Post-Partum PrepU 240

The nurse is caring for a client who underwent an episiotomy. What statement by the client indicates teaching was successful?

"I should refrain from using tampons until advised by my healthcare provider" The nurse should emphasize the need to change peripads frequently and instruct the client not to use tampons until after seeing the healthcare provider (usually at the 6-week postpartum checkup). The client can sit in chairs, but adequate padding will increase comfort. Elevation of the legs is not directly related to the episiotomy care, but it can help if the client has peripheral edema. Episiotomy sutures are self-dissolving and do not need to be removed. Itching does not need to be reported; it is an expected sensation, especially as the sutures dissolve.

A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond?

"It stimulates the smooth muscle of the bladder." Bethanechol stimulates the smooth muscle of the bladder causing it to release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle.

A client has just given birth to her first child, a healthy, full-term girl. The client is Rho(D)-negative and her neonate is Rh-positive. What intervention will be performed to reduce the risk of Rh incompatibility?

Administration of Rho(D) immune globulin I.M. to the mother within 72 hours When a mother is Rho(D)-negative and a neonate is Rh-positive, the mother forms antibodies against the D antigen. Most of the antibodies develop within the first 72 hours after she has given birth as a result of the exchange of maternal and fetal blood during birth. If the mother becomes pregnant again, she'll have a high antibody D level that may destroy fetal blood cells during the second pregnancy. However, if the mother receives an injection of Rho(D) immune globulin within 72 hours, no antibodies will be formed. Rho(D) immune globulin may also be given to the mother during pregnancy if the neonate is Rh-positive. The neonate isn't given Rho(D) immune globulin.

A nurse is caring for a breastfeeding client diagnosed with mastitis in one breast and prescribed antibiotics. What actions will the nurse recommend the client take related to breastfeeding?

Apply a warm compress to affected breast prior to feeding. To help relieve mastitis, the nurse should advise the client to use warm compresses and massage the affected area gently before and during breastfeeding. Cold compresses can be used after or between feedings for comfort; this will hinder milk release, though, so the client should not apply them before feeding. It will not be possible to schedule breastfeeding in relation to antibiotic administration; the client is encourage to feed on demand, at least every 2 to 3 hours. To help empty the affected breast, feedings should start with the affected side.

A mother who is Rh-factor negative should receive Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the client. During birth, the newborn's Rh-positive cells can enter maternal circulation. Ideally, the mother should have received a schedule of RhoGAM to prevent initial isoimmunization against fetal erythrocytes and the formation of antibodies. Since the newborn's Rh factor is known, the father's status is not relevant (but would be positive because Rh negativity is a recessive trait). The newborn is not given the RhoGAM; it is the mother who is at risk for a sensitization reaction.

Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right of the abdomen. Nursing interventions would be completed before notifying the primary healthcare provider or charge nurse in a nonemergency situation. Raising the head of the bed is not helpful to change the position of the uterus.

A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take?

Assess the fundus and massage it if it's boggy The nurse should first asses the fundus to determine if clots are present or if uterine involution has occurred. Clots, no uterine involution, and the saturation of two perineal pads within 30 minutes could indicate postpartum hemorrhage. If the fundus is boggy, massaging it will suppress bleeding by encouraging the uterus to contract upon itself and the open vessels that were attached to the placenta. Massaging also helps to expel clots or tissue remaining from the birth. If the nurse assesses a firm fundus, the nurse should next assess for a full bladder and then ask the client to try to urinate. If the uterus remains boggy after massage, the nurse should obtain an order from the physician for methylergonovine. Waiting 30 minutes without intervening could contribute to uterine hemorrhage.

A 15-year-old client gives birth to a healthy neonate. The neonate's adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action?

Discuss the unit's policy with the charge nurse. Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonate's parents are married or if the mother is an emancipated minor. Therefore, the adolescent mother may not be able to legally make her own decisions about her parents' (the baby's grandparents') presence. She or her parents do have a say as to whether the father's parents can visit. The mother of the neonate does have a say in visitors seeing her baby. Because the family dynamics aren't clear in this scenario, the best answer would be to check with the charge nurse who knows the unit's policy. Although the neonate's father may have demanded to see the baby, the question doesn't indicate violent or threatening behavior; therefore, notifying security isn't necessary. The nurse can instruct the father's parents on how to gown and glove before visiting the neonate if they have permission to visit. Because the family dynamics aren't known, inviting everyone to gather in a conference room isn't advisable.

A client gives birth to a stillborn neonate at 36 weeks gestation. When caring for this client, which strategy by the nurse would be most helpful?

Encourage the client to see, touch, and hold the dead neonate. When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for the client to bond with the dead neonate and allow the neonate to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and provide any information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the client's partner decide which information the client receives is inappropriate.

A charge nurse informs a staff nurse of a new admission in active labor who is coming to the labor and delivery unit. The nurse is currently caring for a client in labor and another client who has a cesarean birth scheduled within the next half hour. How can the nurse best manage the client care assignment?

Inform the charge nurse that the change in client census requires an additional staff member to safely care for the clients. A nurse in the labor and delivery unit can't safely care for three clients. Therefore, the nurse should notify the charge nurse that an additional staff member is needed to safely meet the needs of the increasing client census. Postponing the cesarean birth isn't the best option. Although asking the administrative assistant to assist with paperwork is appropriate, obtaining an additional nurse is a higher priority. The nurse can't refuse to admit a client in labor.

During an annual checkup, a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?

It should begin before conception and end 3 months after childbirth. Ideally, childbirth education should begin before conception (or as soon after conception as possible) and continue for about 3 months after the client gives birth. Beginning childbirth education later and ending it earlier wouldn't provide enough time for optimal preparation of the client and her partner.

A woman who gave birth to a healthy baby 6 hours ago is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. What action should the nurse take?

Notify the health care provider (HCP). The client is experiencing signs of thrombophlebitis. The nurse should notify the HCP because emboli formation is a potential risk. Massaging the area may cause the thrombus to dislocate and become an embolus. Warm compresses will increase circulation to the area and may precipitate embolus formation. Ankle pump exercises are helpful in preventing thrombophlebitis but will not prevent further risk of embolus formation at this time.

When assessing a postpartum client, the nurse notes a continuous flow of bright red blood from the vagina. The uterus is firm and no clots can be expressed. Which action should the nurse take?

Notify the physician. The nurse should notify the healthcare professional because a continuous flow of bright red blood from the vagina and a firm, contracted uterus indicate laceration of the birth canal. Ice application doesn't slow bleeding. Massage isn't necessary because the client's fundus is firm. Telling the client that bleeding is normal would be misleading and would give her a false sense of security.

Which measure included in the care plan for a client in the fourth stage of labor requires revision?

Obtain an order for catheterization to protect the bladder from trauma. Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.

A woman gave birth 1 hour ago to a full-term boy. The nurse's assessment reveals a well-contracted uterus that's midline, and at the level of the umbilicus. The client is bleeding heavily. What should the nurse do next?

Report the bleeding to the healthcare professional (HCP). Heavy bleeding can signal uterine or vaginal lacerations. The nurse should report this finding to the HCP. Massaging a contracted uterus may cause uterine atony. The nurse should assess for a distended bladder if the uterus is soft or boggy. This client's uterus is contracted.

A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?

The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment. Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her neonate after teaching and demonstrating care techniques; discussing the childbirth experience won't help her to meet these needs.

A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care for this postpartum client, which postpartum goal would have the highest priority?

The client will demonstrate self-care and infant care by the end of the shift. Educating the client about caring for herself and her infant are the two highest priority goals. Following birth, all mothers, especially the primigravida, require instructions regarding self-care and infant care. Learning needs should be assessed in order to meet the specific needs of each client. Bonding is significant, but it is only one aspect of the needs of this client and the bonding process would have been implemented immediately postpartum, rather than waiting 2 hours. Planning the discharge occurs after the initial education has taken place for mother and infant and the nurse is aware of any need for referrals. Safety is an aspect of education taught continuously by the nurse and should include maternal as well as newborn safety.

A client who is Rh-factor negative has given birth to a healthy infant who is Rh-factor positive. What teaching will the nurse provide to the client?

The client will need Rh immunoglobulin injection within 72 hours. A mother who is Rh-factor negative should receive Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the client. During birth, the newborn's Rh-positive cells can enter maternal circulation. Ideally, the mother should have received a schedule of RhoGAM to prevent initial isoimmunization against fetal erythrocytes and the formation of antibodies. Since the newborn's Rh factor is known, the father's status is not relevant (but would be positive because Rh negativity is a recessive trait). The newborn is not given the RhoGAM; it is the mother who is at risk for a sensitization reaction.

During the postpartum period, a nurse should assess for signs of normal involution. Which statement would indicate that a client is progressing normally?

The uterus is descending at the rate of one fingerbreadth per day. During the normal involutional process, the uterus will descend approximately one fingerbreadth per day. Blood pressure doesn't change during the postpartum period. Urine output typically increases after childbirth. Usually, the client will need six to seven perineal pads per day at this time.

A client is 9 days postpartum and breast-feeding her neonate. The client experiences pain, redness, and swelling of her left breast and is diagnosed with mastitis. The nurse teaching the client how to care for her infected breast should include which information?

Use a warm moist compress over the painful area. Warm, moist compresses will reduce inflammation and edema of the infected breast tissue. The woman with mastitis should wear a proper fitting bra with good support. Breast-feeding does not have to be interrupted. The client will also need to pump the breast to keep the breast empty of milk and to ensure an adequate milk supply. Adequate emptying of the affected breast helps prevent more bacteria from collecting in the breast and may shorten the duration of the infection. Antibiotics must be taken for the full course of therapy and not stopped when symptoms subside

A nurse is orienting a new nurse to the labor and delivery unit. Which action by the new nurse regarding a neonate's security requires intervention by the preceptor?

allowing volunteers to return neonates to the nursery The new nurse requires additional teaching if allowing volunteers to return neonates to the nursery. Unit staff members won't likely recognize volunteers, whose assignments vary with each shift. Affixing matching identification bands at birth, positioning a rooming-in neonate's bassinet toward the center of the room, and affixing security bracelets are appropriate security measures.

A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which symptom should the nurse instruct the client to report to her primary caregiver?

blurred vision and headache Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the healthcare provider. Because these two effects in particular may result in cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.

A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row, the nurse should instruct the client to

discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure effectiveness and can increase the risk of adverse reactions.

A postpartum nurse should provide care that is

family-centered.

A client reports that she wishes to attempt to breastfeed her newborn. The client indicates that she was unsuccessful at breastfeeding her first child and switched to bottle feeding after 3 days. Which approach by the nurse will be most effective in facilitating the client's current breastfeeding efforts?

having the newborn room-in with the client and teaching the client about feeding cues One way to help support this client's current wishes to breastfeed is to instruct her to room-in with her neonate so she can respond to the neonate's cues. Sending the neonate to the nursery reduces these opportunities. Arranging for the lactation consultant to visit after discharge does not enhance current efforts. Similarly, assuring the client that success is likely or recommending feeding on a schedule will not assist with current efforts.

A nurse notes a postpartum client continues to have heavier bleeding than expected 24 hours after birth. Which laboratory test should the nurse request to identify a probable cause of bleeding?

human chorionic gonadotropin (hCG) levels The circulating hormone hCG disappears within 8 to 24 hours following birth in both lactating and non-lactating clients. If placental fragments remain, hCG remains elevated and can contribute to increased postpartum bleeding. A hemoglobin level can identify the amount of blood loss by comparing the result to the client's baseline, but it cannot be used to determine the cause of bleeding. Similarly, low iron levels can result from blood loss and can contribute to anemia but do not correlate with bleeding causes. Prolactin levels increase sharply in the immediate postpartum period but are not linked to bleeding.

A postpartum client is adapting to her new maternal role. She tells the nurse "I am so glad my baby is becoming their own little person." The nurse concludes that the mother is in what phase?

letting-go phase Rubin identified three phases during which a woman adapts to the maternal role. During the taking-in (dependent) phase, which usually lasts 1 to 2 days after childbirth, the client usually is exhausted and dependent on others, focusing on her own needs. During the taking-hold (dependent-independent) phase, which may last from 3 days to 8 weeks, the client vacillates between seeking nurturing and acceptance for herself and seeking to resume an independent role. During the letting-go (interdependent) phase, the client begins to accept the neonate as an individual who's separate from herself.

A nurse assesses a client's vaginal discharge on the first postpartum day and describes it in the progress note (shown above). Which terms best identifies the discharge?

lochia rubra For the first 3 days after birth, the discharge is called lochia rubra. It consists almost entirely of blood, with only small particles of decidua and mucus. Lochia alba is a creamy white or colorless discharge that occurs 10 to 14 days postpartum. Lochia serosa is a pink or brownish discharge that occurs 4 to 14 days postpartum. The term lochia alone is not a correct description of the discharge.

On a client's first postpartum day, nursing assessment reveals vital signs within normal limits, a boggy uterus, and saturation of the perineal pad with lochia rubra. Which nursing intervention takes highest priority?

massaging the uterus gently If a postpartum client has a boggy (relaxed) uterus, the nurse should first massage her uterus gently to stimulate contraction (involution). The nurse should reassess the client 15 minutes later to ensure that massage was effective. If the uterus doesn't respond to massage, the nurse should administer oxytocin as ordered. The nurse should notify the physician or nurse-midwife if the client's uterus remains boggy after massage and oxytocin administration or if assessment reveals a rapid, thready pulse or decreased blood pressure.

where do you assess DVT at on preg women

o assess for the presence of a DVT, the nurse examines both calves and compares them to each other. Evidence of DVT includes unilateral swelling, redness, and discomfort. Often, the signs are more subtle. Recognizing the risks for DVT is important, as is prophylaxis in clients who are at high risk. In the postpartum client, risk is increased due to changes during pregnancy that produce a hypercoagulable state.

A nurse is caring for a client in the fourth stage of labor. Based on the nurse's note, which postpartum complication has the client developed?

postpartum hemorrhage Blood loss from the uterus that exceeds 500 ml in a 24-hour period is considered postpartum hemorrhage. If uterine atony is the cause, the uterus feels soft and relaxed. A full bladder can prevent the uterus from contracting completely, increasing the risk of hemorrhage. These symptoms are not characteristic of a urinary tract infection or pyelonephritis. Puerperal infection is an infection of the uterus and structures above; its characteristic sign is fever. Uterine rupture is a potentially catastrophic event during childbirth where the wall of the uterus ruptures. A uterine rupture is a life-threatening event for the mother and fetus.

The nurse is caring for a client on her second postpartum day. The nurse should expect the client's lochia to be

red and moderate. During the first 3 days, the lochia will be red (lochia rubra) with moderate flow. Note, however, that the client shouldn't be soaking more than one pad every hour. A continuous flow of moderately clotted blood from the vagina isn't normal and should be reported. Clots may indicate retained pieces of placenta. Lochia changes to pink or brown (lochia serosa) after 3 to 10 days. By day 10, the lochia should be white (lochia alba) and continue for several weeks.

On a client's second postpartum visit, a health care provider reviews the chart. What's the best term for the lochia described?

rubra

The nurse places inflatable compression sleeves on the legs of a client undergoing a cesarean birth under regional anesthetic. When does the nurse tell the client that the sleeves will be removed?

when the client resumes ambulating A cesarean birth is an independent risk factor for thromboembolic event in pregnant women. Inflatable compression sleeves should be placed on the lower extremities of a client until risk of venous stasis is reduced through ambulation. While return of sensation must happen before the client can safely ambulate, this finding alone does not significantly decrease the risk of venous stasis. Platelets continue to be significantly elevated for at least 3 weeks after birth, which is well after a client would be discharged. It is unnecessary to continue wearing the compression sleeves after ambulation has returned.