Maternity Chpt. 22 Nursing Management in the Postpartum Woman at Risk 5-8

Report the finding promptly to the primary care provider.

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of the perineum. What is the nurse's best action? Apply an ice pack and reassess in 30 minutes. Provide the client with a hot pack and analgesia as prescribed. Report the finding promptly to the primary care provider. Document this expected finding and reassess frequently.

by frequently assessing uterine involution

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? by assessing skin turgor by assessing blood pressure by frequently assessing uterine involution by monitoring hCG titers

uterine subinvolution

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

laceration

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? hematoma laceration uterine inversion uterine atony

2 months

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear within which time frame after birth? 3 months 4 months 2 months 5 months

uterine atony

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client? cervical laceration uterine atony retained placental fragment disseminated intravascular coagulation

9

A nurse is assessing the perineum of several postpartum clients using the REEDA score. The nurse initiates interventions to minimize the risk for postpartum infection for the client with which score? 3 5 7 9

1,500 ml

A postpartum woman is being treated for hemorrhage and is to receive a blood transfusion. The nurse understands that this treatment is being instituted based on which amount of estimated blood loss? 750 ml 1000 ml 1,250 ml 1,500 ml

length of labor

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

temperature of 38°C (100.4°F) or higher after the first 24 hours after birth

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client? temperature of 39°C (102.2°F) or higher after the first 48 hours after birth temperature of 37.5°C (99.5°F) or higher after the first 12 hours after birth temperature of 38.5°C (101.3°F) or higher after the first 36 hours after birth temperature of 38°C (100.4°F) or higher after the first 24 hours after birth

"What time did you last change your pad?"

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? "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "What time did you last change your pad?" "When did you last void?"

Postpartum psychosis

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? Postpartum blues Postpartum depression Postpartum psychosis Maladjustment

Dyspnea

The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? Calf pain Pyrexia Edema Dyspnea

Ambulate the client as soon as her vital signs are stable.

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother? Roll a bath blanket or towel and place it firmly behind the knees. Limit oral intake of fluids for the first 24 hours to prevent nausea. Assist client in performing leg exercises every 2 hours. Ambulate the client as soon as her vital signs are stable.

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

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

Interference with the maternal-newborn attachment process

When teaching a postpartum client about possible complications following the birth, which would be the best information to include? Interference with the maternal-newborn attachment process Ineffectiveness of breastfeeding Delayed development of the newborn Alteration in normal maternal hormonal function

Her uterus is at the level of the umbilicus.

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

use of regional anesthesia for birth use of fetal scalp electrode for internal fetal monitoring forceps-assisted vaginal birth history of gestational diabetes

A nurse is reviewing the labor and birth record of a postpartum woman. The nurse determines the need for frequent monitoring for infection based on which factors in the woman's history? Select all that apply. rupture of membranes of 10 hours duration use of regional anesthesia for birth use of fetal scalp electrode for internal fetal monitoring forceps-assisted vaginal birth history of gestational diabetes

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

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

administrating a selective serotonin reuptake inhibitor

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? scheduling electroconvulsive therapy administrating a selective serotonin reuptake inhibitor talking to the client and reassuring her that she will feel better soon telling the client that she has no need to be depressed

carboprost

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes the client's history of asthma. Which medication if prescribed would the nurse question? oxytocin carboprost dinoprostone methylergonovine

Take an oral contraceptive pill daily.

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question? Take aspirin as needed. Take an oral contraceptive pill daily. Plan long rest periods throughout the day. Wear compression stockings.

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

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

Semi-Fowler

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? Flat in bed On her left side Trendelenburg Semi-Fowler

increased vaginal acidity leading to growth of bacteria

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor? loss of protection with premature rupture of membranes increased vaginal acidity leading to growth of bacteria retained placental fragments prolonged labor with multiple vaginal examinations to evaluate progress

Pad count

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? Complete blood count Vital signs Pad count Urine volume excreted

Assess for pedal edema.

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

Risk for fatigue related to chronic bleeding due to subinvolution

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

Fever

A woman who delivered her infant by cesarean section 1 week ago called her physician's office to report chills, fever of 101.6℉ (38.7℃) and a poor appetite. She also tells the nurse that she is having strong afterbirth pains and her lochia has increased in volume and has an odor. Lab work shows an elevated WBC count. Which of these reported findings is the most significant finding related to the suspected diagnosis of endometritis? Fever Lochia odor Strong afterpains Elevated WBC count

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

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? Take analgesics for uterine pain. Encourage an oral intake of 2 to 3 liters per day. Change her perineal pads frequently. Keep the environment quiet to encourage rest.

Consistency, shape, and location

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

multiparity

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem? fetal demise placenta accreta preeclampsia multiparity

retained fragments of placenta pelvic pain profuse dark lochia with blood clots

The nurse is performing a focused assessment on a client who is 2 days postpartum. The client reports pelvic pain, chills, profuse dark, foul-smelling lochia with blood clots. The client states, "my bleeding before was light and now it is heavy." Vital signs: temperature, 99.5°F (37.5°C); heart rate, 102 beats/min; blood pressure, 100/66 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client has Select... retained fragments of placenta, puerperal infection, urinary tract infection (UTI) as evidenced by Select... heart rate 102 beats/min, temperature 99.5°F (37.5°C), pelvic pain and Select... profuse dark lochia with blood clots, decreased appetite, blood pressure 100/66 mm Hg.