Chapter 10: Nursing Care of Women with Complications After Birth

14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. The nurse recognizes that the cause of these signs and symptoms may be: a. dehydration. b. hypovolemic shock. c. endometritis. d. cystitis.

ANS: C Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis. DIF: Cognitive Level: Analysis REF: pp. 241, 242, Table 10-3 OBJ: 2 TOP: Puerperal Infections KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A woman has had persistent lochia rubra for two weeks after her delivery and is experiencing pelvic discomfort. When subinvolution is diagnosed, the nurse explains that the usual treatment for this disorder is: a. uterine massage. b. oxytocin infusion. c. dilation and curettage. d. hysterectomy.

ANS: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall. DIF: Cognitive Level: Knowledge REF: p. 245 OBJ: 2 TOP: Subinvolution of the Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

5. If massage and putting the infant to breast is not effective in controlling a boggy uterus, the nurse explains that the physician may order: a. ritodrine. b. magnesium sulfate. c. oxytocin. d. bromocriptine.

ANS: C Oxytocin (Pitocin) is the most common drug ordered to control uterine atony. DIF: Cognitive Level: Comprehension REF: p. 239 OBJ: 5 TOP: Oxytocin (Pitocin) for Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21. The nurse assesses a positive Homans sign if the patient complains of pain in the _______ when the patient's leg is flexed and the foot is sharply dorsiflexed. a. groin b. Achilles tendon c. top of the foot d. calf of the leg

ANS: D A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign. Homans sign is suggestive of a deep vein thrombosis. DIF: Cognitive Level: Application REF: p. 240 OBJ: 2 TOP: Homans Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. To prevent thrombus formation the nurse would: a. have the woman sit in a chair for meals. b. monitor vital signs every 4 hours and report any changes. c. tell the woman to remain in bed with her legs elevated. d. assist the woman with ambulation for short periods of time.

ANS: D Early ambulation and range-of-motion exercises are valuable aids to preventing thrombus formation in the postpartum woman. DIF: Cognitive Level: Application REF: p. 241 OBJ: 4 TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. The best response to a postpartum woman who tells the nurse that she feels "tired and sick all of the time since I had the baby 3 months ago" is: a. "This is a normal response for the body after pregnancy. Try to get more rest." b. "I'll bet you will snap out of this funk real soon." c. "Why don't you arrange for a babysitter so you and your husband can have a night out?" d. "Let's talk about this further. I am concerned about how you are feeling."

ANS: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive. DIF: Cognitive Level: Application REF: p. 245, Nursing Tip OBJ: 6 TOP: Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

23. By flexing the patient's leg and dorsiflexing the foot, the nurse is: a. assessing for edema in the lower limb. b. performing range-of-motion exercises. c. stimulating circulation to limbs. d. assessing for deep vein thrombus.

ANS: D Performing the maneuver for Homans' sign is an assessment for deep vein thrombosis (DVT). DIF: Cognitive Level: Application REF: p. 240, Table 10-2 OBJ: 7 TOP: Homans' Sign KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

16. Three weeks after delivering her first child, a woman tells the nurse, "I waited so long for this baby and now that she is here, I can't believe how different my life is from what I expected." The best nursing response to the woman's statement is: a. "How is your partner adjusting to the change?" b. "I hear this from a lot of first-time mothers." c. "Have you told anyone else about your feelings?" d. "Tell me how things are different."

ANS: D The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mother's feelings about motherhood and her infant. DIF: Cognitive Level: Application REF: p. 245 OBJ: 2 TOP: Disorders of Mood KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

22. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. The nurse should: a. notify charge nurse of a possible infection. b. prepare to put the patient in isolation. c. have the infant removed from the room and returned to the nursery. d. assess the patient further.

ANS: D The patient should be assessed further for other signs of infection because white blood cell (WBC) count of 20,000 to 30,000 cells/dL are normal in the early postpartum period. DIF: Cognitive Level: Analysis REF: p. 242 OBJ: 6 TOP: Elevated WBC KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. When the 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed, the nurse's most helpful response is: a. "Stop breastfeeding until the infection clears." b. "Pump the breasts to continue milk production, but do not give breast milk to the infant." c. "Begin all feedings with the affected breast until the mastitis is resolved." d. "Breastfeeding can continue unless there is any abscess formation."

ANS: D The woman with mastitis can continue to breastfeed unless an abscess forms. DIF: Cognitive Level: Application REF: p. 244 OBJ: 6 TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. The nurse recognizes this woman's symptoms as: a. bipolar disorder. b. major depression. c. postpartum blues. d. postpartum depression.

ANS: B Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead. DIF: Cognitive Level: Analysis REF: p. 245 OBJ: 2 TOP: Major Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

11. The nurse determines that a woman with mastitis understands treatment instructions when she says she will: a. "Apply cold compresses to the painful areas." b. "Take a warm shower before nursing the baby." c. "Nurse first on the affected side." d. "Empty the affected breast every 8 hours."

ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast. DIF: Cognitive Level: Analysis REF: p. 244 OBJ: 6 TOP: Mastitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. The one-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. Based on these symptoms the nurse should: a. notify the charge nurse of a possible upper respiratory infection. b. notify the physician of a possible pulmonary embolism. c. document expected postpartum mucous membrane congestion. d. medicate with antipyretic remedy for elevated temperature.

ANS: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication. DIF: Cognitive Level: Application REF: p. 240, Table 10-2 OBJ: 2 TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

. The first sign of hypovolemic shock from postpartum hemorrhage is likely to be: a. cold, clammy skin. b. tachycardia. c. hypotension. d. decreased urinary output.

ANS: B Tachycardia is usually the first sign of inadequate blood volume. DIF: Cognitive Level: Knowledge REF: p. 236, Safety Alert OBJ: 2 TOP: Hypovolemic Shock KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 24. The nurse conducting a childbirth preparation class warns the patients that shock, a real threat after delivery, is caused by what factor(s)? Select all that apply. a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage

ANS: B, C, D, E Hypertension is not a cause for postpartum shock; all other options can cause shock. DIF: Cognitive Level: Application REF: pp. 235-237 OBJ: 3 TOP: Postpartum Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

27. In order to reduce the risk of mastitis, what will the nurse teach a nursing mother to do? Select all that apply. a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.

ANS: B, C, D, E Nursing mothers should take in about 3 liters of fluid a day. All other options are interventions to reduce the risk of mastitis and milk accumulation in the breast. DIF: Cognitive Level: Application REF: p. 224 OBJ: 4 TOP: Reduction of the Risk of Mastitis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

25. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? Select all that apply. a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus

ANS: B, E Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy. DIF: Cognitive Level: Analysis REF: p. 238 OBJ: 4 TOP: Cessation of Lochia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. During a postpartum assessment, a woman reports that her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, the nurse explains that the probable treatment will involve: a. anticoagulants for 6 weeks. b. application of ice to the affected leg. c. gentle massage of the affected leg. d. passive leg exercises twice a day.

ANS: A Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism. DIF: Cognitive Level: Analysis REF: p. 241 OBJ: 5 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

2. Although the nurse has massaged the uterus every 15 minutes it remains flaccid, and the patient continues to pass large clots. The nurse recognizes that these signs indicate uterine: a. atony. b. dystocia. c. hypoplasia. d. dysfunction.

ANS: A Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels. DIF: Cognitive Level: Knowledge REF: p. 238 OBJ: 2 TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. The nurse should next assess: a. fullness of the bladder. b. amount of lochia. c. blood pressure. d. level of pain.

ANS: A Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied. DIF: Cognitive Level: Application REF: p. 239 OBJ: 6 TOP: Bladder Distention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. A woman had a vaginal delivery two days ago and is preparing for discharge. To help prevent postpartum complications, the nurse plans to teach the woman to report any: a. fever. b. change in lochia from red to white. c. contractions. d. fatigue and irritability.

ANS: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period. DIF: Cognitive Level: Application REF: p. 245 OBJ: 4 TOP: Puerperal Infections KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

20. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses both a firm uterine fundus and a trickle of bright blood. The nurse is: a. concerned and reports a probable cervical laceration. b. attentive and massages the uterus to expel retained clots. c. distressed and reports a possible clotting disorder. d. satisfied with the normal early postpartum finding.

ANS: A The bright trickle of blood with a firm uterus suggests a cervical laceration. DIF: Cognitive Level: Application REF: p. 239 OBJ: 2 TOP: Laceration KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Reduction of Risk

8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 ° C (99.8° F), rust-colored lochia, and sore breasts. From these symptoms, the nurse suspects: a. phlebitis. b. puerperal infection. c. late postpartum hemorrhage. d. mastitis.

ANS: A The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient. DIF: Cognitive Level: Application REF: p. 240 OBJ: 2 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The statement that would indicate to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage is: a. "My discharge would change to red after it has been pink or white." b. "If I have a postpartum hemorrhage, I will have severe abdominal pain." c. "I should be alert for an increase in bright red blood." d. "I would pass a large clot that was retained from the placenta."

ANS: A When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage. DIF: Cognitive Level: Application REF: p. 240 OBJ: 2 TOP: Color Change in Lochia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

26. The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? Select all that apply. a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe

ANS: A, C, E Legumes and foods containing vitamin C are conducive to healing. Starches are not. DIF: Cognitive Level: Application REF: p. 243 OBJ: 4 TOP: Foods Conducive to Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. In the immediate postpartum period, the nurse would be alert for the development of: a. cervical laceration. b. hematoma. c. endometritis. d. retained placental fragments.

ANS: B Delivering a large infant and a prolonged labor are risk factors for hematoma formation. DIF: Cognitive Level: Analysis REF: p. 239 OBJ: 3 TOP: Hematoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse's first action when postpartum hemorrhage from uterine atony is suspected is to: a. teach the patient how to massage the abdomen and then get help. b. start IV fluids to prevent hypovolemia, then notify the registered nurse. c. begin massaging the fundus while another person notifies the physician. d. ask the patient to void and reassess fundal tone and location.

ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm. DIF: Cognitive Level: Comprehension REF: p. 238 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity