POSTPARTUM
A postpartum client who is bottle-feeding her neonate asks the nurse when she can expect her menstrual period to return. How should the nurse respond?
"In 7 to 9 weeks" In nonlactating clients, menstruation typically resumes 7 to 9 weeks after delivery. The average time before return of ovulation is approximately 10 weeks after delivery.
A new mother who's breast-feeding asks how quickly she can expect to lose the 40 lb she gained during pregnancy. Which response by the nurse is best?
"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended."
A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by:
3 days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7° F to 0.8° F (.39° C to .44° C) and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle isn't significant. Breast tenderness and mittelschmerz aren't reliable indicators of ovulation.
Which client care assignment is the most appropriate assignment for a newly graduated licensed practical nurse (LPN)?
A 24-year-old primigravida who delivered a 6-lb, 4-oz (2,835-g) baby vaginally 4 hours ago and is unable to void
When caring for a client who has recently delivered, the nurse assesses the client for urinary retention with overflow. Which of the following descriptions provides an accurate picture of retention with overflow?
A varying urge to urinate with an average output of 100 ml Retention with overflow is a commonly missed nursing assessment. Because the client may be voiding and may not have an urge to void doesn't mean that bladder function has been properly restored. A varying urge to urinate with an average urine output of 100 ml is a classic picture of a client whose bladder is distended and needs to be catheterized to restore normal function.
At her follow-up examination, a client who's 6 weeks postpartum tells the nurse that she's exhausted and sore from breast-feeding and wants to formula-feed her baby. She also mentions that she feels like a failure and finds it increasingly difficult "just to get out of bed in the morning." Which intervention should the nurse attempt before notifying the physician?
Acknowledging the client's feelings, asking about other life stressors, and identifying the client's support system Mild depression affects more than 70% of clients postpartum but usually lasts no longer than 2 weeks. A client at 6 weeks who verbalizes feelings of failure, sadness, and extreme fatigue is exhibiting symptoms of postpartum depression. The nurse needs to establish priorities by addressing the client's depression before discussing breast-feeding.
One day after having a cesarean birth, a client complains of incisional pain that she rates as a 3 on a 1-to-10 scale, with 10 representing the most severe pain. The physician prescribed ibuprofen (Motrin), 400 mg by mouth every 4 to 6 hours, as needed. Which intervention should the nurse take when administering this drug?
Administer the drug with meals or milk.
A client who delivered by cesarean birth 3 days ago is bottle-feeding her neonate. While the nurse collects data, the client complains that her breasts are painful, hard, and warm to the touch. How should the nurse intervene?
Apply an elastic bandage to bind the breasts.
The nurse is planning to discharge a 24-year-old gravida 1, para 1, non-English-speaking Hispanic client. The client's English-speaking cousin is acting as a translator for the nurse and client. Which nursing intervention takes priority?
Arranging for a home care nurse to assess the client in her home environment The nurse should arrange for a home care nurse to assess the client in her home environment to make sure that she and the baby are adapting adequately. A staff member may not have the education necessary to assess whether discharge instructions are understood. Although a family support system is important, the nurse can't ensure that discharge instructions are understood. The client and family members may not recognize when a problem arises to call an information number.
A client is resting comfortably 4 hours after delivering her first child. When measuring her heart rate, the nurse expects which normal finding?
Bradycardia During the client's first postpartum rest or sleep, which usually occurs 2 to 4 hours after delivery, the heart rate typically decreases, possibly slowing to 50 beats/minute (bradycardia). This probably results from supine positioning and such normal physiologic phenomena as the postpartum rise in stroke volume and a reduction in vascular bed size. An irregular pulse is never normal. Tachycardia may indicate excessive blood loss, especially if accompanied by a thready pulse and such other signs as pallor, an increased respiratory rate, and diaphoresis.
After receiving the shift report, the nurse realizes that she should monitor her postpartum client closely for puerperal infection. Which factor alerted the nurse to the client's risk for this complication?
Cesarean birth The risk of puerperal infection increases by as much as 20 times with a cesarean birth. The use of internal fetal monitoring (not external fetal monitoring), a period of more than 24 hours since rupture of the membranes, premature rupture of membranes, and prolonged (more than 24 hours) or difficult labor also increase the risk of puerperal infection.
A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?
Client will demonstrate ability to bottle-feed the neonate.
The nurse is preparing to perform a physical examination on a postpartum client. Which statement best explains why the nurse must wear gloves during this examination?
Gloves are required for standard precautions.
A client is at risk for which postpartum complication during the fourth stage of labor?
Hemorrhage
A client is receiving oxytocin (Pitocin) to treat postpartum hemorrhage. When planning the client's care, the nurse anticipates monitoring for which common adverse reactions?
Hypertension and tachycardia Oxytocin may cause hypertension and tachycardia. The nurse should monitor the client for these adverse effects. Abdominal cramps, diarrhea, headache, facial flushing, blurred vision, and dizziness aren't typically associated with oxytocin.
The nurse is collecting data on client who is 1 day postpartum. The nurse expects which normal findings?
Lochia rubra Heart rate of 50 to 70 beats/minute The nurse should expect the client to have lochia rubra, a fundus that's palpable at the level of the umbilicus, normal blood pressure, and a heart rate of 50 to 70 beats/minute. Breasts don't become engorged until the third, fourth, or fifth day after birth.
When caring for a client who has had a cesarean section, which of the following actions is appropriate?
Monitoring pain status and providing necessary relief The nurse should monitor the client's pain status and provide relief as needed. Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The nurse should monitor vital signs every 15 minutes until the client is stable. Breast-feeding should be initiated as soon as the mother feels like trying. The nurse shouldn't begin bottle-feeding the baby unless the mother is physically unable to breast-feed.
A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate?
Performing fundal massage
While preparing a client for a postpartum tubal ligation, the nurse overhears the client tell her husband that they can always have reversal surgery if they decide they want more children in the future. Which intervention by the nurse is best?
Privately discussing with the client her understanding of the procedure Informed consent requires that the client has a full disclosure and understanding of information before the surgical procedure. The nurse must ensure that this couple understands that surgical sterilization is considered a permanent end to fertility because reversal surgery isn't always successful. The nurse should discuss the procedure with the client privately to maintain her confidentiality. After the conversation, she should assess whether the physician should be notified. It's inappropriate to confront the couple and wrongfully assume that a signed consent form indicates informed consent.
A client who is breast-feeding her infant is experiencing breast engorgement. The nurse suggests breast pumping to relieve the breast engorgement. Which instruction should the nurse provide?
Pump each breast for at least 10 minutes every 3 to 4 hours; pump at night only if she's awake.
A postpartum client is ready for discharge. During discharge preparation, the nurse should instruct her to report which of the following to her primary health care provider?
Redness, warmth, and pain in the breasts Redness, warmth, and pain in the breasts indicate mastitis. Typically accompanied by fever, headache, and flulike symptoms, mastitis usually occurs 2 to 3 weeks after delivery. Episiotomy discomfort sometimes persists for up to 6 weeks, depending on the extent of trauma. Lochia alba is normal at 2 weeks' postpartum. A temperature of 99.2° F (37.3° C) isn't significant.
A 41-year-old multipara client had a spontaneous vaginal delivery of an 8-lb (3,629-g) baby 3 hours ago. The nurse collects the following data: "Fundus firm, three fingerbreadths above the umbilicus and deviated to the right. Perineal pad saturated after 20 minutes." Which nursing intervention by the licensed practical nurse (LPN) is best?
Reminding the client to void and helping her to the bathroom Postpartum clients commonly don't have the urge to void due to lost muscle tone and perineal trauma. The location of the fundus above the umbilicus and displaced to the right suggests that the bladder is distended, which makes it difficult for the uterus to contract. The LPN can address this common problem and reassess before notifying the registered nurse. It's inappropriate to ignore the data and wait 15 minutes. The physical data collected isn't within normal limits as the fundus should be midline and at the umbilical level and a perineal pad saturated within 20 minutes indicates excessive bleeding.
A client with a first-degree tear and swollen perineum is 28 hours postpartum when she requests assistance with her first sitz bath. Which intervention by the nurse is necessary at this time?
Requesting that the client call for assistance to walk back to bed when she's finished with the sitz bath the localized warmth of the water during a sitz bath commonly makes clients feel tired and unsteady. As a safety precaution, the nurse should instruct the client to call for assistance when she's ready to ambulate. Ice packs are most effective during the first 24 hours after delivery. Sitz baths should be maintained at a temperature of 100º to 105° F (37.8° to 40.6° C). A temperature of 107° F (41.7° C) might cause a burn injury. Topical medications should be applied after the sitz bath, not before, as prescribed; tissue burns may occur if topical medications are applied before the sitz bath.
A client, age 22, is a gravida 1, para 0. During the first 24 hours after delivery, she doesn't show consistent interest in her neonate. How should the nurse interpret her behavior?
The client is showing expected behaviors for the taking-in period. According to Rubin, dependence and passivity are typical during the taking-in period, which may last up to 3 days after delivery. A client experiencing postpartum depression demonstrates anxiety, confusion, or other signs and symptoms consistently. Maternal role attainment occurs over 3 to 10 months. Attachment also is an ongoing process that occurs gradually.
A clinical pathway is guiding care for an Rh-negative postpartum client who vaginally delivered a 9-lb, 1-oz (4,121-g) baby 5 hours ago. During the delivery, a second-degree median episiotomy was necessary. Which client outcome should be achieved during the first 12 hours postpartum?
The client will verbalize and demonstrate appropriate self-perineal care. Excellent perineal care cleanses, comforts, and prevents infection. The nurse must ensure that the client understands perineal care for the immediate postpartum recovery period. Vaginal lochia is initially rubra (bloody) for 1 to 3 days postpartum. Rho(D) immune globulin is given within 72 hours after delivery if laboratory results determine that the infant is Rh-negative and the mother hasn't been sensitized to Rh antigens. Immediately after delivery, the fundus is located midway between the symphysis pubis and umbilicus; within a few hours, it will rise to the level of the umbilicus and will remain there for up to 24 hours.
A client who is breast-feeding her baby experiences pain, redness, and swelling of her left breast 9 days postpartum. She 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.
The nurse should tell new mothers who are breast-feeding that breast milk is produced when:
the placenta is delivered, causing the secretion of prolactin.
