Chapter 17: Postpartum Physiologic Adaptations

Which documentation in the client's chart on the 14th postpartum day indicates a normal involution process? a. Breasts firm and tender b. Episiotomy slightly red and puffy c. Moderate bright red lochial flow d. Fundus below the symphysis and not palpable

ANS: D The fundus descends 1 cm/day, so by postpartum day 14 it is no longer palpable. Breasts are not part of the involution process. The episiotomy should not be red or puffy at this stage. The lochia should be changed by this day to serosa. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.) a. Pertussis b. Rubella c. Diphtheria, tetanus (Tdap) d. RhoGAM

ANS: A, B, C If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results. PTS: 1 DIF: Cognitive Level: Application REF: 335 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance

If the client's white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take? a. Document the finding. b. Tell the health care provider. c. Begin antibiotic therapy immediately. d. Have the laboratory draw blood for reanalysis.

ANS: A An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. Because this is a normal finding, there is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated. PTS: 1 DIF: Cognitive Level: Application REF: 331 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which of the following would indicate an abnormal finding during the postpartum period? a. Lochia flow changing from alba to rubra b. Unable to palpate uterine fundus at 6-week postpartum checkup c. Presence of afterbirth pains d. Lochia flow heavier in the early morning 2 days following vaginal birth

ANS: A Lochia flow should progress from rubra to serosa to alba as part of the normal sequence. A change in sequence would indicate an abnormal finding and possible infection and/or bleeding. The uterine fundus should no longer be palpable at 2 weeks postbirth. Afterbirth pains during the postpartum period are a normal finding based on involution of the uterus. Lochia flow may be heavier on arising because of the effects of gravity and pooling of blood while recumbent. PTS: 1 DIF: Cognitive Level: Analysis REF: 329, 330 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective? a. No swelling or edema to the perineal area b. Patient complains that the sitz bath is too cold c. Patient reports she took two sitz baths in 12 hours d. Edges of the perineal laceration are well approximated

ANS: A Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma. PTS: 1 DIF: Cognitive Level: Evaluating REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Which client would be most likely to have severe afterbirth pains and request a narcotic analgesic? a. Gravida 5, para 5 b. Primipara who delivered a 7-lb boy c. Client who is bottle feeding her first child d. Client who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems. She should empty her breasts regularly to stimulate milk production so she will have the milk when the baby is strong enough to nurse. PTS: 1 DIF: Cognitive Level: Understanding REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

If the fundus is palpated on the right side of the abdomen above the expected level, the nurse should suspect that the client has which? a. Distended bladder b. Normal involution c. Been lying on her right side too long d. Stretched ligaments that are unable to support the uterus

ANS: A The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the client should not alter uterine position. The problem is a full bladder displacing the uterus. PTS: 1 DIF: Cognitive Level: Understanding REF: 340 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse is planning comfort measures to implement for a client after a vaginal birth. Which measures should the nurse plan to implement? (Select all that apply.) a. Sitz baths four times a day b. Use of only warm water with the sitz baths c. Topical anesthetic spray after perineal care d. Ice pack to the perineum for the first 24 hours e. Sitting while relaxing the perineal and buttock areas

ANS: A, C, D Sitz baths provide continuous circulation of water, cleansing and comforting the traumatized perineum. Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Anesthetic sprays decrease surface discomfort and allow more comfortable ambulation. Cool water in the sitz bath reduces pain caused by edema and may be most effective within the first 24 hours. The mother should be advised to squeeze her buttocks together, not relax them, before sitting, and to lower her weight slowly onto her buttocks. PTS: 1 DIF: Cognitive Level: Application REF: 339 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is teaching a client with a midline episiotomy about perineal care after a vaginal birth. Which statements by the client indicate she understands the teaching? (Select all that apply.) a. "I will gently pat the perineum dry rather than wipe." b. "I will only use the perineal bottle after bowel movements." c. "I will use cold water in the perineal bottle as I cleanse." d. "I will use the perineal bottle without touching the perineum

ANS: A, D The bottle should not touch the perineum. The perineum is gently patted rather than wiped dry. Perineal care consists of squirting warm water over the perineum after each voiding or bowel movement. Therefore, cold water should not be used; perineal care should be performed after voiding and after bowel movements. PTS: 1 DIF: Cognitive Level: Analysis REF: 339 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

The nurse is teaching a non-breastfeeding client measures to suppress lactation. Which should the nurse include in the teaching session? (Select all that apply.) a. Avoid massaging the breasts. b. Allow warm shower water to run over the breasts. c. If the breasts become engorged, pumping is recommended . d. Ice packs can be applied to the breasts to relieve discomfort. e. Wear a sports bra 24 hours a day until the breasts become soft.

ANS: A, D, E The client should be advised to avoid massaging the breasts because this will stimulate milk production. Instruct the client to wear a sports bra or other well-fitting bra 24 hours a day until the breasts become soft. Manage breast discomfort by application of ice, which reduces vasocongestion. Advise the client to refrain from allowing warm water to fall directly on the breasts during showers and pumping because these actions will stimulate milk production. PTS: 1 DIF: Cognitive Level: Application REF: 344 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

In which area should the nurse expect that the postbirth care of a cesarean section will differ from that of a vaginal birth? a. Quantity of lochia rubra b. Pain management techniques c. Frequency of vital signs and fundal checks d. Assessment of infection risk from loss of skin integrity

ANS: B A cesarean section is major surgery. Pain relief is provided in various ways, including patient-controlled analgesia and oral and intramuscular analgesics. Postvaginal birth pain is managed with oral analgesic combinations that include acetaminophen; the quantity of lochia, frequency of vital signs, and fundal checks and assessment of infection risk are the same for both types of birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 341 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance

The nurse has completed a postpartum assessment on a client who delivered an hour ago. Which amount of lochia consists of a moderate amount? a. Saturated peripad b. 4- to 6-inch stain on the peripad c. 1- to 4-inch stain on the peripad d. Less than a 1-inch stain on the peripad

ANS: B Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels: · Scant—less than a 1-inch stain on the peripad · Light—1- to 4-inch stain · Moderate—4- to 6-inch stain · Heavy—saturated peripad · Excessive—saturated peripad in 15 minutes Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery. PTS: 1 DIF: Cognitive Level: Analysis REF: 330

The postpartum nurse has completed discharge teaching for a client being discharged after an uncomplicated vaginal birth. Which statement by the client indicates that further teaching is needed? a. "I may not have a bowel movement until the 2nd postpartum day." b. "If I breastfeed and supplement with formula, I won't need any birth control." c. "I know my normal pattern of bowel elimination won't return until about 8 to 10 days." d. "If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband."

ANS: B For some women, ovulation resumes as early as 3 weeks postpartum. Therefore, contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the client does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth. PTS: 1 DIF: Cognitive Level: Analysis REF: 333 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

Which fundal assessment finding at 12 hours after birth requires further assessment? a. The fundus is palpable at the level of the umbilicus. b. The fundus is palpable two fingerbreadths above the umbilicus. c. The fundus is palpable one fingerbreadth below the umbilicus. d. The fundus is palpable two fingerbreadths below the umbilicus.

ANS: B The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum, but is still appropriate. PTS: 1 DIF: Cognitive Level: Application REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

The nurse decides to perform a prescribed PRN intermittent sterile catheterization on a postpartum client if which occurs? (Select all that apply.) a. The client has not voided but the bladder cannot be palpated. b. The fundus is displaced from the midline and the client has been unable to void. c. The client has been medicated for pain but she has not voided; the fundus is midline. d. The amount voided is less than 150 mL and the fundus is displaced from the midline.

ANS: B, D The nurse makes the decision to perform an intermittent sterile catheterization if the client is unable to void, the amount is less than 150 mL, and the fundus is displaced. A nonpalpable bladder and firm fundus at or below the umbilicus and in the midline confirm that the bladder is empty and rule out urinary retention with overflow. PTS: 1 DIF: Cognitive Level: Analysis REF: 340 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

The nurse is conducting discharge teaching for a client going home after a cesarean birth. Which signs and symptoms should the client be taught to report? (Select all that apply.) a. Mild incisional pain b. Feeling of pelvic fullness c. Lochia changing from red to pink in color d. Frequency, urgency, or burning on urination e. Redness or edema of the abdominal incision

ANS: B, D, E The signs and symptoms to watch for after a cesarean birth are feelings of pelvic fullness, frequency, urgency or burning on urination, and redness or edema of the abdominal incision. Mild incisional pain is expected and the lochia should change from a bright red (rubra) to a pinkish color (serosa). PTS: 1 DIF: Cognitive Level: Application REF: 348 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

Which is the best measure to prevent abdominal distention following a cesarean birth? a. Rectal suppositories b. Carbonated beverages c. Early and frequent ambulation d. Tightening and relaxing abdominal muscles

ANS: C Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs, but do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention. PTS: 1 DIF: Cognitive Level: Application REF: 342, 343 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity

The nurse is caring for a postpartum client who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider? a. Pulse rate of 50 b. Temperature of 38° C (100.4° F) c. Firm fundus, but excessive lochia d. Lightheaded when moving from a lying to standing position

ANS: C Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38° C (100.4° F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand. PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

When assessing the A of the acronym REEDA, the nurse should assess the: a. skin color. b. degree of edema. c. edges of the episiotomy. d. episiotomy for discharge

ANS: C In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage. PTS: 1 DIF: Cognitive Level: Application REF: 337 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

The nurse is caring for a client who delivered by cesarean birth 6 hours ago. The nurse assesses light bilateral rales when auscultating lung sounds. Which priority action should the nurse take? a. Decrease IV fluid rate. b. Document the finding. c. Encourage the use of an incentive spirometer. d. Ambulate the client around the nurses' station

ANS: C Incentive spirometers help expand the lungs to prevent hypostatic pneumonia that can result from immobility and shallow, slow respirations. The IV rate should not be decreased as the reason for light rales is caused by immobility and the client needs fluids to replace blood loss and NPO status before the cesarean birth. Because this is indication of possible pneumonia, the nurse should institute measures to mobilize secretions, and documenting is not the priority action. Activity will be gradually increased, so ambulating around the nurses' station should not be done at this time. PTS: 1 DIF: Cognitive Level: Application REF: 342 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity

A postpartum client asks, "Will these stretch marks go away?" Which is the nurse's best response? a. "No, never." b. "Yes, eventually." c. "They will fade to silvery lines but won't disappear completely." d. "They will continue to fade and should be gone by your 6-week checkup."

ANS: C Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear. PTS: 1 DIF: Cognitive Level: Application REF: 333 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is providing care to a patient 2 hours after a cesarean section. In the hand-off report, the preceding nurse indicated that the patient's lochia was scant rubra. On initial assessment, the oncoming nurse notes the patient's peripad is saturated with lochia rubra immediately after breastfeeding her infant. What is the nurse's priority action with this finding? a. Weigh the peripad. b. Replace the peripad. c. Contact the health care provider. d. Document the finding in the patient's chart.

ANS: C The lochia of the cesarean mother will go through the same phases as that of the woman who had a vaginal birth, but the amount will be reduced. The finding of a saturated pad is abnormal, even after breastfeeding, and a sign of hemorrhage; the health care provider needs to be notified immediately. Weighing the peripad will give an estimation of the blood loss, but this assessment can result in a delay of care. Replacing the peripad and documentation of the findings are appropriate when the data are within normal limits. PTS: 1 DIF: Cognitive Level: Analysis REF: 330 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance

To assess fundal contraction 6 hours after cesarean birth, which action should the nurse perform? a. Assess lochial flow rather than palpating the fundus. b. Palpate forcefully through the abdominal dressing. c. Place hands on both sides of the abdomen and press downward. d. Gently palpate, applying the same technique used for vaginal deliveries

ANS: D Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked. PTS: 1 DIF: Cognitive Level: Application REF: 336 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention? a. Pain level 5 on scale of 0 to 10 b. Saturated pad over a 2-hour period c. Urinary output of 500 mL in one voiding d. Uterine fundus 2 cm above the umbilicus

ANS: D By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum client. PTS: 1 DIF: Cognitive Level: Analysis REF: 336 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity

To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention in the plan of care? a. Have the client drink carbonated beverages to promote urinary excretion. b. Tell the client that because of postpartum diuresis there is less risk to develop dehydration. c. Limit fluid intake to prevent polyuria. d. Teach the client to do pelvic floor exercises to combat potential stress incontinence

ANS: D Educating the client to use pelvic floor exercises will help strengthen pelvic muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the client is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period. PTS: 1 DIF: Cognitive Level: Application REF: 332 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

Which maternal event is abnormal in the early postpartal period? a. Diuresis and diaphoresis b. Flatulence and constipation c. Extreme hunger and thirst d. Lochial color changes from rubra to alba

ANS: D For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor. PTS: 1 DIF: Cognitive Level: Analysis REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

Postpartal overdistention of the bladder and urinary retention can lead to which complication? a. Fever and increased blood pressure b. Postpartum hemorrhage and eclampsia c. Urinary tract infection and uterine rupture d. Postpartum hemorrhage and urinary tract infection

ANS: D Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth. PTS: 1 DIF: Cognitive Level: Understanding REF: 332 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity

If rubella vaccine is indicated for a postpartum client, which instructions to the client should be included? a. No specific instructions b. Drinking plenty of fluids to prevent fever c. Recommendation to stop breastfeeding for 24 hours after the injection d. Explanation of the risks of becoming pregnant within 28 days following injection

ANS: D Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding. PTS: 1 DIF: Cognitive Level: Application REF: 334 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance

The nurse is providing care to a patient who delivered a 3525-g infant 14 hours ago. The nurse palpates the fundus of the uterus as firm and at the umbilicus. What is the nurse's priority action related to this finding? a. Inform the health care provider. b. Encourage the patient to urinate. c. Massage the uterus to expel clots. d. Document the finding in the patient's chart

ANS: D The location of the uterine fundus helps determine whether involution is progressing normally. Immediately after birth, the uterus is about the size of a large grapefruit or softball and weighs approximately 1000 g (2.2 lb). The fundus can be palpated midway between the symphysis pubis and umbilicus in the midline of the abdomen. Within 12 hours, the fundus rises to approximately the level of the umbilicus. This finding is expected and can be followed with documentation. No further action is needed. PTS: 1 DIF: Cognitive Level: Application REF: 329 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance

Vaginal exam findings reveal a slitlike opening of the cervix. What is the correct interpretation of this finding with regard to obstetric history? a. Client has not been pregnant. b. Client has had a C section as a method of birth. c. Client has been treated for an STD with resultant scarring of the cervix. d. Client has a history of pregnancy.

ANS: D With pregnancy, the cervix becomes slitlike in appearance on examination. The appearance of the cervix caused by pregnancy does not correlate with the method of birth. Treatment of STD is not associated with cervical changes. PTS: 1 DIF: Cognitive Level: Application REF: 330 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential