OB R&R ch 11 (the complicated postpartal experience)

The nurse should monitor which postpartum clients who are at high risk for thrombophlebitis? Select all that apply. 1. A client who had a cesarean delivery 2. A client of normal pre-pregnant weight 3. A client who has five children 4. A client who smokes cigarettes 5. A client who kept active during pregnancy

1. A client who had a cesarean delivery 3. A client who has five children 4. A client who smokes cigarettes Rationale: The postpartal woman is prone to develop superficial thrombophlebitis from increased clotting factors, increased number and adhesiveness of platelets during the postpartal period. Numerous factors place clients at risk. Among the most common are cesarean deliveries, lack of mobility, obesity, cigarette smoking, previous history, trauma such as leg stirrups during birth, varicosities, diabetic mothers, multiparas, and anemia. Cognitive Level: Analyzing Client Need: Physiological Adaptation Integrated Process: Nursing Process: Assessment Content Area: Maternal-Newborn Strategy: The wording of the question indicates that more than one option is correct. Use knowledge of risk factors for thrombophlebitis to make your selections. Reference: Ladewig, P. A., London, M. L., & Davidson, M. R. (2010). Contemporary maternal-newborn nursing care (7th ed.). Upper Saddle River, NJ: Pearson Education, pp. 902-903.

The nurse interprets that which factor in a client's history places the woman at greatest risk for postpartal endometritis? 1. Cesarean delivery after 24 hours of labor and failure to progress 2. Use of external fetal monitoring during labor 3. Ruptured membranes for four hours prior to delivery 4. Spontaneous vaginal delivery after eight hours of labor

1. Cesarean delivery after 24 hours of labor and failure to progress Rationale: Factors contributing to postpartum endometritis include the introduction of pathogens with invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of endometritis is greatest after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. The other options are neither invasive nor do they increase the client's risk for infection.

The client is a 36-year-old woman, gravida 6 and para 6, who delivered a 7 pound, 14 ounce baby girl at term after an eight-hour labor. The client's vital signs are stable, and her lochia is bright red, heavy, and contains various clots; some are half dollar size. The nurse would consider the client to be at high risk for uterine atony for which reason? 1. Grandmultiparity 2. Large for gestational age baby 3. Labor of long duration 4. Advancing maternal age

1. Grandmultiparity Rationale: Women that are parity of six or above (grandmultiparity) are at the greatest risk of uterine atony because of repeated distention of uterine musculature during pregnancy. Labor leads to muscle stretching, diminished tone, and muscle relaxation. The client's age is not a factor in uterine atony, the length of labor is not considered to be prolonged or precipitous, and the size of the baby is considered appropriate for gestational age, and is not considered to be macrosomic.

After delivery of a large-for-gestational-age infant, the nurse notes bright red blood continuously trickling from the client's vagina. Her fundus is firm and midline. The nurse suspects which of the following as the most likely cause of bleeding? 1. Lacerations 2. Hematoma 3. Uterine atony 4. Retained fragments of conception

1. Lacerations Rationale: Suspect lacerations if the client is bleeding and the fundus is firm. If the cause were uterine atony, the fundus would not be firm. When there are fragments of the placenta or the membranes, the uterus will not contract effectively.

If the nurse suspects a uterine infection in the post-partum client, the nurse should make which priority assessment? 1. Pulse and blood pressure 2. Odor of the lochia 3. Episiotomy site 4. The abdomen for distention

2. Odor of the lochia Rationale: An abnormal odor of the lochia indicates infection in the uterus. The vital signs may be affected by an infection, but that is not definitive enough to suspect a uterine infection. A distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus. Inspection of the episiotomy site would not provide information regarding a uterine infection.

A woman who delivered three weeks ago calls the postpartum unit with breastfeeding questions. She wants to know if she can continue to breastfeed while she has the flu. She states that she feels achy all over and has chills and a fever of 103°F. What other question is important for the nurse to ask? 1. "Have you been sleeping well?" 2. "Are you still experiencing vaginal flow?" 3. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" 4. "Do you have any swelling in your legs or visual disturbances?"

3. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" Rationale: Mastitis most frequently occurs at two to four weeks after delivery with initial flu-like symptoms plus breast tenderness and redness. The client may be describing symptoms of a breast infection. Sleep, lochia, and edema with visual disturbances are not associated with breast problems.

On the client's third postpartum day, the nurse enters the room and finds the client crying. The client states that she does not know why she is crying and she cannot stop. What is the most appropriate reply by the nurse? 1. "There is no need to cry, you have a healthy baby." 2. "Are you dissatisfied with your care? I will see that any issues are addressed." 3. "Many new mothers have shared with us their same confusion of feelings, would you like to talk about them?" 4. "This happens to lots of mothers, and be reassured that it will pass with time."

3. "Many new mothers have shared with us their same confusion of feelings, would you like to talk about them?" Rationale: Creating an environment where a client and her family can discuss emotional concerns is essential. Sharing time with the new mother to discuss thoughts and feelings is important to clients. Responding with patronizing answers does nothing to assist the mother to talk about her thoughts and feelings and may increase her sense of isolation and feelings of inadequacy and despair.

Which intervention, if medically prescribed and then carried out by the nurse, would have the most direct effect on reducing postpartum hemorrhage? 1. Continuous fundal massage to decrease bleeding and contract the uterus 2. Trendelenburg position to facilitate cardiac function 3. Bladder catheterization to maintain uterine contraction 4. Administration of a tocolytic drug

3. Bladder catheterization to maintain uterine contraction Rationale: A full bladder may cause uterine atony and contribute to bleeding. If a client has hemorrhaged, a Foley catheter may also be needed to allow accurate measurement of urine output, which is an indicator for kidney function. Overly aggressive stimulation of the fundus may cause decreased uterine tone; this is detrimental because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A tocolytic agent relaxes the uterus; in this case, an oxytocic drug to contract the uterus would be indicated.

The home health nurse is making a home visit to a postpartal client. The nurse would document and report which of the following as a symptom of infection? 1. Lochia that is pink tinged 2. Apical pulse of 68 3. Generalized abdominal tenderness 4. Oral temperature of 99.2°F

3. Generalized abdominal tenderness Rationale: The signs of a postpartal infection would include a temperature of greater than 100.4°F on two successive days after the first 24 postpartal hours, tachycardia, foul-smelling lochia, and pain and tenderness of the abdomen. The pinkish lochia is normal, and the temperature might indicate a cold or breast milk coming in. Bradycardia would be an unrelated finding.

Which sign of thrombophlebitis should the nurse instruct the postpartal client to look for when at home after discharge from the hospital? 1. Muscle soreness in her legs after exercise 2. Enlarging varicose veins in her legs 3. Localized posterior leg tenderness, heat, and swelling 4. New areas of ecchymosis

3. Localized posterior leg tenderness, heat, and swelling Rationale: These are classic signs of thrombophlebitis that appear at the site of inflammation; the other signs listed are not.

It is most important for the nurse to have which drug readily available when the client is being treated with heparin therapy for thrombophlebitis? 1. Calcium gluconate 2. Vitamin K 3. Protamine sulfate 4. Ferrous sulfate

3. Protamine sulfate Rationale: Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. One option raises serum calcium levels; another is the antidote for warfarin, and the other option is an iron supplement.

A new mother with mastitis is concerned about breastfeeding while she has an active infection. How should the nurse respond to the client's concern? 1. The infant is protected from infection by immunoglobulins in the breast milk. 2. The infant is not susceptible to the organisms that cause mastitis. 3. The organisms that cause mastitis are not passed in the milk. 4. The organisms will be inactivated by gastric acid.

3. The organisms that cause mastitis are not passed in the milk. Rationale: The organisms are localized in breast tissue and are not excreted in the breast milk. The other answers are factually incorrect.

A postpartum client develops a temperature during her postpartum course. Which temperature measurement indicates to the nurse the presence of postpartum infection? 1. 99.0°F at 12 hours postdelivery that decreases after 18 hours 2. 100.2°F at 24 hours postdelivery that decreases the second postpartum day 3. 100.4°F at 24 hours postdelivery that remains until the second postpartum day 4. 100.6°F at 48 hours postdelivery that continues into the third postpartum day

4. 100.6°F at 48 hours postdelivery that continues into the third postpartum day Rationale: A temperature elevation greater than 100.4°F on two postpartum days not including the first 24 hours meets the criteria for infection. This criterion is the most common standard in the United States. It is not abnormal for a postpartum client to run a low-grade fever in the first 24 hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. Postpartum nurses should assess other signs and symptoms of infection in addition to fever and WBCs when evaluating the possibility of infection in mothers who had epidural analgesia.

Because postpartum depression occurs in 3 to 30% of postpartal women, the prenatal nurse assesses clients for risk factors for postpartum depression during the prenatal period. Which clients would the nurse consider to be at risk for postpartum depression? Select all that apply. 1. A client who is an unmarried primipara with family support 2. A client who has previously had postpartum blues 3. A client who is a primipara with documented ambivalence about her pregnancy in the first trimester 4. A client who is a primipara with a history of depression and lack of a supportive relationship 5. A client who is a primipara living alone and was consistently ambivalent about pregnancy

4. A client who is a primipara with a history of depression and lack of a supportive relationship 5. A client who is a primipara living alone and was consistently ambivalent about pregnancy Rationale: Risk factors for postpartum depression include primiparity, ambivalence about maintaining the pregnancy throughout the pregnancy, history of previous depression or bipolar illness, lack of a stable support system, lack of a stable relationship with parents or partner, poor body image, and lack of a supportive relationship with parents, especially her father as a child. Ambivalence regarding pregnancy is a normal response in the first and into the second trimester, but should be resolved by the third trimester. Postpartum blues occurs in approximately 50 to 80% of postpartum women; the blues does not particularly indicate that a woman will develop postpartum depression.

Despite the nurse's attempt to massage a boggy fundus, a postpartum client continues to pass several large clots in the presence of bright red lochia. The uterine fundus remains boggy and fundal massage and oxytocin (Pitocin) are not successful. What medication does the nurse expected to be prescribed next? 1. Dinoprostone (Cervidil) 2. Terbutaline sulfate (Brethine) 3. Magnesium sulfate 4. Carboprost (Prostin 15-M or Hemabate)

4. Carboprost (Prostin 15-M or Hemabate) Rationale: Cervidil is used to ripen the cervix before labor; terbutaline sulfate is a tocolytic, and could cause further muscle relaxation; magnesium sulfate is used to decrease contractions or prevent seizures; and Hemabate is a prostaglandin, used to manage uterine atony. Oxytocin remains the first-line drug, the prostaglandins now are more commonly used as the second-line drug, and carboprost (Prostin 15-M or Hemabate) is the most commonly used uterotonin. As many as 68% of clients respond to a single carboprost injection, with 86% responding by the second dose.

A client delivered a 9 pound, 10 ounce infant assisted by forceps. When the nurse performs the second 15-minute assessment, the client reports increasing perineal pain and a lot of pressure. What action should the nurse take? 1. Apply ice to the client's perineum, reassuring the client that this is normal. 2. Call for assistance from another nurse. 3. Assess the fundus for firmness. 4. Check the perineum for a hematoma.

4. Check the perineum for a hematoma. Rationale: Bleeding into the connective tissue beneath the vulvar skin may cause the formation of vulvar hematomas, which develop as a result of injury to tissues with spontaneous as well as operative deliveries (use of forceps). One of the first signs of a hematoma may be complaint of pressure, pain, or an inability to void. An ice pack to the perineum can be used to reduce swelling, but a hematoma is abnormal and should be reported to the physician. The fundus should be assessed, but the client's complaints warrant perineal or vaginal assessment.

Which of the following actions by a lactating client would the nurse support to help the client prevent mastitis? Select all that apply. 1. Apply vitamin E cream to soften the nipples. 2. Wear a tight, supportive bra. 3. When the client's nipples are sore, offer the infant a bottle. 4. Encourage the client to breastfeed her infant frequently. 5. Teach breastfeeding techniques soon after birth and reinforce as needed.

4. Encourage the client to breastfeed her infant frequently. 5. Teach breastfeeding techniques soon after birth and reinforce as needed. Rationale: Preventing stasis of the milk and emptying the breast frequently will help prevent mastitis. Vitamin E cream will not help to prevent mastitis. A supportive bra is helpful, but a bra that is tight will not be comfortable. Offering a bottle will reduce the milk supply if it occurs frequently and will not help mastitis.

A client is in the immediate postpartal period after delivery of a 9-pound, 14-ounce baby. The client is a gravida 6, para 5. The nurse notices some new blood stains on the top sheet and discovers the client lying in a pool of blood. The fundus is located above the umbilicus and is boggy. What would be the nurse's priority action? 1. Take the client's blood pressure 2. Have the client empty her bladder 3. Start an IV 4. Massage the uterus

4. Massage the uterus Rationale: Of the options given the only one that immediately affects the bleeding is uterine massage. It might be important to start an IV with oxytocin at a rapid rate, and to allow the client to empty her bladder; however, the first action is to massage the uterus to stop or slow down the blood flow.

Which instruction should the nurse include in the discharge teaching plan to assist the postpartal client to recognize early signs of complications? 1. Expect to pass clots, which occasionally can be the size of a golf ball. 2. Report a decrease in the amount of brownish-red lochia. 3. Palpate the fundus daily to make sure it is soft. 4. Notify the health care provider of increased lochia or bright red bleeding.

4. Notify the health care provider of increased lochia or bright red bleeding. Rationale: An increase in lochia or a return to bright red bleeding after the lochia has changed to pink indicates a complication. The other statements are false.

The home-care nurse is caring for a postpartal client and suspects the development of postpartum psychosis. Which client findings support the nurse's judgment? Select all that apply. 1. Has a history of a bipolar (manic-depressive) disorder 2. Reports voices telling her the baby is evil and must die 3. Can't remember details of delivery or when the infant fed last 4. Is tearful without an identifiable reason 5. Is calm and remains seated during the home visit

Answer: 1, 2, 3 1. Has a history of a bipolar (manic-depressive) disorder 2. Reports voices telling her the baby is evil and must die 3. Can't remember details of delivery or when the infant fed last Rationale: Postpartum psychosis usually becomes evident within three months of delivery. Delusions and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic woman's distorted thoughts about herself or the baby. The psychotic woman would typically display agitation, hyperactivity, and confusion. Adjustment reaction with depressed mood, commonly known as maternal or baby blues, occurs in 50-70% of women and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously about the 10th postpartal day.