High Risk OB Postpartum

A couple has delivered a 28-week fetal demise. Which of the following nursing actions are appropriate to take? Select all that apply. 1. Swaddle the baby in a baby blanket. 2. Discuss funeral options for the baby. 3. Encourage the couple to try to get pregnant again soon. 4. Ask the couple whether or not they would like to hold the baby. 5. Advise the couple that the baby's death was probably for the best.

1, 2, and 4 are correct. 1. This is an appropriate action. The baby should be handled with respect. 2. This is an appropriate action. Funerals help clients to achieve closure and to provide others with a means of acknowledging the baby's death. 3. This is inappropriate. The couple must grieve the loss of this child. 4. This is an appropriate action. Although there are some clients who will decline to hold their babies, the action is very important for those who accept the opportunity. 5. This action is inappropriate. Stating that the loss of a baby is for the best is very demeaning and unfeeling. Clients must be encouraged and assisted through the process of grieving and mourning their babies. In addition, since most women will remain on the obstetric unit, there must be a mechanism, like a specific picture placed on the woman's door, for communicating to every department in the hospital, from nursing to housekeeping to dietary, and so on, that the client has had a fetal death.

A nurse massages the atonic uterus of a woman who delivered 1 hour earlier. The nurse identifies the nursing diagnosis: Risk for injury related to uterine atony. Which of the following outcomes indicates that the client's condition has improved? 1. Moderate lochia flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus above the umbilicus.

1. A moderate lochia flow would indicate that the action was successful.

A client is postpartum 24 hours from a spontaneous vaginal delivery with rupture of membranes for 42 hours. Which of the following signs/symptoms should the nurse report to the client's health care practitioner? 1. Foul-smelling lochia. 2. Engorged breasts. 3. Cracked nipples. 4. Cluster of hemorrhoids.

1. Foul-smelling lochia is a sign of endometritis. TEST-TAKING TIP: Some nursing actions are dependent functions. For example, nurses are only able to administer antibiotics after receiving a physician's order. Other actions, however, are independent actions. For example, assisting a client with engorged breasts to self-express breast milk, to apply warm soaks to the breasts, and to breastfeed effectively are independent actions. The nurse must report foul-smelling lochia to the physician so that the doctor can decide whether or not to order antibiotics for the client.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The woman should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The woman must have her vitals assessed every two days.

1. It is essential that the client never be left alone with her baby. Clients who have been diagnosed with postpartum psychosis have been known to have homicidal and suicidal ideations. Because the baby and other children are vulnerable, the mother should always be supervised when in their presence. In addition, if she exhibits suicidal behaviors, she should be supervised at all times.

A client is on magnesium sulfate via IV pump for severe preeclampsia. Other than patellar reflex assessments, which of the following noninvasive assessments should the nurse perform to monitor the client for early signs of magnesium sulfate toxicity? 1. Serial grip strengths. 2. Kernig assessments. 3. Pupillary responses. 4. Apical heart rate checks.

1. Serial grip strengths can be performed to monitor a client for magnesium sulfate toxicity. The only accurate way to assess for magnesium toxicity is to do a serum magnesium level. Normal magnesium levels are 1.8 to 3.0 mg/dL. Therapeutic levels are 4 to 8 mg/dL. Reflex depression begins to appear when the levels reach 8 to 12 mg/dL. When levels rise to 15 mg/dL or higher, respiratory depression and, eventually, cardiac arrest occur. Hourly grip strengths performed with reflex assessments are excellent noninvasive assessments to monitor for neuromuscular blockage. If changes are noted, the nurse can notify the health care provider, who can order a stat magnesium level.

The nurse is circulating on a cesarean delivery of a G5P4004. All of the client's previous children were delivered via cesarean section. The physician declares after delivering the placenta that it appears that the client has a placenta accreta. Which of the following maternal complications would be consistent with this diagnosis? 1. Blood loss of 2000 mL. 2. Blood pressure of 160/110. 3. Jaundice skin color. 4. Shortened prothrombin time.

1. The client with a placenta accreta is high risk for a large blood loss. A placenta accreta's chorionic villi burrow through the endometrial lining into the myometrial lining. Separation of the placenta from the uterine wall is severely hampered. Clients often lose large quantities of blood, and it is not uncommon for the physician to have to perform a hysterectomy to control the bleeding. Clients who have had multiple uterine scars are especially at high risk for this problem. If the test taker were unfamiliar with placenta accreta, he or she could deduce the answer since the placenta is highly vascular and only one answer referred to a vascular issue. In addition, the average blood loss during a cesarean delivery is 1000 cc.

A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.

1. The client with postpartum psychosis will experience hallucinations. Clients who have been diagnosed with postpartum psychosis have a psychiatric disease. They experience hallucinations, usually auditory, including voices that may tell them to kill their babies.

A client who is post-cesarean section for severe preeclampsia is receiving magnesium sulfate via IV pump and morphine sulfate via patient-controlled anesthesia (PCA) pump. The nurse enters the room on rounds and notes that the client is not breathing. Which of the following actions should the nurse perform first? 1. Give two breaths. 2. Discontinue medications. 3. Call a code. 4. Check carotid pulse.

1. The nurse should call a code before beginning rescue breathing. TEST-TAKING TIP: The nurse should call a code as soon as he or she discovers a client who is nonresponsive. Immediately after calling the code, the nurse should stop the medications, begin rescue breathing, and provide chest compressions, if necessary, until the code team arrives. Only after receiving an order to do so, should calcium gluconate, the antidote to magnesium sulfate, be administered.

A woman has just had a macrosomic baby after a 12-hour labor. For which of the following complications should the woman be carefully monitored? 1. Uterine atony. 2. Hypoprolactinemia. 3. Infection. 4. Mastitis.

1. This client is high risk for uterine atony.

A client, 1 day postpartum (PP), is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for last 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.

1. This output is below the accepted minimum for 8 hours. TEST-TAKING TIP: The nurse must divide the amount of urine output by the number of hours. The output in the scenario is equal to 25 cc/hr. This is well below the accepted output of 30 cc/hr. Plus, because this is a postpartum client, the nurse would expect high urinary outputs. Postpartum clients often have slowed heart beats.

A nurse is caring for the following four laboring patients. Which client should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? 1. G1P0000, delivery at 29 weeks' gestation. 2. G2P1001, prolonged first stage of labor. 3. G2P0010, delivery by cesarean section. 4. G3P0200, delivery of 2200-gram neonate.

2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). The muscles of the uterus of a client who has experienced a prolonged first stage of labor are fatigued. In the postpartum period, therefore, they may fail to contract fully enough to control bleeding at the site of placental separation. These clients must be monitored carefully for postpartum hemorrhage.

The nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The nurse notes a firm uterus at the umbilicus with heavy lochial flow. Which of the following nursing actions is appropriate? 1. Massage the uterus. 2. Notify the obstetrician. 3. Administer an oxytocic as ordered. 4. Assist the client to the bathroom.

2. It is important for the nurse to notify the physician. The client is bleeding more than she should after the delivery. TEST-TAKING TIP: The nurse must act as a detective to determine why he or she is seeing symptoms. In this scenario, the uterus is contracted and at the expected location-that is, firm at the umbilicus. The lochia flow, however, is heavy. The nurse must notify the practitioner for assistance since there is no additional action the nurse can take at this time.

6. A client has been receiving magnesium sulfate for severe preeclampsia for 12 hours. Her reflexes are 0 and her respiratory rate is 10. Which of the following situations could be a precipitating factor in these findings? 1. Apical heart rate 104. 2. Urinary output 240 cc/12 hr. 3. Blood pressure 160/120. 4. Temperature 100°E

2. The urinary output is the likely cause of the client's changes. The hourly output for this client is 20 cc/hr. This is well below the minimum urinary output of 30 cc/hr. Since the medication is excreted via the kidneys, when a client's output is low, the concentration of the medication can increase to toxic levels in the bloodstream. This client is exhibiting signs of magnesium toxicity.

A couple, accompanied by their 5-year-old daughter, have been notified that their 32-week-gestation fetus is dead. The father is yelling at the staff. The mother is crying uncontrollably. The 5-year-old is banging the head of her doll on the floor. Which of the following nursing actions is appropriate at this time? 1. Tell the father that his behavior is inappropriate. 2. Sit with the family and quietly communicate sorrow at their loss. 3. Help the couple to understand that their daughter is acting inappropriately. 4. Encourage the couple to send their daughter to her grandparents.

2. This action is appropriate. The nurse is acknowledging that every member of the family is grieving the loss.

A woman, 26 weeks' gestation, has just delivered a fetal demise. Which of the following nursing actions is appropriate at this time? 1. Remind the mother that she will be able to have another baby in the future. 2. Dress the baby in a tee shirt and swaddle the baby in a receiving blanket. 3. Ask the woman if she would like the doctor to prescribe a sedative for her. 4. Remove the baby from the delivery room as soon as possible.

2. This response is correct. The nurse should treat this baby with care and concern. Even though the baby has died he is still a valued child to the parents. The parents should be asked whether they would like to see or hold their baby. If they would, the nurse should help the parents to see the normalcy in their baby. Sedating a client only delays her inevitable grief.

Which of the following is a priority nursing diagnosis for a woman, G10P6226, who is PP 1 from a spontaneous vaginal delivery with a significant postpartum hemorrhage? 1. Alteration is comfort related to afterbirth pains. 2. Risk for altered parenting related to grand multiparity. 3. Fluid volume deficit related to blood loss. 4. Risk for sleep deprivation related to mothering role.

3. Fluid volume deficit related to blood loss is the priority nursing diagnosis.

A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.

3. It is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales. A cesarean section client is a postoperative client as well as a postpartum client. The nurse must perform needed physiological assessments. Because this client had general anesthesia during her surgery, she is high risk for pulmonary complications, including atelectasis and pneumonia.

The blood glucose of a client with type 1 diabetes 12 hours after delivery is 96 mg/dL. The client has received no insulin since delivery. The drop in serum levels of which of the following hormones of pregnancy is responsible for the glucose level? 1. Estrogen. 2. Progesterone. 3. Human placental lactogen (hPL). 4. Human chorionic gonadotropin (hCG).

3. The drop in human placental lactogen (hPL) is related to the glucose level. The hormone hPL is an insulin antagonist. Throughout pregnancy, the insulin needs of type 1 diabetics rise incrementally as the levels of hPL in the bloodstream rise. Once the placenta is birthed, however, the levels drop precipitously. As a result, it is not uncommon for the glucose levels of type 1 diabetics to be within normal limits for a day or so after delivery-as seen in this client.

A client is 1-day post cesarean delivery for eclampsia. The client is receiving 5% dextrose in 'h normal saline IV at 125 cc/hr and magnesium sulfate IV via infusion pump. Which of the following laboratory values should the nurse report to the surgeon? 1. Serum magnesium 7 mg/dL. 2. Serum sodium 136 mg/dL. 3. Serum potassium 3.0 mg/dL. 4. Serum calcium 9 mg/dL.

3. The serum potassium is below normal. The nurse should report the finding to the physician.

The nurse is caring for a postoperative cesarean client. The woman is obese and is an insulin-dependent diabetic. For which of the following complications should the nurse carefully monitor this client? 1. Ineffective lactogenesis. 2. Dysfunctional parenting. 3. Wound dehiscence. 4. Projectile vomiting.

3. This client is at high risk for wound dehiscence. Her wound healing may be impaired because of her diabetes and because of her obesity.

A nurse is working on the postpartum unit. Which of the following patients should the nurse assess first? 1. PP1 from vaginal delivery complains of burning on urination. 2. PP1 from forceps delivery with blood loss of 500 mL at time of delivery. 3. PP3 from vacuum delivery with hemoglobin of 7.2 g/dL. 4. P03 from cesarean delivery complains of firm and painful breasts.

3. This client should be assessed first. The hemoglobin level is well below normal. TEST-TAKING TIP: The nurse must recognize normal and abnormal findings. For example, 500 mL blood loss is an expected loss during a vaginal delivery. A hemoglobin of 7.2 g/dL, however, is well below the normal of 12 to 15 g/dL. This client is likely exhibiting signs of hypovolemia, including tachycardia, fatigue, and dizziness. She should be assessed first.

A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority? 1. Lochia is serosa. 2. Client cries throughout the visit. 3. Nipples are cracked. 4. Client yells at the baby for crying.

4. The client is exhibiting inappropriate behavior when she yells at the baby for crying. The nurse must make additional assessments to determine whether there is any other evidence of abuse or neglect. TEST-TAKING TIP: The baby is the most vulnerable member of the mother-infant dyad. Since the baby is completely dependent on the care of the mother, if the nurse discovers any behavior or other evidence that makes him or her suspicious of child abuse or neglect, he or she is obligated both morally and legally to report the situation. Clients who are experiencing postpartum depression usually perform baby care competently.

A client, who is 2 weeks postpartum, calls her obstetrician's nurse and states that she has had a whitish discharge for 1 week but today she is, "Bleeding and saturating a pad about every '12 hour." Which of the following is an appropriate response by the nurse? 1. "That is normal. You are starting to menstruate again." 2. "You should stay on complete bed rest until the bleeding subsides." 3. "Pushing during a bowel movement may have loosened your stitches." 4. "The physician should see you. Please come in whenever you are ready."

4. This is the correct response. This client needs to be evaluated. The quantity of lochia discharge is usually described as scant, moderate, or heavy. A heavy discharge is described as a discharge that saturates a pad in 1 hour or less. Since this client's lochia has already changed to alba (whitish), it is especially concerning that she is now experiencing a heavy lochia rubra (reddish) flow.

The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching in the hospital was successful? 1. The client is breastfeeding her baby every two hours. 2. The client is using a diaphragm for family planning. 3. The client is taking her temperature every morning. 4. The client is seeking care for a recent weight loss.

4. The client should seek care for a recent weight loss. This may be a symptom of full-blown AIDS. Although obstetric clients who enter the hospital are usually aware of their HIV status, the nurse must still review the actions clients should take after discharge. These actions include taking all medications, bottlefeeding rather than breastfeeding, and reporting any changes in health, like weight loss or the appearance of thrush.

A breastfeeding woman has been diagnosed with retained placental fragments 4 days postdelivery. Which of the following breastfeeding complications would the nurse expect to see? 1. Engorgement. 2. Mastitis. . 3. Blocked milk duct. 4. Low milk supply.

4. The nurse would expect that the woman would have a low milk supply. The placenta produces the hormones of pregnancy, including estrogen and progesterone. When placental fragments are retained, those hormones are still being produced. Estrogen inhibits prolactin, which is the hormone of lactogenesis, or milk production. Women who have retained placental fragments, therefore, often complain of an insufficient milk supply for their babies.

The nurse is caring for a couple who are in the labor/delivery room immediately after the delivery of a dead baby with visible defects. Which of the following actions by the nurse is appropriate? 1. Discourage the parents from naming the baby. 2. Advise the parents that the baby's defects would be too upsetting for them to see. 3. Transport the baby to the morgue as soon as possible. 4. Give the parents a lock of the baby's hair and a copy of the footprint sheet.

4. This is appropriate. The small mementos will provide the couple with something tangible to remember the pregnancy and baby by. TEST-TAKING TIP: It is very difficult for parents who have delivered a fetal demise. The only contact they have had with the baby is through the pregnancy. Small mementos, such as a picture, lock of hair, or baby bracelet, provide the parents with tangible remembrances of the baby.

A client is to receive a blood transfusion after significant blood loss following a placenta previa delivery. Which of the following actions by the nurse is critical prior to starting the infusion? Select all that apply. 1. Look up the client's blood type in the chart. 2. Check the client's arm bracelet. 3. Check the blood type on the infusion bag. 4. Obtain an infusion bag of dextrose and water. 5. Document the time the infusion begins.

1, 2, 3, and 5 are correct. 1. The nurse must check the client's blood type. 2. The nurse must check the client's name by checking the bracelet and asking the client her name. 3. The nurse must compare the client's blood type with the blood type on the infusion bag. 4. The nurse must obtain an infusion of normal saline, not dextrose and water. 5. The time the infusion begins and ends must be documented. The potential for blood transfusion incompatibility is very real. It is essential, therefore, that two health care practitioners check simultaneously to make sure that the client is receiving the correct blood. If any sign of a reaction should develop, the transfusion should be stopped immediately. Only normal saline solution is used as a solution immediately before or after blood administration. Dextrose in water will hemolyze the red blood cells. In addition, a special filtered infusion set must be used.

1. A gestational diabetic client, who delivered yesterday, is currently on the postpartum unit. Which of the following statements is appropriate for the nurse to make at this time? 1. "Monitor your blood glucose five times a day until your 6-week check-up." 2. "I will teach you how to inject insulin before you are discharged." 3. "Daily exercise will help to prevent you from becoming diabetic in the future." 4. "Your baby should be assessed every 6 months for signs of juvenile diabetes."

3. This is an appropriate statement to make. TEST-TAKING TIP: Women who develop gestational diabetes are high risk for developing type 2 diabetes. They should be encouraged to eat healthy and to exercise in order to prevent the onset of the chronic disease or, at the very least, to delay its onset.

A client, G1P0000, is PP1 from a normal spontaneous delivery of a baby boy, Apgar 5/6. Because the client exhibited addictive behaviors, a toxicology assessment was performed; the results were positive for alcohol and cocaine. Which of the following interventions is appropriate for this postpartum client? 1. Strongly advise the client to breastfeed her baby. 2. Perform hourly incentive spirometer respiratory assessments. 3. Suggest that the nursery nurse feed the baby in the nursery. 4. Provide the client with supervised instruction on baby care skills.

4. Providing instruction on baby care skills is a very important action for the nurse to perform. TEST-TAKING TIP: Babies of mothers who are addicted to illicit drugs go through a withdrawal period and, because of the addiction, often have very disorganized behavior patterns. The nurse must provide guidance for the primipara regarding care of her difficult infant, especially because the client has already exhibited poor judgment. In addition, of course, the nurse must report the family to child protective services.