Maternal-newborn Ch. 23 Conditions Occurring after Delivery

A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question? Urging her to drink all the milk on her tray Administration of acetaminophen and codeine for pain Administration of a sitz bath Administration of an enema

Administration of an enema

A postpartal 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.

A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? Administer the drug as an IV bolus injection. Give as a vaginal or rectal suppository. Piggyback the IV infusion into a primary line. Withhold the drug if the woman is hypertensive.

Piggyback the IV infusion into a primary line

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

Uterine atony

A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? dyspnea, diaphoresis, hypotension, and chest pain dyspnea, bradycardia, hypertension, and confusion weakness, anorexia, change in level of consciousness, and coma pallor, tachycardia, seizures, and jaundice

dyspnea, diaphoresis, hypotension, and chest pain

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? prophylactic heparin administration compression stockings early ambulation warm compresses

early ambulation

The mental health clinical nurse specialist is teaching a postpartum nurse how to use the Postpartum Depression Screening Scale tool to assess for postpartum depression. The nurse specialist determines the need for additional teaching when the nurse identifies which component as being screened with the tool? family and social support system emotional liability guilt cognitive impairment

family and social support system

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? hematoma laceration bladder distention uterine atony

hematoma

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 A ruptured bladder Bladder distention

Bladder distention

The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, complains about being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum blues postpartum depression postpartum psychosis anxiety disorders

postpartum depression

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma? Impaired urinary elimination Ineffective tissue perfusion Deficient fluid volume Impaired tissue integrity

Impaired urinary elimination

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

Measure blood pressure.

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 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

Infection

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? Advise her to take acetaminophen to ease symptoms. Ask primary care provider to prescribe an analgesic. Instruct to use a sitz bath while voiding. Teach that adequate hydration helps clear the infection quicker.

Teach that adequate hydration helps clear the infection quicker

A nurse is conducting a class for pregnant women who are in their third trimester. The nurse is reviewing information about the emotional changes that occur in the postpartum period, including postpartum blues and postpartum depression. After reviewing information about postpartum blues, the group demonstrates understanding when they make which statement about this condition? "Postpartum blues is a long-term emotional disturbance." "Getting some outside help for housework can lessen feelings of being overwhelmed." "The mother loses contact with reality." "Extended psychotherapy is needed for treatment."

"Getting some outside help for housework can lessen feelings of being overwhelmed."

On the third day postpartum, which temperature is internationally defined as a postpartal infection? 99.6° F (37.5° C) 100.4° F (38° C) 102.4° F (39.1° C) 104.2° F (40.1° C)

100.4° F (38° C)

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A client who had a nonelective cesarean birth A primaparous 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

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? Prothrombin time Platelet level Fibrinogen level Activated partial thromboplastin time

Activated partial thromboplastin time

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing? Providing a sitz bath Administering an enema Urging to drink all the milk provided during meals Administering acetaminophen and codeine for pain

Administering an enema

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication? Her urine output is over 50 mL/h. Her blood pressure is below 140/90 mm Hg. She can walk without experiencing dizziness. Her hematocrit level is over 45%.

Her blood pressure is below 140/90 mm Hg.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine

applying ice

A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? increase in clotting factors vessel damage immobility increase in red blood cell production

increase in red blood cell production

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time? Breast-feeding 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.

Breast-feeding can continue.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? thromboembolic disorder of the lower extremities hormonal shifting of relaxin and estrogen infection normal response to the body converting back to prepregnancy state

thromboembolic disorder of the lower extremities

The nurse is assessing vital signs on the client and notes a normal blood pressure along with an elevated pulse when the patient moves from a lying to a standing or sitting position. What would this indicate? Delayed labor Overhydration Arrested labor Low fluid volume

Low fluid volume

During a home visit, a postpartum patient is complaining of a painful area on one breast. The nurse notes a local area on one breast to be red and warm to touch. For which health problem should the nurse plan care for this patient? Mastitis Breast cancer Engorgement Plugged milk duct

Mastitis

A nurse is providing education to a woman who is experiencing postpartum hemorrhage and is to receive a uterotonic agent. The nurse determines that additional teaching is needed when the woman identifies which drug as treating postpartum hemorrhage? oxytocin methylergonovine carboprost terbutaline

terbutaline

A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "I just feel so overwhelmed and tired." "I'm feeling so guilty and worthless lately." "It's strange, one minute I'm happy, the next I'm sad." "I keep hearing voices telling me to take my baby to the river."

"I'm feeling so guilty and worthless lately."

The nurse is administering a postpartal 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."

A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? "I will use a soft toothbrush to brush my teeth." "I can take ibuprofen if I have any pain." "I need to avoid drinking any alcohol." "I will call my health care provider if my stools are black and tarry."

"I can take ibuprofen if I have any pain."

A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "Tell me, are you seeing things that aren't there, or hearing voices?"

"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."

After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? "I need to call my doctor if my temperature goes above 100.4° F (38° C)." "When I put on a new pad, I'll start at the back and go forward." "If I have chills or my discharge has a strange odor, I'll call my doctor." "I'll point the spray of the peri-bottle so it the water flows front to back."

"When I put on a new pad, I'll start at the back and go forward."

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? Bend the knee and palpate the calf for pain. Ask the client to raise the foot and draw a circle. Blanch a toe, and count the seconds it takes to color again. Assess for warmth, erythema, and pedal edema.

Assess for warmth, erythema, and pedal edema

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

It is discovered that a new mother has developed a puerperal 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 or 38° 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 or 38° C orally.

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.

The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady gush of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider? Uterine atony Laceration Perineal hematoma Infection of the uterus

Laceration

The client reports to the health care providers office stating that her lochia has changed from lochia alba to lochia rubra. Which does the nurse suspect? Retained placental fragments Uterine atony Cervical or vaginal lacerations Uterine inversion

Retained placental fragments

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response? Risk factors include breast pumps. Risk factors include nipple piercing. Risk factors include complete emptying of the breast. Risk factors include frequent feeding.

Risk factors include nipple piercing

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 beta-hemolytic streptococci (GBS) Staphylococcus aureus Streptococcus pyogenes

Staphylococcus aureus

A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? Uterine protrusion into the vagina Uterine bleeding present Foul smelling lochia Pain in the lower abdomen

Uterine protrusion into the vagina

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the RN and/or health care provider? Warm and flushed skin Weak and rapid pulse Elevated blood pressure Decreased respiratory rate

Weak and rapid pulse

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

A client with a perineal hematoma undergoes an incision and drainage. Which of the following 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

A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. restlessness feelings of worthlessness feeling overwhelmed sleeping well hunger

restlessness feelings of worthlessness feeling overwhelmed

The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which measures would the nurse most likely include in this teaching plan? Select all that apply. taking the prescribed antibiotic until it is finished checking temperature once a week washing hands before and after perineal care handling perineal pads by the edges directing peribottle to flow from back to front

taking the prescribed antibiotic until it is finished washing hands before and after perineal care handling perineal pads by the edges

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? retained placental fragments hypertension thrombophlebitis uterine subinvolution

thrombophlebitis

Which complication is most likely responsible for a late postpartum hemorrhage? cervical laceration clotting deficiency perineal laceration uterine subinvolution

uterine subinvolution

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

A nurse is assessing a client who gave birth vaginally about 4 hours ago. The client tells the nurse that she changed her perineal pad about an hour ago. On inspection, the nurse notes that the pad is now saturated. The uterus is firm and approximately at the level of the umbilicus. Further inspection of the perineum reveals an area, bluish in color and bulging just under the skin surface. Which action would the nurse do next? Apply warm soaks to the area. Notify the health care provider. Massage the uterine fundus. Encourage the client to void.

Notify the health care provider

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 100 mL 250 mL 300 mL 500 mL

500 mL