Chapter 22: Nursing Management of the Postpartum Woman at Risk

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

DVT

A postpartal 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.

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 the fundus

A woman arrives at the office for her 4-week postpartal 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

A woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed metritis? Select all that apply.

pain on both sides of the abdomen leukocytosis

Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of least help in identifying the possibility of hemorrhage?

signs of shock

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

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 4 Ts tool will recognize which potential causes of postpartum hemorrhage? Select all that apply.

Tone Tissue Thrombin (Trauma, not listed)

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C)

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 distension while encouraging the client to void

It is discovered that a new mother has developed a puerperal 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 or 38° C orally.

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

Perform handwashing before breast-feeding.

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?

Post-partum psychosis

Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?

Uterus is at the level of the umbilicus

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

applying ice

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

avoid products containing aspirin

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?

continue breast-feeding; mastitis doesn't effect the neonate

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?

frequent assessment for uterine involution

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

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

1000mL

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next?

Assess for uterine contractions

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count.

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 one the two pads?"

The nurse is providing education to a postpartal 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."

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

Endomitritis

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

Finish all antibiotics to decrease a genital tract infection.

The nurse palpates a postpartal 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 client's bladder is distended and is causing the uterus to deviate to the right.

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?

The client's pulse is 130 beats/min at rest and base line was 98 beat/min

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

Uterine atony

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?

Assess the fundus

On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which findings would be consistent with a diagnosis of endometritis? Select all that apply.

Foul-smelling lochia Tender uterus

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

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

Oxytocic agent

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? Select all that apply.

bleeding gums tachycardia acute renal failure

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly