OB: Chapter 22: Nursing Management of the Postpartum Woman at Risk

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

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 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 metritis, but some species of Klebsiella may cause urinary tract infections.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first?

coagulation studies Coagulation studies should be prescribed immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

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 should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?

increased vaginal acidity leading to growth of bacteria Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

The nurse assesses the client who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. What is the most likely cause of this finding?

lacerations A gush of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.

When assessing a client for postpartum hemorrhage, the nurse monitors what every hour?

pad count The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to:

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

Two weeks after their baby is born, a father calls to report that his wife is behaving strangely. She is extremely talkative and energetic, and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when the father asks her about the child, "As if," the father says, "she's forgotten that we even have a baby!" The nurse tells him to bring the mother in right away because the nurse suspects the mother is suffering from what condition?

postpartum psychosis Postpartum psychosis can present with a client in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.

A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

within 3 months of giving birth Postpartum psychosis generally surfaces within 3 months of giving birth

A client who is hypertensive and who received corticosteroids during pregnancy gave birth by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care the nurse should teach her?

wound care and hand washing The use of systemic corticosteroids prior to birth has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.

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 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.

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

Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus.

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 Postpartum hemorrhage is defined as blood loss of 500 mL or more after a vaginal birth and 1000 ml or more after a cesarean birth.

In which time period would the nurse expect a client who has given birth to twins to experience late postpartum hemorrhage?

24 hours to 12 weeks after birth Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

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. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

laceration of the cervix There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?

temperature of 38° C or higher after the first 24 hours after birth Postpartum infection is defined as a fever of 38° C or 100.4° F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which possible effect?

interference with the maternal-newborn attachment process The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breastfeeding, delayed development of the newborn, or altered maternal hormonal function.

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 client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

Which clinical manifestation in a woman with deep vein thombosis (DVT) should the nurse report immediately?

dyspnea Dyspnea in any client with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A client who has a DVT would be expected to have calf pain, pyrexia, and edema.

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 client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

The nurse is caring for a client within the first four hours of her cesarean birth. Which nursing intervention would be appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable. The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery.

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. Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4° F (38° C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

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. 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 (30.0° 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.

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. As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

A postpartal woman is developing a 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 positive Homans' sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for reddness and warmth and if she has increased pain when she ambulates or bears weight.

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing. 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 instruction would the nurse include in the teaching plan for a postpartal client with a history of thromboembolism to reduce the risk of a recurrence?

Wear support hose or antiembolic stockings. When caring for a postpartal client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.

A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?

a nonelective cesarean birth 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.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply.

abruptio placenta severe preeclampsia septicemia DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

activated partial thromboplastin time 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 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?

by frequently assessing uterine involution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case?

carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

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?

deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.

A woman is two 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?

endometritis The woman with endometritis typically looks ill and commonly develops a fever of 100.4° F (38° C) or higher (more commonly 101° F [38.4° C], possibly as high as 104° F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: temp 101.2° F (38.4° C); HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

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 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. Ergotrate 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.

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?

oxytoxic agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.

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?

postpartum psychosis The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

A postpartum woman is diagnosed as having endometritis. Which position would the nurse expect to place her in based on this diagnosis?

semi-Fowler's A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would be contraindicated.

A client develops mastitis 3 weeks after giving birth. What part of self-care does the nurse tell her is most important?

to breastfeed or otherwise empty her breasts every 1 to 2 hours Mastitis treatment involves complete removal of the milk from the breast as often as possible but no longer than a 3 hour time span and antibiotic therapy. It is most important to have the women keep the breast empty to prevent further stasis of milk ducts and worsening mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

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

uterine subinvolution Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.

When providing care for a postpartum client at a 6-week check up, which behavior would alert the nurse the client may have postpartum psychosis?

restless and agitated, concerned with self When a woman has postpartum psychosis the signs may vary, but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation.

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. The nurse needs to identify whether the bleeding is from lacerations or uterine atony. This can be done by looking for a well contracted uterus with bright-red vaginal bleeding. Lacerations commonly occur during forceps birth. In subinvolution of the uterus, there is inadequate contraction, resulting in bleeding. A boggy uterus with vaginal bleeding is seen in uterine atony. Once the nurse knows the cause of the bleeding, the condition can be treated.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

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. The nurse should caution the client to avoid products containing aspirin, which inhibits 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. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become "boggy." Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension 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 a 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's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

A nurse is caring for a 38-year-old overweight client 24-hours post cesarean birth. The client is reporting calf tenderness. Which should the nurse do first?

Have the client rest with the extremity elevated. The client is probably experiencing a deep vein thrombosis (DVT). The nurse would maintain bed rest with the effected extremity elevated until the diagnosis could be confirmed. Once the diagnosis is confirmed, and anticoagulant may be prescribed. It is not priority to determine the severity of the pain or a respiratory rate.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed 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 delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

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 Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

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 Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

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 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.

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

100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.

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 Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings. The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed.

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

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

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. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

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 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 nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question?

Take an oral contraceptive daily. When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptives, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.

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 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

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?

femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

An Rh positive client vaginally gives birth 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 prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal birth, and Rh status of the client do not place the mother at increased risk

A Hispanic 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 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

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 The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.