Chapter 12 OB
A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching?
Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum
Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply.
"It will take between 6-8 weeks for my uterus to return to normal size" "Contractions will cause my uterus to shrink"
A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient?
-Assess the position, tone, and location of the fundus -Massage a boggy uterus -Quantify blood loss -Instruct client to void and reevaluate
A nurse is caring for a G2P2 patient in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this patient? Select all that apply.
-Assess the uterus for location, position and tone of fundus every 15 minutes -Titrate IV Oxytocin infusion rate to uterine tone -Provide information regarding afterpains (cramp like pains) -Assess lochia for color, amount, and odor
The postpartum nurse is preparing to administer Rh (D) Immune Globulin (RhoGAM) to a post- cesarean section patient on the mother-baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply.
-I need this because my blood type is negative and my baby is positive -This medication will help protect my future babies
A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply.
-The hard work of labor can cause your temperature to increase -It is common for women to experience mild temperature elevation after giving birth -Your body is going through a lot of hormonal changes right now, which can increase your temperature
When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply.
-Wear a supportive bra or sports bra 24 hours a day -You can take an analgesic for pain
A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order.
1. Perform fundal massage 2. Notify the physician or midwife of excessive blood loss 3. Achieve free-flowing venous access 4. Increase frequency of vital signs
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient does the nurse assess as being at the highest risk for fluid volume overload?
A G3P2 who was induced with Pitocin for preeclampsia
A nurse is caring for a patient in the first hour following a vaginal delivery. What is the priority nursing intervention?
Assess the fundus for location, position, and tone
A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider?
Boggy uterus
When performing a fundal assessment on a patient, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this patient?
Massage the fundus with the palm of the hand (fundal massage stimulates contraction of the uterus)
Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action?
Document the findings as within normal limits
A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse?
I understand your concern. Let's take a look at the back of your legs together
A primiparous patient tells the nurse she wants to bottle-feed her baby. What is the most therapeutic response by the nurse?
You'll want to wear a sports bra for 24 hours a day until your breasts are soft
