#2 OB EAQ Normal Postpartum

As the nurse helps a postpartum client change her perineal pad, the client comments, "I wish you didn't have to look at the pad. It's so embarrassing for me." What is the best response by the nurse? 1. "This seems to be uncomfortable for you; however, I have to estimate the amount of blood loss to identify any potential problems." 2. "There can be more blood loss than you might realize. We can determine how much you've lost with a formula." 3. "Examining the pad is a common practice that helps us keep you safe. It's a necessary part of the job, and I don't mind." 4. "Looking at your pad is a procedure we follow to determine the extent of your bleeding so we can give you the necessary care."

1. "This seems to be uncomfortable for you; however, I have to estimate the amount of blood loss to identify any potential problems." (Recognizing the client's discomfort and informing the client of the need to estimate the amount of blood loss acknowledges her feelings and provides an explanation for the intervention. Blood loss can be estimated from the pad count, the degree of saturation, and the time taken for the saturation to occur; an estimate of loss can give the nurse an opportunity to prevent complications caused by hemorrhage. Informing the client that the blood loss can be calculated does not identify the client's feelings; also, this statement may be alarming. Telling the client that examining the pad is a common practice or policy does not acknowledge the client's feelings; it is a general response that does not educate the client about why this assessment is necessary.)

The nurse is caring for a postpartum client who has chosen formula feeding. What should the nurse teach her regarding minimizing breast discomfort? 1. Apply covered ice packs to the breasts. 2. Gently apply cocoa butter to the nipples. 3. Place warm, wet washcloths on the nipples. 4. Manually express colostrum from the breasts.

1. Apply covered ice packs to the breasts. (Covered ice packs promote comfort by decreasing vasocongestion. Nipple stimulation with either cocoa butter application or warm, wet washcloths precipitates the release of prolactin, which leads to more milk production and further engorgement and discomfort. Emptying the breasts stimulates lactation, leading to further engorgement and discomfort.)

During a home visit the nurse obtains information regarding a postpartum client's behavior and suspects that she is experiencing postpartum depression. Which assessments support this conclusion? Select all that apply. 1. Lethargy 2. Ambivalence 3. Emotional lability 4. Increased appetite 5. Long periods of sleep

1. Lethargy 2. Ambivalence 3. Emotional lability (Lethargy reflects the lack of physical and emotional energy that is associated with depression. Ambivalence, the coexistence of contradictory feelings about an object, person, or idea, is associated with postpartum depression. Emotional lability is associated with postpartum depression. Anorexia, rather than increased appetite, is associated with postpartum depression; the client lacks the physical and emotional energy to eat. Insomnia, rather than long periods of sleep, is also associated with postpartum depression.)

What is the priority nursing intervention for the postpartum client whose fundus is three fingerbreadths above the umbilicus, boggy, and midline? 1. Massaging the uterine fundus 2. Helping the client to the bathroom 3. Assessing the peripad for the amount of lochia 4. Administering intramuscular methylergonovine (Methergine) 0.2 mg

1. Massaging the uterine fundus (A uterus that is displaced and above the fundus indicates relaxation of the uterine muscle. Fundal massage is necessary to stimulate uterine contractions. The status of the fundus and correction of uterine relaxation must be done before the client is helped to the bathroom, the amount of lochia is assessed, or methylergonovine is administered.)

The nurse is caring for four clients on the postpartum unit. Which client will most likely state that she is having difficulty sleeping due to afterbirth pains? 1. Multipara who has vaginally delivered three children 2. Primipara whose newborn weighed 7 lb 3. Multipara with effectively controlled diabetes 4. Multipara whose second child was small for gestational age

1. Multipara who has vaginally delivered three children (A multipara's uterus tends to contract and relax spasmodically, even if uterine tone is effective, resulting in pain that may require an analgesic for relief. A primipara's uterus usually remains in the contracted state unless the newborn is large for gestational age. However, she is less likely to have afterbirth pains requiring an analgesic than a multipara is. If a client's diabetes is controlled during pregnancy, she is not likely to give birth to a large infant. Although a multipara might have afterbirth pains even with a small newborn, the pain probably will be mild because the uterus was not fully stretched.)

The nurse plans to assess a postpartum client's uterine fundus. What should the nurse ask the client to do before this assessment? 1. Drink fluids 2. Empty her bladder 3. Perform the Valsalva maneuver 4. Assume the semi-Fowler position

2. Empty her bladder (Having the client empty her bladder will help ensure accurate assessment of fundal height. A full bladder may promote a boggy uterus and may elevate the uterus upward and toward the client's right side. There is no need to drink fluids before this assessment; however, the client should drink at least 2 L of fluid a day during the postpartum period. The Valsalva maneuver has no effect on the assessment of fundal height. Assessing the fundus while the client is in the semi-Fowler position will result in an inaccurate assessment. The bed should be flat, and the client should assume the supine position.)

The postpartum nurse is delegating tasks to an unlicensed health care worker. Which task should the nurse delegate? 1. Evaluation of a postpartum client's lochia 2. Vital signs on a client 4 hours after delivery 3. Assessment of a postpartum client's episiotomy 4. Assisting the postpartum client to breastfeed for the first time

2. Vital signs on a client 4 hours after delivery (Evaluating the client's lochia, assessing the client's episiotomy, and helping the client breastfeed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem, and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, then look at all of the choices and select the one that most nearly matches the answer you recalled. It is important that you consider all the choices and not just choose the first option that seems to fit the answer you recall. Remember the distractors. The second choice may look okay, but the fourth choice may be worded in a way that makes it a slightly better choice. If you do not weigh all the choices, you are not maximizing your chances of correctly answering each question.)

The nurse in the postpartum unit is teaching self-care to a group of new mothers. What color does the nurse teach them that the lochial discharge will be on the fourth postpartum day? 1. Dark red 2. Deep brown 3. Pinkish brown 4. Yellowish white

3. Pinkish brown (Lochia serosa is the expected vaginal discharge between the third and tenth postpartum days; it is pinkish to brownish and consists of serous exudate, shreds of degenerating decidua, erythrocytes, leukocytes, cervical mucus, and numerous microorganisms. Lochia rubra is the expected vaginal discharge on the first 2 or 3 postpartum days; it is dark red and consists of epithelial cells, erythrocytes, leukocytes, shreds of decidua, and occasionally fetal meconium, lanugo, and vernix caseosa. Lochia is never dark brown. Lochia alba is the expected vaginal discharge about 10 days postpartum; it persists for 1 to 2 weeks. A creamy or yellowish color, it consists of leukocytes, decidual cells, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.)

When palpating a client's fundus on the second postpartum day, the nurse determines that it is above the umbilicus and displaced to the right. What does the nurse conclude? 1. There is a slow rate of involution. 2. There are retained placental fragments. 3. The bladder has become overdistended. 4. The uterine ligaments are overstretched

3. The bladder has become overdistended. (A distended bladder will displace the fundus upward and laterally to the right. A slow rate of involution is manifested by slow contractions and uterine descent into the pelvis. If retained placental fragments were present, the uterus would be boggy in addition to being displaced, and vaginal bleeding would be heavy. From this assessment the nurse cannot make a judgment regarding overstretched uterine ligaments.)

A postpartum client is being prepared for discharge. The laboratory report indicates that she has a white blood cell (WBC) count of 16,000/mm3. (16 X 109/L) What is the next nursing action? 1. Checking with the nurse manager to see whether the client may go home 2. Reassessing the client for signs of infection by taking her vital signs 3. Delaying the client's discharge until the practitioner has conducted a complete examination 4. Placing the report in the client's record because this is an expected postpartum finding

4. Placing the report in the client's record because this is an expected postpartum finding (Leukocytosis (15,000 to 20,000/mm3 WBC) (15 to 20 X 109/L) typically occurs during the postpartum period as a compensatory defense mechanism. There is no need for further intervention because the client is exhibiting an expected postpartum leukocytosis.)