within a few days of birth? The client is nervous about taking the baby home. The client feels empty since she gave birth to the neonate. The client would like to watch the nurse give the baby her first bath. The client would like the nurse to take her baby to the nursery so she can sleep.

The client feels empty since she gave birth to the neonate.

A client is experiencing postpartum hemorrhage and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus? Place the hands on the sides of the abdomen to grasp the uterus. Use an up-and-down motion to massage the uterus. Wait until the uterus is firm to express clots. Continue massaging the uterus for at least 5 minutes.

Wait until the uterus is firm to express clots.

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? an inverted nipple on the affected breast no breast milk in the affected breast an ecchymotic area on the affected breast hardening of an area in the affected breast

hardening of an area in the affected breast

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? administering broad-spectrum antibiotics inspecting the placenta after delivery for intactness manually removing the placenta at birth applying pressure to the umbilical cord to remove the placenta

inspecting the placenta after delivery for intactness

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? breast yeast mastitis plugged milk duct engorgement

mastitis

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? "I will stop breastfeeding until I finish my antibiotics." "I am able to pump my breast milk for my baby and throw away the milk." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." "When breastfeeding, it is recommended to begin nursing on the infected breast first."

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. She says she is extremely thirsty. Her perineum is obviously edematous on inspection.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.

A postpartum client is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the client? Assess ambulation. Measure urine output. Measure blood pressure. Evaluate current hematocrit level.

Measure blood pressure

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? Obtain a clean-catch urine specimen. Administer amoxicillin, as prescribed. Encourage her to drink large amounts of fluid. Suggest that she take an oral analgesic.

Obtain a clean-catch urine specimen.

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? Mastitis Endometritis Subinvolution Episiotomy infection

Endometritis

A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client? Encourage an oral intake of 2 to 3 liters per day. Keep the environment quiet to encourage rest. Change her perineal pads frequently. Take analgesics for uterine pain.

Encourage an oral intake of 2 to 3 liters per day.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum psychosis postpartum blues postpartum depression postpartum panic disorder

postpartum psychosis

A postpartum woman is prescribed an antibiotic because of endometritis. Her breastfed infant should be observed particularly for which of the following? decreased sleep levels and increased appetite jaundice that does not respond to phototherapy irritability and loss of appetite signs of oral candidiasis (thrush) and easy bruising

signs of oral candidiasis (thrush) and easy bruising

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "When did you last void?"

"How much blood was on the two pads?"

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? "I will make handprints and footprints of the baby for you to keep." "I know you are hurting, but you can have another baby in the future." "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" "Have you named your baby yet? I would like to know your baby's name."

"I know you are hurting, but you can have another baby in the future."

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client? Call her caregiver if amount of lochia decreases. Call her caregiver if lochia moves from serosa to alba. Call her caregiver if lochia moves from serosa to rubra. Call her caregiver if lochia moves from rubra to serosa.

Call her caregiver if lochia moves from serosa to rubra.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next? Perform vigorous fundal massage for the client. Check for bladder distention, while encouraging the client to void. Use semi-Fowler position to encourage uterine drainage. Offer analgesics prescribed by health care provider.

Check for bladder distention, while encouraging the client to void.

The nurse is caring for four postpartum client, monitoring them for postpartum infection. Which client is the priority due to current vital signs suggesting a postpartum infection? Client 35 hours postpartum with a temperature of 99.6°F (37.5°C) Client 30 hours postpartum with a temperature of 100.4°F (38°C) Client 20 hours postpartum with a temperature of 102.4°F (39.1°C) Client 25 hours postpartum with a temperature of 99.2°F (37.3°C)

Client 30 hours postpartum with a temperature of 100.4°F (38°C)

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client's temperature remains below 100.4°F (38.8°C) orally. Fundus remains firm and midline with progressive descent. Client maintains a urinary output greater than 30 ml per hour. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.

Client's temperature remains below 100.4°F (38.8°C) orally.

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? Assess for redness and warmth. Ask about increased pain with weight bearing. Ask if she has pain or tenderness in the lower extremities. Dorsiflex her right foot and ask if she has pain in her calf.

Dorsiflex her right foot and ask if she has pain in her calf.

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? Her uterus is 2 cm above the symphysis pubis. Her uterus is three finger widths under the umbilicus. Her uterus is at the level of the umbilicus. She experiences "pulling" pain while breastfeeding.

Her uterus is at the level of the umbilicus.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Drink plenty of fluids to decrease a bladder infection. Apply ice to the perineum to decrease pain of a perineal infection. Finish all antibiotics to decrease a genital tract infection.

Finish all antibiotics to decrease a genital tract infection.

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? Risk for fatigue related to chronic bleeding due to subinvolution Risk for infection related to microorganism invasion of episiotomy Risk for impaired breastfeeding related to development of mastitis Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

Risk for fatigue related to chronic bleeding due to subinvolution

When assessing a client who is 5 days postpartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage? Oliguria Fundal tenderness Rubra colored lochia Increased rectal pressure

Rubra colored lochia

A new mother is holding her infant after a feeding. Which behavior by the mother would be concerning to the nurse related to malattachment? She looks into the infant's face. She rocks the infant when the infant begins to cry. She refers to the infant as "it" instead of saying the infant's name. She changes the infant's diaper.

She refers to the infant as "it" instead of saying the infant's name.

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 Transthoracic echocardiogram Venogram of the right leg Noninvasive arterial studies of the right leg

Venous duplex ultrasound of the right leg

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth a client who had an 8-hour labor a client who conceived following fertility treatments

a client who had a nonelective cesarean birth

A client is 10 days postpartum. Which of the following would the nurse expect to assess if the client develops a genital tract infection? hypotension and chills cyanosis and oliguria hypovolemic shock lochia rubra and excessive clots

hypotension and chills

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? leg pain on ambulation with mild ankle edema calf pain with dorsiflexion of the foot perineal pain with swelling along the episiotomy sharp, stabbing chest pain with shortness of breath

sharp, stabbing chest pain with shortness of breath

A postpartal client is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the client about breastfeeding during this time? Breastfeeding can continue. The baby will need weekly blood work. The effect of anticoagulants is counteracted by infant gastric juices. All anticoagulants pass in breast milk so breastfeeding will have to stop.

Breastfeeding can continue

The nurse instructs a client on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective? The client complains of fatigue. The client appears disheveled and listless. The client is chatting on the telephone with a friend. The client is cleaning the kitchen while the baby naps.

The client is chatting on the telephone with a friend.

The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client? weak and rapid pulse warm and flushed skin elevated blood pressure decreased respiratory rate

weak and rapid pulse

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

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

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. "I am sad because I am not spending as much time with my toddler now that my newborn is here." "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit." "The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client? "It is appropriate for you to sit with your legs crossed over each other." "It is expected for you to have minimal blood in your urine during therapy." "You need to avoid medications which contain acetylsalicylic acid." "You can breastfeed your newborn while taking any anticoagulation medication."

"You need to avoid medications which contain acetylsalicylic acid."

Which measurement best describes delayed postpartum hemorrhage? blood loss in excess of 3000 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 300 ml, occurring within the first 24 hours after birth blood loss in excess of 1,000 ml, occurring within 24 hours after birth

blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth

An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection? length of labor maternal Rh status method of birth size of the neonate

length of labor

What is a risk factor for developing a postpartum infection? Select all that apply. type 1 diabetes thin build prolonged labor cesarean birth rupture of membranes at time of birth

type 1 diabetes prolonged labor cesarean birth

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine atony uterine prolapse uterine subinvolution uterine contraction

uterine atony

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? hemoglobin level of 12 g/dl (120 g/L) uterine atony thrombophlebitis moderate amount of lochia rubra

uterine atony