Maternal Child Nursing Care Chapter 19 Nursing Care of the Family During the Postpartum Period

3 If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination.

The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding? 1 Risk of infection 2 Evidence of severe pain 3 Potential risk of hypovolemic shock 4 Potential risk of impaired urinary elimination

4 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? 1 Run warm water over the patient's breasts. 2 Administer strong analgesics. 3 Administer oral and intravenous fluids. 4 Advise the patient to wear a breast binder for the first 72 hours after giving birth.

1 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? 1 Apply ice packs in the perineum. 2 Administer fluids to the patient. 3 Administer blood to the patient. 4 Refer the patient for hematologic tests.

3 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? 1 Administer prostaglandins. 2 Administer oxytocin. 3 Document the findings and continuing to monitor. 4 Massage the fundus every 15 minutes.

4 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? 1 Change the baby's diapers when needed. 2 Position the baby comfortably. 3 Demonstrate eye-to-eye contact with the baby. 4 Complete the child care activities silently, without looking at the baby.

4 The patient must not become pregnant for 3 months 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? 1 "The vaccine is safe even if you have an egg allergy." 2 "You cannot breastfeed for 5 days after taking the vaccine." 3 "You will not have joint pains or skin rashes after the vaccination." 4 "You should use proper contraception for 3 months after the vaccination."

2 In most cases, the patient can continue to breastfeed. If the affected breast is too sore, the patient can pump the breast gently. Regular emptying of the breast is important to prevent the formation of abscess. Use of a supportive bra suppresses milk production and prevents breast engorgement. Additional supportive measures include ice packs, breast supports, and analgesics. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours.

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching? 1 "I need to wear a supportive bra to relieve the discomfort." 2 "I need to stop breastfeeding until this condition resolves." 3 "I can use analgesics to alleviate some of the discomfort." 4 "I need to take antibiotics, and I should begin to feel better in 24 to 48 hours."

3 The recommended caloric intake for a lactating mother who breastfeeds more than one infant is more than 2700 kcal/day. If a lactating mother of twins takes less than 2200 kcal/day, she may not produce enough milk. An intake of 1800 to 2200 kcal/day is recommended for nonlactating mothers.

A lactating patient who gave birth to twins 1 month earlier approaches the primary health care provider (PHP) for a general checkup. What suggestion does the nurse give to the patient about the recommended calorie intake? 1 Less than 1800 kcal/day 2 Less than 2200 kcal/day 3 More than 2700 kcal/day 4 Should be 1800 to 2200 kcal/day

2, 5 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. 1 Advise the patient to apply a hot compress at the reddened site. 2 Inform the primary health care provider (PHP) about the patient's condition immediately. 3 Advise the patient to apply an antiinflammatory ointment at the reddened site. 4 Have the patient sit upright and lower the reddened leg. 5 Have the patient remain in bed with reddened limb elevated on pillows.

3, 4, 5 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. Expressing milk from the breast or performing nipple stimulation may increase milk production and may worsen breast engorgement.

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. 1 Express the milk from both breasts. 2 Perform regular breast stimulation. 3 Wear a well-fitted support bra. 4 Use a breast binder. 5 Apply ice packs on the breasts

1 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? 1 Take stool softeners regularly. 2 Continue prenatal vitamins. 3 Include iron supplements. 4 Take analgesics as prescribed.

3 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, the most common is: 1 vaginal or vulvar hematomas. 2 unrepaired lacerations of the vagina or cervix. 3 failure of the uterine muscle to contract firmly. 4 retained placental fragments.

4 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? 1 Risk of uterine atony 2 Hypotensive shock 3 Risk of developing mastitis 4 Venous thromboembolism (VTE)

4 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. STUDY TIP: When forming a study group, carefully select members for your group. Choose students who have abilities and motivation similar to your own. Look for students who have a different learning style than you. Exchange names, email addresses, and phone numbers. Plan a schedule for when and how often you will meet. Plan an agenda for each meeting. You may exchange lecture notes and discuss content for clarity or quiz one another on the material. You could also create your own practice tests or make flash cards that review key vocabulary terms.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse recognizes the need for additional instruction if the woman: 1 uses soap and warm water to wash the vulva and perineum. 2 washes from the symphysis pubis back to the episiotomy. 3 changes her perineal pad every 2 to 3 hours. 4 uses the peribottle to rinse upward into her vagina.

2 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 physician 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 woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: 1 place her on a bedpan to empty her bladder. 2 massage her fundus. 3 call the physician. 4 administer Methergine, 0.2 mg IM, which has been ordered prn.

2 A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient.

The nurse finds that a postpartum patient's perineal pad is soaked after 15 minutes. What should the nurse infer from the finding? 1 Normal finding after childbirth 2 Sign of excessive hemorrhage 3 Presence of lochial discharge 4 Sign of postpartum hypotension

2 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? 1 Light bleeding 2 Scanty bleeding 3 Heavy bleeding 4 Moderate bleeding

3 To reduce breast irritation, the nurse advises the patient to wear breast shells. This will increase comfort during breastfeeding. Application of ice packs between feedings reduces breast engorgement. Hydrogel pads can be applied if the patient has sore nipples between feedings. 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 breast irritation. Which intervention would be beneficial to the patient? 1 Apply ice packs to the breasts between feedings. 2 Place hydrogel pads to the breasts between feedings. 3 Tell the patient to wear breast shells. 4 Apply cold cabbage leaves to the breasts between the feedings.

3 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? 1 Encourage the patient to drink coffee. 2 Administer analgesic medications to patient. 3 Encourage the patient to use a rocking chair. 4 Offer soups and beverages to the patient

4 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 return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn

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? 1 Hand the father the newborn and instruct him to change the diaper. 2 Ask the father why he is so anxious and nervous. 3 Tell the father that he will get used to the newborn in time. 4 Provide education about newborn care when the father is present.

1, 2, 4 Engorgement in a breastfeeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Taking warm showers can increase milk flow. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. Cold cabbage leaves work well to reduce pain and swelling and should be applied every 4 hours. Binding the breasts is not appropriate because it decreases the milk supply. To ease the discomfort associated with sore nipples, the mother may apply topical preparations such as purified lanolin or hydrogel pads.

The nurse is caring for a lactating patient with a body temperature of 102° F (38.9° C). The nurse finds that the patient's breasts are engorged, swollen, hard, and red. Which interventions related to patient care would be helpful in managing breast engorgement? Select all that apply. 1 Taking warm showers before breastfeeding 2 Nursing the baby frequently 3 Using a tight supportive bra or a breast binder 4 Applying cold cabbage leaves to the breasts 5 Avoiding use of lanolin or hydrogel pads

3 Patients with episiotomy may have soreness and back pain. To relieve soreness and back pain, the nurse should advise the patient to place an ice pack on the affected area. This provides comfort and reduces the inflammation and pain. A sitz bath helps relieve lower back pain and discomfort, so the patient should be encouraged to use sitz baths at a temperature of 38° to 40° C (100° to 104° F) at least twice a day to prevent edema. Not cleaning the perineal area may cause infection, so the nurse should advise the patient to clean her perineum frequently. Drinking plenty of water and eating foods such as fresh fruit and vegetables that contain fibers can relieve constipation or hemorrhoids but does not help reduce soreness.

The nurse is caring for a postpartum patient who has an episiotomy wound. The nurse finds that the patient has soreness at the incision site and lower back pain. What does the nurse tell the patient? 1 Avoid using sitz baths. 2 Avoid cleaning the perineal area frequently. 3 Place a covered ice pack on the affected area. 4 Drink plenty of water and eat foods containing fiber

4 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? 1 To prevent urine retention 2 To provide relief of lower back pain 3 To tone the abdominal muscles 4 To strengthen the perineal muscles

2 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 100.4º 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? 1 A body temperature of 100.4º F 2 An increase in pulse from 88 to 102 beats/min 3 An increase in respiratory rate from 18 to 22 breaths/min 4 A blood pressure change from 130/88 to 120/80 mm Hg

3 Rubella vaccine is made from duck eggs; therefore women who are allergic to duck eggs can develop a hypersensitivity reaction to the vaccine. As a result, the patient might develop rashes on her skin. The PHP would prescribe adrenaline to combat hypersensitivity reactions. Oxytocin is injected to increase the tone of the uterine muscles but not to combat hypersensitivity. Rh immune globulin suppresses the immune system, which would worsen the condition; therefore this medication is unlikely to be prescribed. Magnesium sulfate is used for preeclampsia and is not used to minimize hypersensitivity reactions caused by rubella vaccine.

The nurse is preparing to administer rubella vaccine to a patient during the postpartum period. At the follow-up visit, the patient reports to the nurse that she has rashes on her skin. What does the nurse expect the primary health care provider (PHP) to prescribe in this situation? 1 Oxytocin (Pitocin) 2 Rh immune globulin 3 Adrenaline (Epinephrine) 4 Magnesium sulfate

1 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. A dose of 400 mcg of intramuscular Rh immune globulin may result in an overdosage. A dose of 100 mcg or 200 mcg of intramuscular Rh immune globulin is not 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? 1 300 mcg of intramuscular Rh immune globulin 2 400 mcg of intramuscular Rh immune globulin 3 100 mcg of intramuscular Rh immune globulin 4 200 mcg of intramuscular Rh immune globulin

4, 5 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. Mothers who receive the varicella vaccine can continue to breastfeed because the vaccine is not transmitted to the fetus through breast milk. Postpartum women usually have low immunity, so one dose is not sufficient. Stopping of all medications is not necessary and can endanger the patient.

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. 1 "Stop breastfeeding after receiving the vaccine." 2 "You need not return to the hospital because one dose is enough for you." 3 "Stop taking all medications after returning home." 4 "You must return for a second dose in 4 to 8 weeks." 5 "Use contraception for 1 month to avoid pregnancy."

3 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. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.

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. The nurse should: 1 massage the fundus. 2 administer Methergine, 0.2 mg PO, that has been ordered prn. 3 assist the woman to empty her bladder. 4 recognize this as an expected finding during the first 24 hours following birth.

3 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. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it.

Which measure is least effective in preventing postpartum hemorrhage? 1 Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered 2 Encouraging the woman to void every 2 hours 3 Massaging the fundus every hour for the first 24 hours following birth 4 Teaching the woman the importance of rest and nutrition to enhance healing

1 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? 1 Apply an ice pack to limit edema during the first 12 to 24 hours. 2 Instruct the patient to use two or more perineal pads. 3 Teach the patient to avoid taking sitz baths. 4 Remind the patient to avoid doing perineal (Kegel) exercises.