chapter 22

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."

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

Uterine atony

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."

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."

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." Explanation:

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500ml

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?

Ambulate the client as soon as her vital signs are stable.

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

Assess for pedal edema.

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema.

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.

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?

Bladder distention

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia.

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begins to feel better.

The nurse reviews the history of a postpartum woman, G3, P3 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?

DVT

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?

Escherichia coli

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

Instruct the client to empty her bladder before the examination.

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

Oxytocin

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. How should the nurse respond?

Pierced nipple

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 with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

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.

When caring for a client with postpartum blues, which intervention would be most appropriate?

Validate the client's emotions, allowing her to express them freely.

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?

Weak and rapid pulse

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 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

A nurse is preparing for a class to teach pregnant women and their partners about postpartum complications. Which measure would be most important for the nurse to emphasize as helping to prevent postpartum infection?

handwashing

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 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.

inability to concentrate loss of confidence decreased interest in life

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

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

Which complication is most likely responsible for a late postpartum hemorrhage?

uterine subinvolution

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?

"I should brush my teeth vigorously to stimulate the gums."

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

infection

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

Mastitis

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?"

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 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