Chapter 19: Postpartum Woman at Risk Prep- U Maternal

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?

in the reproductive tract

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

A postpartum woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breastfeeding. The nurse's best response would be that:

it depends on the type of anticoagulant she is taking.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?

laceration

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?

length of labor

A nurse is caring for a postpartum client with urinary tract infection. Which instruction would the nurse include in the teaching plan for the client to help prevent future infections?

"Empty your bladder frequently."

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?

"How much blood was on the two pads?"

A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider?

"I am so angry with myself, I just want to give up my life right now."

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 can continue breastfeeding my infant, but it may be somewhat uncomfortable."

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

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

"I know you are hurting, but you can have another baby in the future."

A postpartum woman is being discharged with anticoagulant therapy for treatment of deep vein thrombosis. After teaching the woman about this therapy, the nurse determines that the teaching was successful based on which statement?

"I need to apply pressure to any cut for 5 to 10 minutes."

The nurse is working with several clients who have recently delivered healthy newborns. Which statement by a mother would alert the nurse to further assess the mother for postpartum depression?

"I seem to cry more each and every day that goes by."

The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

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 the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

"Postpartum depression develops gradually, appearing within the first 6 weeks."

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

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."

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?

"When I am sleeping or lying in bed, I should lie flat on my back."

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."

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem?

multiparity

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 need to avoid medications which contain acetylsalicylic acid."

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 hours to 12 weeks after birth

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

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.

obtain a culture initiate antibiotics

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

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.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema.

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply.

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 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

Assess the fundus.

The nurse notes uterine atony in the postpartum client. Which assessment is completed next?

Assessment of the perineal pad

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

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

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 over-the-counter (OTC) salicylates.

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

A postpartal client is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the client about breastfeeding during this time?

Breastfeeding can continue.

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.

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?

Check for bladder distention, while encouraging the client to void.

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4°F (38.8°C) orally.

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

Which disorder is described as a transient, self-limiting mood disorder that affects postpartum clients after birth?

postpartum blues

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?

Encourage an oral intake of 2 to 3 liters per day.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection.

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution?

Her uterus is at the level of the umbilicus.

A postpartum client is diagnosed with a vaginal laceration. What intervention will the nurse provide to the client at this time?

Insert an indwelling urinary catheter.

When teaching a postpartum client about possible complications following the birth, which would be the best information to include?

Interference with the maternal-newborn attachment process

A nurse is caring for a client who has had a cesarean birth and has developed a wound infection. What precautions should be taken by the nurse as a primary prevention measure?

Keep the incisions clean and dry.

A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation?

Massage the fundus.

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.

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

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

Perform handwashing before breastfeeding.

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

The nurse receives a report on a client with type 1 diabetes 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

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 the client frequently indulges 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 psychosis

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purplish area of edema on the left side of the perineum. What action will the nurse take?

Report the finding promptly to the primary health care provider.

A postpartum client calls the nurse to her room and states that she knows something awful is going to happen to her. What should the nurse do?

Report this immediately to the health care provider.

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 fatigue related to chronic bleeding due to subinvolution

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.

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.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The bladder is distended.

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 nurse instructs a client on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?

The client is chatting on the telephone with a friend.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth

A nurse is assessing a postpartum client. Which finding causes the nurse the greatest concern?

acute onset of sharp, stabbing chest pain with shortness of breath

A postpartum client has a swollen area of purplish discoloration in the vuvlar area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this client?

acute pain

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client?

administrating a selective serotonin reuptake inhibitor

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

Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth

A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis?

delirium

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

A 37-year-old client experienced a perinatal loss 3 days ago. Which client characteristic would be communicated to the health care provider?

denial of the death

A first time breast-feeding mother asks how she can prevent mastitis. Which intervention should the nurse recommend?

exposing the nipples to air for at least part of every day

On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which finding(s) will cause the nurse to suspect endometritis? Select all that apply.

foul-smelling lochia tender uterus fever

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 question the woman about which symptom?

hardening of an area in the affected breast

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

rectal pressure

The nurse is performing a focused assessment on a client who is 2 days postpartum. The client reports pelvic pain, chills, profuse dark, foul-smelling lochia with blood clots. The client states, "my bleeding before was light and now it is heavy." Vital signs: temperature, 99.5°F (37.5°C); heart rate, 102 beats/min; blood pressure, 100/66 mm Hg.

retained fragments of placenta pelvic pain profuse dark lochia with blood clots

Eight days after birth, the woman notices a return to red lochia. What condition does the nurse anticipate this client is experiencing?

retained placental fragments

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

rubra colored lochia

When giving a postpartum client self-care instructions, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?"

saturating 1 pad in 1 hour

A postpartum woman is prescribed an antibiotic because of endometritis. Her breastfed infant should be observed particularly for which of the following?

signs of oral candidiasis (thrush) and easy bruising

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

When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for postpartum hemorrhage because:

these measurements may not change until after the blood loss is large.

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?

uterine atony

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

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg

The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client?

weak and rapid pulse

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

As part of an in-service program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn?

within the first 6 weeks