OB Chapter 16: Nursing Management During the Postpartum Period

A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: A. heavy. B. scant. C. light. D. moderate.

D Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss; light or small- an approximately 4-inch stain or a 10- to 25-mL loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 mL; and large or heavy-a pad is saturated within 1 hour after changing it.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: A. specific gravity. B. consistency. C. odor. D. pH.

C The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

A pregnant woman's pulse fluctuates throughout pregnancy and the early postpartum period. When assessing a 1-day postpartum woman's pulse, what is the first action a nurse should take in response to a rate of 56 bpm? A. Ask the woman what she has had to eat today. B. Advise that the woman not get out of bed until the nurse returns with assistance. C. Do nothing, this is normal. D. Compare the pulse rate of 56 bpm with her pulse rate on the first prenatal care visit.

D During pregnancy, the distended uterus obstructs the amount of venous blood returning to the heart; after birth, to accommodate the increased blood volume returning to the heart, stroke volume increases. Increased stroke volume reduces the pulse rate to between 50 and 70 beats per minute. The nurse should be certain to compare a woman's pulse rate with the slower range expected in the postpartum period, not with the normal pulse rate in the general population. Pulse usually stabilizes to prepregnancy levels within 10 days.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A. dehydration B. fluid volume overload C. change in the temperature from the birth room D. infection

A Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount? A. moderate B. heavy C. light D. scant

A Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A. women who had difficulties with breastfeeding in the past B. women on antithyroid medications C. women using street drugs D. women with more than one infant E. women on antineoplastic medications

B, C, E While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? A. "My mom always used dibucaine." B. "Sitz baths worked the last time." C. "I only eat a low-fiber diet." D. "I already have some pads with witch hazel at home."

C Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A. generally within 3 to 6 weeks B. generally after 12 weeks C. whenever the couple wishes D. usually within a couple weeks

A There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: A. list signs of infection that she will report to her health care provider. B. maintain previous household routines to prevent infection. C. discuss methods that the woman will use to prevent infection. D. the client will show no signs of infection.

B The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? A. infection B. nothing—it is normal C. DVT D. hematoma

D If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

A nurse is working with the parents of a newborn. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? A. "Ask your 2-year-old to pick out a special toy for his sister." B. "Talk to your 2-year-old about the baby when you're driving him to day care." C. "Expect to see your 2-year-old become more independent when the baby gets home." D. "Have your 2-year-old stay at home while you're here in the hospital."

A The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: A. assess and massage the fundus. B. inspect the perineum for lacerations. C. increase the flow of an IV. D. call the primary care provider or the nurse-midwife.

A This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? A. oral temperature 100.8° F (38.2° C) B. respiratory rate 16 breaths/minute C. pulse rate 75 beats per minute D. uterine fundus 1 cm below umbilicus

A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. A. newborn's vital signs B. vital signs of mother C. pain level D. head-to-toe assessment of newborn E. head-to-toe assessment

B, C, E Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery.

A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. A. Urination of 100 mL every 4 hours B. Moderate saturation of peripad every 3 hours C. Hypotonic bowel sounds D. Fundus one fingerbreadth below the umbilicus E. Inverted nipples following breastfeeding

B, D A fundus should be one fingerbreadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of100 mL every 4 hours is inadequate given the occurrence of diuresis.

When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. A. Bleeding B. Edema C. Discharge D. Slight bruising E. Redness

B, D During the early postpartum period, the perineal tissue surrounding the episiotomy is typically edematous and slightly bruised. The normal episiotomy site should not have redness, bleeding or discharge.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. A. Encourage breastfeeding of the newborn infant on demand. B. Give newborns water and other foods to balance nutritional needs. C. Provide breastfeeding newborns with pacifiers. D. Help the mother initiate breastfeeding within 30 minutes of birth. E. Place baby in uninterrupted skin-to-skin contact with the mother.

A, D, E The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A. hemorrhage B. infection C. pulmonary emboli D. depression

B There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is: A. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." B. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-positive blood." C. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-negative blood." D. "Rho(D) immune globulin suppresses antibody formation in a woman with Rh-positive blood who gave birth to a baby with Rh-negative blood."

A Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? A. fundus is above the umbilicus B. fever more than 100.4° F (38° C) C. presence of lochia rubra D. fundus is firm

B A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor? A. hemoglobin of 11.5 mg/dL B. placenta removed via manual extraction C. labor less than 3 hours D. multiparity

B Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

During assessment of the mother during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony? A. firm fundus B. purulent vaginal drainage C. boggy or relaxed uterus D. foul-smelling urine

C A boggy or relaxed uterus is a sign of uterine atony. This can be the result of bladder distention, which displaces the uterus upward and to the right, or retained placental fragments. Foulsmelling urine and purulent drainage are signs of infections but are not related to uterine atony. The firm fundus is normal and is not a sign of uterine atony.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A. looking B. feeding C. touching D. talking

C Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval? A. 3 weeks B. 4 weeks C. 2 weeks D. 5 weeks

C The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next? A. Determine if this is the client's first baby. B. Ask if the client received rH immunoglobulins during the pregnancy. C. Determine the newborn's blood type and rhesus. D. Administer Rh immunoglobulins intramuscularly.

C The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? A. too much milk being retained B. an improperly positioned baby during feedings C. normal findings in breastfeeding mothers D. mastitis

D Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? A. encouraging the woman to empty her bladder completely every 2 to 4 hours B. increasing oral fluid intake C. screening for bacteriuria in the urine D. increasing intravenous fluids

A The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? A. 250 additional calories per day B. 500 additional calories per day C. 1,000 additional calories per day D. 750 additional calories per day

B The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration? A. first degree B. fourth degree C. third degree D. second degree

B The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure? A. Apply ice packs directly to the perineal area. B. Use ice packs for a week after birth. C. Ensure ice pack is changed frequently. D. Apply ice packs for 40 minutes continuously.

C The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

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? A. venous duplex ultrasound of the right leg B. noninvasive arterial studies of the right leg C. venogram of the right leg D. transthoracic echocardiogram

A Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? A. Offer suggestions based on observation to correct positioning or latching. B. Recommend a moisturizing soap to clean the nipples. C. Encourage use of breast pads with plastic liners. D. Fasten nursing bra flaps immediately after feeding.

A The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A. normal involution B. hemorrhage C. infection D. atony

D The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth? A. Avoid performing pelvic floor exercises. B. Resume intercourse if bright red bleeding stops. C. Avoid use of water-based gel lubricants. D. Use oral contraceptives for contraception.

B The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply. A. elevated oral temperature B. dullness on percussion over symphysis pubis C. moderate lochia rubra D. rounded mass over symphysis pubis E. fundus boggy to the right of the umbilicus

B, D, E If the bladder is distended, the nurse would most likely palpate a rounded mass at the the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

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? A. Have the charge nurse review the assessment. B. Ask the client when she last changed her perineal pad. C. Immediately call the primary care provider. D. Vigorously massage the fundus.

B If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A. Her uterus is soft to your touch. B. The flow contains large clots. C. The flow is over 500 mL. D. The color of the flow is red.

D A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.