Chapter 22: Nursing Management of the Postpartum Woman at Risk

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? A.) history of hypertension B.) birth of a large newborn C.) excessive traction on umbilical cord D.) development of endometritis

Answer: B.) birth of a large newborn

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? A.) Staphylococcus aureus B.) Escherichia coli C.) Gardnerella vaginalis D.) Klebsiella pneumoniae

Answer: B.) Escherichia coli Rationale: E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections.

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? A.) "I will stop breastfeeding until I finish my antibiotics." B.) "I am able to pump my breast milk for my baby and throw away the milk." C.) "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." D.) "When breastfeeding, it is recommended to begin nursing on the infected breast first."

Answer: C.) "I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

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 she 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? A.) postpartum psychosis B.) postpartum blues C.) postpartum depression D.) postpartum panic disorder

Answer: A.) postpartum psychosis

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? A.) "I need to apply pressure to any cut for 5 to 10 minutes." B.) "It's okay for me to use a regular razor to shave my legs." C.) "I should avoid taking acetaminophen if I have a headache." D.) "The medicine will make my stools turn black."

Answer: A.) "I need to apply pressure to any cut for 5 to 10 minutes."

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? A.) Oxytocin B.) Magnesium sulfate C.) Domperidone D.) Calcium gluconate

Answer: A.) Oxytocin

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? A.) "If you don't attempt to void, I'll need to catheterize you." B.) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." C.) "I'll contact your health care provider." D.) "I'll check on you in a few hours."

Answer: B.) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." Rationale: After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

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 - manifestations of mania - decreased interest in life - bizarre behavior

Answer: - inability to concentrate - loss of confidence - decreased interest in life

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? A.) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. B.) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. C.) She says she is extremely thirsty. D.) Her perineum is obviously edematous on inspection.

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

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? A.) Client's temperature remains below 100.4°F (38.8°C) orally. B.) Fundus remains firm and midline with progressive descent. C.) Client maintains a urinary output greater than 30 ml per hour. D.) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.

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

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 101.8°F (38.8°C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client? A.) Complete the full course of antibiotic prescribed, even if you begin to feel better. B.) Use NSAIDs, warm showers, and warm compresses to relieve discomfort. C.) Breastfeed or otherwise empty your breasts at least every 3 hours. D.) Increase your fluid intake to ensure that you will continue to produce adequate milk.

Answer: A.) Complete the full course of antibiotic prescribed, even if you begin to feel better.

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A.) a client who had a nonelective cesarean birth B.) a primiparous client who had a vaginal birth C.) a client who had an 8-hour labor D.) a client who conceived following fertility treatments

Answer: A.) a client who had a nonelective cesarean birth Rationale: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection.

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? A.) length of labor B.) maternal Rh status C.) method of birth D.) size of the neonate

Answer: A.) length of labor Rationale: The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk.

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? A.) massaging the fundus firmly B.) performing bimanual compressions C.) administering ergonovine D.) notifying the primary care provider

Answer: A.) massaging the fundus firmly Rationale: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? A.) meticulous handwashing B.) use of clean gloves for invasive procedures C.) unlimited visitation from family and friends D.) fluid intake limitations

Answer: A.) meticulous handwashing

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? A.) uterine atony B.) uterine prolapse C.) uterine subinvolution D.) uterine contraction

Answer: A.) uterine atony

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? A.) uterine atony B.) cervical laceration C.) retained placental fragment D.) disseminated intravascular coagulation

Answer: A.) uterine atony Rationale; Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.

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? A.) Attachment, lochia color, complete blood cell count B.) Blood pressure, pulse, reports of dizziness C.) Degree of responsiveness, respiratory rate, fundus location D.) Height, level of orientation, support systems

Answer: B.) Blood pressure, pulse, reports of dizziness Rationale; Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

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? A.) Perform vigorous fundal massage for the client. B.) Check for bladder distention, while encouraging the client to void. C.) Use semi-Fowler position to encourage uterine drainage. D.) Offer analgesics prescribed by health care provider.

Answer: B.) Check for bladder distention, while encouraging the client to void. Rationale: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

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? A.) Use of breast pumps B.) Pierced nipple C.) Complete emptying of the breast D.) Frequent feeding

Answer: B.) Pierced nipple Rationale: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.

Which situation should concern the nurse treating a postpartum client within a few days of birth? A.) The client is nervous about taking the baby home. B.) The client feels empty since she gave birth to the neonate. C.) The client would like to watch the nurse give the baby her first bath. D.) The client would like the nurse to take her baby to the nursery so she can sleep.

Answer: B.) The client feels empty since she gave birth to the neonate.

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? A.) scheduling electroconvulsive therapy B.) administrating a selective serotonin reuptake inhibitor C.) talking to the client and reassuring her that she will feel better soon D.) telling the client that she has no need to be depressed

Answer: B.) administrating a selective serotonin reuptake inhibitor Rationale: Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? A.) administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) B.) administration of platelet transfusions as prescribed C.) avoiding administration of oxytocics D.) continual firm massage of the uterus

Answer: B.) administration of platelet transfusions as prescribed Rationale: When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

Which measurement best describes postpartum hemorrhage? A.) blood loss of 400 ml, occurring at least 24 hours after birth B.) blood loss of 1,000 ml, occurring at least 24 hours after birth C.) blood loss of 800 ml, occurring at least 24 hours after birth D.) blood loss of 600 ml, occurring at least 24 hours after birth

Answer: B.) blood loss of 1,000 ml, occurring at least 24 hours after birth

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? A.) in the milk ducts B.) in the reproductive tract C.) in the urinary bladder D.) within the blood stream

Answer: B.) in the reproductive tract

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? A.) hemoglobin level of 12 g/dl (120 g/L) B.) uterine atony C.) thrombophlebitis D.) moderate amount of lochia rubra

Answer: B.) uterine atony

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? A.) "I will change my perineal pad regularly to remove the infected drainage." B.) "I will take frequent walks around my home to promote drainage." C.) "When I am sleeping or lying in bed, I should lie flat on my back." D.) "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor."

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

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? A.) "It is appropriate for you to sit with your legs crossed over each other." B.) "It is expected for you to have minimal blood in your urine during therapy." C.) "You need to avoid medications which contain acetylsalicylic acid." D.) "You can breastfeed your newborn while taking any anticoagulation medication."

Answer: C.) "You need to avoid medications which contain acetylsalicylic acid." Rationale: The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? A.) Content, lochia, place B.) Location, shape, and content C.) Consistency, shape, and location D.) Consistency, location, and place

Answer: C.) Consistency, shape, and location Rationale: Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day.

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? A.) Escherichia coli B.) group B streptococcus (GBS) C.) Staphylococcus aureus D.) Streptococcus pyogenes (group A strep)

Answer: C.) Staphylococcus aureus Rationale: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. The health care provider is concerned the woman may have retained placental tissue. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue? A.) The client's blood pressure is 160/78 mm Hg with a base line of 102/62 mm Hg. B.) The client reports perineal discomfort and burning pain. C.) The client's pulse is 130 beats/min at rest and base line was 98 beat/min. D.) The client states being slightly nauseated and having no appetite since giving birth.

Answer: C.) The client's pulse is 130 beats/min at rest and base line was 98 beat/min. Rationale: Retained placental fragments (or tissue) is a cause of postpartum hemorrhage. The nurse would assess the client for signs of hemorrhage, including a high pulse rate. The blood pressure would be lower if hemorrhaging. The client's appetite and perineal pain are not indicative of a hemorrhage as stand-alone data.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? A.) Prothrombin time B.) Platelet level C.) Fibrinogen level D.) Activated partial thromboplastin time

Answer: D.) Activated partial thromboplastin time Rationale: The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? A.) Bend her knee, and palpate her calf for pain. B.) Ask her to raise her foot and draw a circle. C.) Blanch a toe, and count the seconds it takes to color again. D.) Assess for pedal edema.

Answer: D.) Assess for pedal edema. Rationale: Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? A.) Initiate Ringer's lactate infusion. B.) Assess the woman's vital signs. C.) Call the woman's health care provider. D.) Assess the woman's fundus.

Answer: D.) Assess the woman's fundus. Rationale: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

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? A.) Urinary infection B.) Excessive bleeding C.) A ruptured bladder D.) Bladder distention

Answer: D.) Bladder distention

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? A.) She should stop breastfeeding until completing the antibiotic. B.) She should supplement feeding with formula until the infection resolves. C.) She should not use analgesics because they are not compatible with breastfeeding. D.) She should continue to breastfeed; mastitis will not infect the neonate.

Answer: D.) She should continue to breastfeed; mastitis will not infect the neonate.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? A.) Check the lochia. B.) Assess the temperature. C.) Monitor the pain level. D.) Assess the fundal height.

Answer; A.) Check the lochia. Rationale: The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.

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? A.) Risk for fatigue related to chronic bleeding due to subinvolution B.) Risk for infection related to microorganism invasion of episiotomy C.) Risk for impaired breastfeeding related to development of mastitis D.) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

Answer; A.) Risk for fatigue related to chronic bleeding due to subinvolution Rationale: Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

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? A.) Warm and flushed skin B.) Weak and rapid pulse C.) Elevated blood pressure D.) Decreased respiratory rate

Answer; B.) Weak and rapid pulse Rationale: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.