Chapter 25
Uterine atony Early postpartum hemorrhage usually results from one of the following conditions: uterine atony, lacerations, or hematoma. Most cases of early postpartum hemorrhage result from uterine atony, which is due to the uterine muscles remaining relaxed and not contracting as they should. Disseminated intravascular coagulation is a complication which can occur with excessive postpartum hemorrhage.
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? Hematoma Uterine atony Perineal lacerations Disseminated intravascular coagulation
Infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? Dehydration Normal vital signs Infection Shock
mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.
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
Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or lightheadedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.
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
Call her caregiver if lochia moves from serosa to rubra. Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).
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.
"If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the client is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. The client will not have large amounts of drainage for several months. An elevated temperature indicates an infection. The drainage should not fluctuate between bright and dark red and could indicate retained placental fragments.
The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective? "If the drainage changes from clear to bright red, I am to call the doctor." "I will have large amount of vaginal drainage for at least several months." "An elevated temperature is normal during the first few weeks after delivery." "My drainage will fluctuate between bright red and dark red for several weeks."
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.
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."
Ask the client to elaborate on her feelings. The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed.
A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first? Contact the primary care provider to report the client's deteriorating mental status. Discuss the client's potential depression with her family members. Ask the client to elaborate on her feelings. Document the conversation.
Prepare the client for surgery. Rationale: The use of an epidural, prolonged second stage labor and forceps delivery are predisposing factors for hematoma formation, and a collection of up to 500 ml of blood can occur in the vaginal area. Although the other options may be implemented, the immediate action would be to prepare the client for surgery to stop the bleeding.
A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to: Monitor fundal height Apply perineal pressure Prepare the client for surgery. Reassure the client
sharp, stabbing chest pain with shortness of breath Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent.
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
birth of a large newborn The nurse knows that lacerations of the genital tract may occur with the birth of a large infant. Other risk factors for lacerations include forceps or vacuum birth, precipitous second stage, and rapid expulsion. Scarring from prior gynecologic or birth events and vulvar, perineal, or vaginal varicosities increase the incidence of lacerations. When the client experiences excessive traction on the umbilical cord coupled with rapid expulsion of the uterine contents, it leads to uterine inversion and not lacerations of the genital tract. Endometritis is the primary cause of postpartum infections; it is not known to lead to lacerations of the genital tract.
A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract? history of hypertension birth of a large newborn excessive traction on umbilical cord development of endometritis
Changes in vital signs
A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma? Complaints of a tearing sensation Complaints of intense pain Changes in vital signs Signs of heavy bruising
Keep the incisions clean and dry. When caring for a client who has developed a wound infection, the nurse should keep the incision clean and dry to eliminate the opportunity for bacterial growth and proliferation. The nurse should apply ice and heat alternatively to decrease swelling when caring for a client who has undergone incision and drainage of a hematoma. Sitz baths are performed every 4 to 6 hours, not every 24 hours. Sitz baths aid in promoting comfort to the perineum after vaginal delivery. The nurse should apply ice packs every 12 to 24 hours when caring for a client with postpartum lacerations.
A nurse is caring for a client who has had a cesarean birth and has developed a wound infection. What precautions should be taken by the nurse as a primary prevention measure? Apply ice packs every 12 to 24 hours. Keep the incisions clean and dry. Use a sitz bath once every 24 hours. Apply ice and heat alternatively.
"Empty your bladder frequently." The nurse should instruct the client to empty her bladder frequently to prevent urinary stasis. In addition, the nurse would instruct the client to practice good perineal hygiene, and wipe from meatus to rectum to prevent bacterial contamination. Elastic compression stockings are helpful in preventing venous stasis, which is associated with venous thrombosis. Avoiding foods that are salty have no effect on urinary tract infections. Applying ice packs to the infected area would be appropriate for a client with mastitis.
A nurse is caring for a postpartum client with urinary tract infection. Which instruction would the nurse include in the teaching plan for the client to help prevent future infections? "Empty your bladder frequently." "Wear your elastic compression stockings." "Avoid foods that are salty." "Apply ice to the infected area."
Prepare an ice pack for application to the area. Rationale: Application of ice will reduce swelling caused by hematoma formation in the vulvar area. The other options are not interventions that are specific to the plan of care for a client with a small vulvar hematoma.
A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client? Assess vital signs every 4 hours Inform health care provider of assessment findings Measure fundal height every 4 hours Prepare an ice pack for application to the area.
inspecting the placenta after delivery for intactness After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
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
"I am so angry with myself, I just want to give up my life right now."
A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider? "It has been hard getting enough sleep with the infant waking up during the night." "I am so angry with myself, I just want to give up my life right now." "I get tearful every so often and then suddenly I am all smiles." "I feel really restless and sad, nothing seems to make me happy."
Keep the client informed of her rights and options and support her decision. The nurse caring for a mother placing her infant up for adoption must recognize the mother's distress and support whatever decision she makes, trying not to influence her toward personal beliefs about the situation. The nurse is the client advocate in this situation and should not influence the mother in any way.
A woman who has just given birth to her infant tells the nurse that she is putting the baby up for adoption. The nurse must serve as an advocate for this mother. What would the nurse do to assist the client in placing the child for adoption? Keep the client informed of her rights and options and support her decision. Provide the client with personal opinions on adoption. Share a personal belief system. Urge the client to explore the possibility of keeping the child.
femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.
About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition? femoral thrombophlebitis uterine atony mastitis subinvolution
"How much blood was on the two pads?" The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.
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?"
delusional beliefs Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.
On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? delusional beliefs feelings of anxiety sadness insomnia
Oxytocin Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.
The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue? Ibuprofen Oxytocin Penicillin Digoxin
Not responding to the infant crying When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. The other options are normal activities for a new mother who is 2 weeks postpartum.
The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider? Talking to the infant and rocking the infant Not responding to the infant crying Discussing her birth with another new mom Breast-feeding the infant in public
Bladder distention The displacement of the uterus to one side is suggestive of bladder distention. The bladder should be emptied and then fundal massage instituted to encourage the uterus to contract and stop the excessive bleeding. If the uterus was in the midline, then this would be related solely to uterine bleeding. It's important to ensure the bladder is empty before starting the fundal massage to ensure the uterus will stay contracted. A urinary infection would be noted to cause burning on urination. A ruptured bladder would be indicative of hematuria as well as pelvic pain.
The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication? Urinary infection Excessive bleeding ruptured bladder Bladder distention
Anticoagulants The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Opioid analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation.
The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client? NSAIDS Anticoagulants Opioid analgesics Beta-blockers
Encourage fluid intake Adequate fluid intake is necessary during antibiotic therapy. Mobility should be encouraged whenever possible and safe. Small meals do not enhance healing or mitigate adverse effects. Antacids may or may not be prescribed.
The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention? Encourage fluid intake. Encourage the client to limit mobility. Provide several small meals daily rather than three larger meals. Administer antacids with each dose of antibiotics.
Assessment of the perineal pad Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern.
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
weak and rapid pulse The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider as soon as possible.
When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? warm and flushed skin weak and rapid pulse elevated blood pressure decreased respiratory rate
massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. A primary care provider (PCP) is a health care practitioner who sees people that have common medical problems. This person is most often a doctor. However, a PCP may be a physician assistant or a nurse practitioner. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.
When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? massaging the fundus firmly performing bimanual compressions administering ergonovine notifying the primary care provider
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Postpartum women who void in small amounts may be experiencing bladder overflow from retention. Normal urine output every 24 hours is 1,500 ml to 2,000 ml.
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.
uterine atony Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also 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.
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
Wear support hose or antiembolic stockings. When caring for a postpartum client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet. Another therapeutic exercise is for the client to push the back of the knees into the mattress and then flex slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.
Which instruction would the nurse include in the teaching plan for a postpartum client with a history of thromboembolism to reduce the risk of a recurrence? Refrain from performing leg exercises. Wear support hose or antiembolic stockings. Flex the muscles at the groin. Avoid pressure on the thigh muscles.
"Try applying warm compresses to your breasts to encourage the milk to be released." Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.
Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? "Stop breastfeeding until the pain and swelling subside." "You'll need to take this medication to stop the milk from being produced." "Try applying warm compresses to your breasts to encourage the milk to be released." "Limit the amount of fluid you drink so your breasts don't get much fuller."
She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.
Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? She should stop breastfeeding until completing the antibiotic. She should supplement feeding with formula until the infection resolves. She should not use analgesics because they are not compatible with breastfeeding. She should continue to breastfeed; mastitis will not infect the neonate.
