306 Ricci PrepU Chapter 22: Nursing Management of the Postpartum Woman at Risk

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond?

pierced nipple Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

e coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid." The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.

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?

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

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

500 ml Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL after a vaginal birth and greater than 1,000 mL after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.

It is discovered that a new mother has developed a postpartum 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 (38.8°C) orally. As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

assess for pedal edema Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

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" The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

"I know you are hurting, but you can have another baby in the future" Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:

postpartum depression Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate my gums" The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

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?

blood pressure, pulse, and reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

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?

Ambulate the client as soon as her vital signs are stable. The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

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 frequently assessing uterine subinvolution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

her blood pressure is below 140/90 mmHg Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

instruct the client to empty her bladder before the examination An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis.

The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider?

not responding to the infant crying When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. The other options are normal activities for a new mother who is 2 weeks postpartum.

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 psychosis Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

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 over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

the bladder is distended If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection.

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?

length of labor The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection?

foul smelling vaginal discharge The nurse should monitor for foul-smelling vaginal discharge to verify the presence of an episiotomy infection. Sudden onset of shortness of breath, along with apprehension and diaphoresis, are signs of pulmonary embolism and do not indicate episiotomy infection. Pain in the lower leg is indicative of a thrombosis.

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.

use of regional anesthesia for birth use of fetal scalp electrode for internal fetal monitoring forceps-assisted vaginal birth history of gestational diabetes Factors that increase a woman's risk for postpartum infection include: prolonged rupture of membranes (greater than 18 to 24 hours); regional anesthesia that decreases the perception of the need to void; insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity); instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genitalia); and gestational diabetes (decreases body's healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth).

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 ml Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.

After teaching a class of pregnant women on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states:

"At least I don't have to give up smoking for this one." Preventing thrombotic conditions is an important aspect of postpartum care and proper nursing management. There are many simple measures that can be utilized: encouraging leg exercises and walking; using intermittent sequential compression devices; stopping smoking to reduce or prevent vascular vasoconstriction; using compression stockings; performing passive range-of-motion exercises while in bed; using postoperative deep breathing exercises to improve venous return; and increasing fluid intake to prevent dehydration.

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away.

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?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

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 depression develops gradually, appearing within the first 6 weeks." Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill.

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?

"When I am sleeping or lying in bed, I should lie flat on my back." With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

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 fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

activated partial thromboplastin time The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

check the lochia The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

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?

bladder distension The displacement of the uterus to one side is suggestive of bladder distention. The bladder should be emptied and then fundal massage instituted to encourage the uterus to contract and stop the excessive bleeding. If the uterus was in the midline, then this would be related solely to uterine bleeding. It's important to ensure the bladder is empty before starting the fundal massage to ensure the uterus will stay contracted. A urinary infection would be noted to cause burning on urination. A ruptured bladder would be indicative of hematuria as well as pelvic pain.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client?

oxytocin agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

palpate her fundus The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended.

A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis?

perform handwashing before and after breastfeeding The nurse should educate the client to perform handwashing before and after breastfeeding to prevent mastitis. Discontinuing breastfeeding to allow time for healing, avoiding hot or cold compresses on the breast, and discouraging manual compression of the breast for expressing milk are inappropriate interventions. The nurse should educate the client to continue breastfeeding, because it reverses milk stasis, and to manually compress the breast to express excess milk. Hot and cold compresses can be applied for comfort.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

the client feels empty since she gave birth to the neonate A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

What is a risk factor for developing a postpartum infection? Select all that apply.

type 1 diabetes prolonged labor cesarean birth Several risk factors make it more likely for a postpartum woman to develop a wound infection. They include prolonged labor, prolonged ruptured membranes, obesity, history of chronic illnesses such as diabetes or hypertension, and a surgical incision from a cesarean birth. Hematomas and chorioamnionitis are also contributory factors.

Initial measures to stop a client's bleeding have not proved successful, and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula. The client's brother suddenly says to her partner, "This is all your fault!" What is the best response by the nurse?

Explain the client's care, focus on signs of improvement, and acknowledge this is a difficult time. The nurse's first responsibility is to the client. She needs to be aware of the interaction and focus the family on the client, explaining the cares and acknowledging the difficult time for all involved. Leaving the room is not an appropriate action. The nurse would only ask the client's brother to leave if he could not be redirected and continued to cause a disruption. The nurse would not have the RN explain the client's treatment.

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?

calf swelling The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention.

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

inability to concentrate loss of confidence decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

she should continue to breastfeed; mastitis will not affect the neonate The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

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?

staph aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

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?

9 The nurse would implement measures to minimize the risk for postpartal infection for the woman with a REEDA score of 9. The acronym REEDA is frequently used for assessing a woman's perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include: redness, edema, ecchymosis, discharge and approximation of skin edges. Each category is assessed and a number assigned (0 to 3 points, with 0 indicating none or intact and 3 indicating more significant problems). The total REEDA score ranges from 0 to 15. Higher scores indicate increased tissue trauma predisposing the woman to an increased risk for infection and a greater risk for postpartal hemorrhage. Therefore the woman with a total score of 9 is at greatest risk for problems.

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begin to feel better. Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.

The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?

encourage fluid intake Adequate fluid intake is necessary during antibiotic therapy. Mobility should be encouraged whenever possible and safe. Small meals do not enhance healing or mitigate adverse effects. Antacids may or may not be prescribed.

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 oral intake of 2 to 3 liters a day Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client.

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

dorsiflex her right foot and ask if she has pain in her calf A positive Homans sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for redness and warmth/ In addition, assess to see if she has increased pain when she ambulates or bears weight.

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?

report the finding promptly to the primary care provider This client's presentation is consistent with a hematoma, which indicates a hemorrhage and which must be treated promptly. Reporting this change in status is priority over hot/cold treatments. This is not an expected finding.

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 health care provider?

weak and rapid pulse Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.