Ch 22
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 administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) avoiding administration of oxytocics continual firm massage of the uterus
administration of platelet transfusions as prescribed
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 psychosis usually appears soon after the woman comes home." "Postpartum blues usually resolves by the 4th or 5th postpartum day." "Postpartum depression develops gradually, appearing within the first 6 weeks." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."
"Postpartum depression develops gradually, appearing within the first 6 weeks."
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? "If my lochia increases, I need to call my health care provider." "I should brush my teeth vigorously to stimulate the gums." "I need to avoid using any aspirin-containing products." "If I get a cut, I need to apply direct pressure for about 5 minutes or more."
"I should brush my teeth vigorously to stimulate the gums."
nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "I just feel so overwhelmed and tired." "I'm feeling so guilty and worthless lately." "It's strange, one minute I'm happy, the next I'm sad." "I keep hearing voices telling me to take my baby to the river."
"I'm feeling so guilty and worthless lately."
After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching? "I need to call my doctor if my temperature goes above 100.4°F" "When I put on a new pad, I'll start at the back and go forward." "If I have chills or my discharge has a strange odor, I'll call my doctor."I'll point the spray of the peribottle so the water flows front to back."
"When I put on a new pad, I'll start at the back and go forward."
The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage? 24 to 48 hours after birth 24 hours to 12 weeks after birth 6 weeks to 3 months after birth 6 weeks to 6 months after birth
24 hours to 12 weeks after birth
The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage? Disseminated intravascular coagulation A cervical laceration Uterine atony Retained placental fragments
A cervical laceration
The nurse is assessing a woman with abruption placentae who has just given birth. The nurse would be alert for which of the following? Severe uterine pain Board-like abdomen Appearance of petechiae Inversion of the uterus
Appearance of petechiae
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Initiate Ringer's lactate infusion. Assess the woman's vital signs. Call the woman's health care provider. Assess the woman's fundus.
Assess the woman's fundus.
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? Urinary infection Excessive bleeding Bladder distention A ruptured bladder
Bladder distention
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? Use semi-Fowler position to encourage uterine drainage. Check for bladder distention, while encouraging the client to void. Offer analgesics prescribed by health care provider. Perform vigorous fundal massage for the client.
Check for bladder distention, while encouraging the client to void.
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Monitor the pain level. Check the lochia. Assess the temperature. Assess the fundal height.
Check the lochia.
A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition? Delirium Feelings of anxiety Sadness Insomnia
Delirium
Assessment of a postpartum woman experiencing postpartum hemorrhage reveals mild shock. Which of the following would the nurse expect to assess? (Select all that apply.) Diaphoresis Tachycardia Oliguria Cool extremities Confusion
Diaphoresis Cool extremities
A postpartum woman is diagnosed with metritis. The nurse interprets this as an infection involving which of the following? (Select all that apply.) Endometrium Decidua Myometrium Broad ligament Ovaries Fallopian tubes
Endometrium Decidua Myometrium
A client experienced prolonged labor with prolonged premature rupture of membranes.The nurse would be alert for which of the following in the mother and the newborn? Infection Hemorrhage Trauma Hypovolemia
Infection
After presenting a class on measures to prevent postpartum hemorrhage, the presenter determines that the teaching was successful when the class states which of the following as an important measure to prevent postpartum hemorrhage due to retained placental fragments? Administering broad-spectrum antibiotics Inspecting the placenta after delivery for intactness Manually removing the placenta at delivery Applying pressure to the umbilical cord to remove the placenta
Inspecting the placenta after delivery for intactness
A postpartum client comes to the clinic for her routine 6-week visit. The nurse assesses the client and suspects that she is experiencing subinvolution based on which of the following? Nonpalpable fundus Moderate lochia serosa Bruising on arms and legs Fever
Moderate lochia serosa
A group of students are reviewing risk factors associated with postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as associated with uterine tone? (Select all that apply.) Rapid labor Retained blood clots Hydramnios Operative birth Fetal malposition
Rapid labor Hydramnios
A group of nursing students are reviewing information about mastitis and its causes. The students demonstrate understanding of the information when they identify which of the following as the most common cause? E. coli S. aureus Proteus Klebsiella
S. aureus
A nurse is assessing a postpartum woman. Which finding would cause the nurse to be most concerned? Leg pain on ambulation with mild ankle edema Calf pain with dorsiflexion of the foot. Perineal pain with swelling along the episiotomy Sharp stabbing chest pain with shortness of breath
Sharp stabbing chest pain with shortness of breath
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client. Symptoms include fever, chills, malaise, and localized breast tenderness.
Symptoms include fever, chills, malaise, and localized breast tenderness.
A group of students are reviewing the causes of postpartum hemorrhage. The students demonstrate understanding of the information when they identify which of the following as the most common cause? Labor augmentation Uterine atony Cervical or vaginal lacerations Uterine inversion
Uterine atony
Which of the following would be most appropriate when massaging a woman's fundus? Place the hands on the sides of the abdomen to grasp the uterus. Use an up-and-down motion to massage the uterus. Wait until the uterus is firm to express clots. Continue massaging the uterus for at least 5 minutes.
Wait until the uterus is firm to express clots.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who conceived following fertility treatments a client who had an 8-hour labor a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth
a client who had a nonelective cesarean birth
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? restricting fluids administering bromocriptine applying ice applying warm compresses
applying ice
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 lack of social support from family or friends medications used during labor and birth preexisting conditions in the client
drop in estrogen and progesterone levels after birth
A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? She feels like eating all the time. lack of pleasure She is over her interest in her baby. extreme periods of elation
lack of pleasure
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. decreased interest in life manifestations of mania inability to concentrate bizarre behavior loss of confidence
decreased interest in life inability to concentrate loss of confidence
The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? metritis uterine atony postpartum hemorrhage deep venous thrombosis
deep venous thrombosis
A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? Bend her knee, and palpate her calf for pain. Blanch a toe, and count the seconds it takes to color again. Assess for pedal edema. Ask her to raise her foot and draw a circle.
Assess for pedal edema.
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 iron replacement therapy. Wear knee-high stockings when possible. Shortness of breath is a common adverse effect of the medication. Avoid over-the-counter (OTC) salicylates.
Avoid over-the-counter (OTC) salicylates.
As part of an inservice program, a nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth. The nurse correctly identifies this as postpartum: Depression Psychosis Bipolar disorder Blues
Blues
A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which of the following would the nurse include as the most cost-effective method for prevention? Prophylactic heparin administration Compression stocking Early ambulation Warm compresses
Early ambulation
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? Change her perineal pads frequently. Encourage an oral intake of 2 to 3 liters per day. Keep the environment quiet to encourage rest. Take analgesics for uterine pain.
Encourage an oral intake of 2 to 3 liters per day.
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? Pierced nipple Complete emptying of the breast Use of breast pumps Frequent feeding
Pierced nipple
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. The client is nervous about taking the baby home. The client would like to watch the nurse give the baby her first bath. The client would like the nurse to take her baby to the nursery so she can sleep.
The client feels empty since she gave birth to the neonate.
A woman experiencing postpartum hemorrhage is ordered to receive a uterotonic agent. Which of the following would the nurse least expect to administer? Oxytocin Methylergonovine Carboprost Terbutaline
Terbutaline
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? "What time did you last change your pad?" "How much blood was on the two pads?" "Are you in any pain with your bleeding?" "When did you last void?"
"How much blood was on the two pads?"
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 will stop breastfeeding until I finish my antibiotics." "I am able to pump my breast milk for my baby and throw away the milk." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." "When breastfeeding, it is recommended to begin nursing on the infected breast first."
"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman states which of the following? "I will use a soft toothbrush to brush my teeth." "I can take ibuprofen if I have any pain." "I need to avoid drinking any alcohol." "I will call my health care provider if my stools are black and tarry."
"I can take ibuprofen if I have any pain."
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? "I will change my perineal pad regularly to remove the infected drainage." "When I am sleeping or lying in bed, I should lie flat on my back." "I will take frequent walks around my home to promote drainage." "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor."
"When I am sleeping or lying in bed, I should lie flat on my back."
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 can breastfeed your newborn while taking any anticoagulation medication." "You need to avoid medications which contain acetylsalicylic acid." "It is expected for you to have minimal blood in your urine during therapy." "It is appropriate for you to sit with your legs crossed over each other."
"You need to avoid medications which contain acetylsalicylic acid."
A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear within which time frame after birth? 2 months 5 months 4 months 3 months
3 months
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? Limit oral intake of fluids for the first 24 hours to prevent nausea. Ambulate the client as soon as her vital signs are stable. Roll a bath blanket or towel and place it firmly behind the knees. Assist client in performing leg exercises every 2 hours.
Ambulate the client as soon as her vital signs are stable.
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? Attachment, lochia color, complete blood cell count Blood pressure, pulse, reports of dizziness Degree of responsiveness, respiratory rate, fundus location Height, level of orientation, support systems
Blood pressure, pulse, reports of dizziness
The nurse is caring for four postpartum clients, monitoring them for postpartum infection. Which client is the priority due to current vital signs suggesting a postpartum infection? Client 35 hours postpartum with a temperature of 99.6°F (37.5°C) Client 20 hours postpartum with a temperature of 102.4°F (39.1°C) Client 30 hours postpartum with a temperature of 100.4°F (38°C) Client 25 hours postpartum with a temperature of 99.2°F (37.3°C)
Client 30 hours postpartum with a temperature of 100.4°F (38°C)
A client presents to the clinic with a 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101.8°F (38.8°C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client? Increase your fluid intake to ensure that you will continue to produce adequate milk. Breastfeed or otherwise empty your breasts at least every 3 hours. Complete the full course of antibiotic prescribed, even if you begin to feel better. Use NSAIDs, warm showers, and warm compresses to relieve discomfort.
Complete the full course of antibiotic prescribed, even if you begin to feel better.
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 Consistency, location, and place Location, shape, and content Content, lochia, place
Consistency, shape, and location
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? Gardnerella vaginalis Klebsiella pneumoniae Escherichia coli Staphylococcus aureus
Escherichia coli
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Drink plenty of fluids to decrease a bladder infection. Apply ice to the perineum to decrease pain of a perineal infection. Finish all antibiotics to decrease a genital tract infection.
Finish all antibiotics to decrease a genital tract infection.
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 skin turgor. Get a pad count. Monitor the client's vital signs. Assess deep tendon reflexes. Assess the client's uterine tone.
Get a pad count. Monitor the client's vital signs. Assess the client's uterine tone.
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the following? An inverted nipple on the affected breast No breast milk in the affected breast An ecchymotic area on the affected breast Hardening of an area in the affected breast
Hardening of an area in the affected breast
A nurse is massaging a postpartum client's fundus and places the nondominant hand on the area above the symphysis pubis based on the understanding that this action: Determines that the procedure is effective Helps support the lower uterine segment Aids in expressing accumulated clots Prevents uterine muscle fatigue
Helps support the lower uterine segment
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which of the following? Hematoma Laceration Bladder distention Uterine atony
Hematoma
A nurse is caring for a client with a postpartum laceration. Which nursing diagnoses would be most appropriate? Select all that apply. Ineffective tissue perfusion Ineffective thermoregulation Risk for injury Risk for disuse syndrome Impaired tissue integrity
Ineffective tissue perfusion Risk for injury Impaired tissue integrity
A home health care nurse is assessing a postpartum woman who was discharged 2 days ago. The woman tells the nurse that she has a low-grade fever and feels "lousy." Which of the following findings would lead the nurse to suspect metritis? (Select all that apply.) Lower abdominal tenderness Urgency Flank pain Breast tenderness Anorexia
Lower abdominal tenderness Anorexia
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Avoid frequent breastfeeding. Perform handwashing before breastfeeding. Apply cold compresses to the breast.
Perform handwashing before breastfeeding.
A postpartum woman is ordered to receive oxytocin to stimulate the uterus to contract. Which of the following would be most important for the nurse to do? Administer the drug as an IV bolus injection. Give as a vaginal or rectal suppository. Piggyback the IV infusion into a primary line. Withhold the drug if the woman is hypertensive.
Piggyback the IV infusion into a primary line.
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? Maladjustment Postpartum blues Postpartum depression Postpartum psychosis
Postpartum psychosis
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 impaired breastfeeding related to development of mastitis Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis Risk for infection related to microorganism invasion of episiotomy Risk for fatigue related to chronic bleeding due to subinvolution
Risk for fatigue related to chronic bleeding due to subinvolution
Which intervention(s) will the nurse recommend for a breastfeeding mother diagnosed with mastitis? Select all that apply. Rub expressed breast milk on the nipples after each feeding session Take acetaminophen as needed for pain Encourage client to breastfeed the infant every 3 to 4 hours Take antibiotics as prescribed Do not breastfeed from the affected breast Apply warm compresses to the affected breast PRN
Rub expressed breast milk on the nipples after each feeding session Take acetaminophen as needed for pain Take antibiotics as prescribed Apply warm compresses to the affected breast PRN
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? Streptococcus pyogenes (group A strep) Escherichia coli Staphylococcus aureus group B streptococcus (GBS)
Staphylococcus aureus
The nurse is developing a discharge teaching plan for a postpartum woman who has developed a postpartum infection. Which of the following would the nurse most likely include in this teaching plan? (Select all that apply.) Taking the prescribed antibiotic until it is finished Checking temperature once a week Washing hands before and after perineal care Handling perineal pads by the edges Directing peribottle to flow from back to front
Taking the prescribed antibiotic until it is finished Washing hands before and after perineal care Handling perineal pads by the edges
A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The priority actions of the nurse should be to first: -recheck the client's temperature-administer antibiotics-obtain a culture followed by: -administer nonsteroidal anti-inflammatory drug (NSAID)-initiate antibiotics-encourage intake of fluids
The priority actions of the nurse should be to first obtain a culture followed by initiate antibiotics.
When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage based on the knowledge that: These measurements may not change until after the blood loss is large The body's compensatory mechanisms activate and prevent any changes They relate more to change in condition than to the amount of blood lost Maternal anxiety adversely affects these vital signs
These measurements may not change until after the blood loss is large
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the following? Retained placental fragments Hypertension Thrombophlebitis Uterine subinvolution
Thrombophlebitis
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? Elevated blood pressure Weak and rapid pulse Decreased respiratory rate Warm and flushed skin
Weak and rapid pulse
Which measurement best describes postpartum hemorrhage? blood loss of 1,000 ml, occurring at least 24 hours after birth blood loss of 400 ml, occurring at least 24 hours after birth blood loss of 600 ml, occurring at least 24 hours after birth blood loss of 800 ml, occurring at least 24 hours after birth
blood loss of 1,000 ml, occurring at least 24 hours after birth
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 assessing skin turgor by frequently assessing uterine involution by monitoring hCG titers by assessing blood pressure
by frequently assessing uterine involution
Which finding(s) leads the nurse to suspect that a postpartum woman has developed endometritis? Select all that apply. flank pain hematuria leukocytosis foul-smelling lochia pain on both sides of the abdomen
foul-smelling lochia pain on both sides of the abdomen
The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication? if blood pressure is lower than 140/90 mm Hg if hematocrit level is higher than 45% if urine output is higher than 50 ml/h if the client can walk without experiencing dizziness
if blood pressure is lower than 140/90 mm Hg
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? size of the neonate method of birth length of labor maternal Rh status
length of labor
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 nifedipine magnesium sulfate indomethacin
oxytocin agent
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 they frequently indulge 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 depression postpartum psychosis postpartum panic disorder postpartum blues
postpartum psychosis
Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5 Ts tool will recognize which of the following as potential causes of postpartum hemorrhage? Select all that apply. tone tissue thrombin time technique of birth
tone tissue thrombin
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine atony uterine subinvolution uterine prolapse uterine contraction
uterine atony
