Ch. 13 Postpartum Complications

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis?

Assess for redness and warmth in the affected leg. Assess for edema in the affected leg. Assess for a low-grade fever.

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 teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?

"When I put on a new pad, I'll start at the back and go forward."

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition?

delusional beliefs

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

On completing fundal palpation, the nurse notes that the fundus is situated in the client's left abdomen. Which action is appropriate?

Ask the client to empty her bladder

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.

A 37-year-old client experienced a perinatal loss 3 days ago. The nurse, who's concerned about the possibility of dysfunctional grieving, should assess the client for which sign?

Denial of the death

The nurse receives a report on a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware of these complications and knows to monitor the client closely for which of the following?

Postpartum hemorrhage

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding.

A client with postpartum hematoma is admitted to a local healthcare facility. Which of the following would the nurse assess as characteristic of this condition?

Rectal pressure

Your patient calls you to her room and tells you that she knows something awful is going to happen to her. What should you do?

Report this immediately to the RN

When assessing a client who is 5 days pospartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage?

Rubra colored lochia

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

Symptoms include fever, chills, malaise, and localized breast tenderness.

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 woman gave birth to a healthy baby girl two days ago. Which observation by the nurse indicates the need for additional assessment and follow up?

The woman tells a friend, referring to her baby, "It just cries all the time."

A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?

a nonelective cesarean birth

A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract?

birth of a large newborn

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?

femoral thrombophlebitis

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?

mastitis

A postpartum client is prescribed medication therapy as part of the treatment plan for postpartum hemorrhage. Which medication would the nurse least expect to administer in this situation?

nifedipine

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

uterine atony

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

uterine atony

Which complication is most likely responsible for a late postpartum hemorrhage?

uterine subinvolution

When caring for a client with postpartum depression (PPD), which of the following would the nurse assess? Select all that apply

*Sense of isolation *Decreased energy *Hostility toward others

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin.

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, reports of dizziness

The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum:

blues

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra.

Which of the following would the nurse expect to assess in a client to verify the development of hypovolemic shock? Select all that apply.

*Tachycardia *Cold, clammy skin *Extreme thirst

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C)

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

Assess the woman's fundus

A postpartal woman is developing a 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 woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

Obtain a clean-catch urine specimen

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 infect the neonate.

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis?

Try applying warm compresses to your breasts to encourage the milk to be released."

After presenting an in-service presentation on measures to prevent postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which measure to prevent postpartum hemorrhage due to retained placental fragments?

inspecting the placenta after birth for intactness

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program?

inspecting the placenta after delivery for intactness

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse