post test postpartum client

The night shift nurse gets report on four clients who delivered between​ 7:00 a.m. and​ 8:00 a.m. that morning. The nurse is going to assess which client​ first? Vaginal​ delivery, episiotomy, has not voided since delivery

It is generally expected that a postpartum client will void within 6 hr of delivery. The risks of not voiding include hemorrhage or excessive vaginal bleeding or both. The client who has not voided is the priority for the nurse. A client who has had pain medication 30 min ago will need reassessment within an hour of medication administration. This is not the priority. A client who is ambulating well is not the priority for the nurse. The nurse should provide assistance with breastfeeding.​ However, this education is not the priority in this example.

The nurse is assisting a postpartum client in the bathroom. What teaching would the nurse use to help promote hygiene and​ comfort? Cleansing the vulva and perineum with a spray bottle of warm water after voiding

It is very important to cleanse the vulva and perineum with a spray bottle after voiding or a bowel movement to promote hygiene and comfort. The nurse may teach the mother to use a​ peri-bottle for cleansing. The client should​ pat, not​ wipe, which will also aid in comforting and promote healing. The client should always pat from front to back to prevent urinary tract infection. A sitz bath can and should be done as soon as the client wants to relieve discomfort. This can be done while in the hospital.

The nurse is assessing a postpartum client and finds the client​'s uterus to be boggy. Which intervention would be the most appropriate nursing​ action? Massage the fundus until firm.

Massaging the fundus should cause uterine contractions. This will decrease the risk of hemorrhage. The uterus should be firm in the postpartum period. A boggy uterus can lead to postpartum hemorrhage. Massaging the fundus should be done first to determine if uterine contraction occurs. The healthcare provider will need to be notified if the uterus remains boggy after fundal massage. Oxytocin may then be ordered by the healthcare provider.

The nurse is teaching a postpartum client about her nutritional needs. What statement is appropriate to​ include? ​"You should continue to take your prenatal​ vitamins."

Mothers should be advised to continue their prenatal vitamins and iron as prescribed as part of discharge teaching about nutrition. Postpartum clients need to stay well​ hydrated, especially those who are breastfeeding. The nurse will encourage the mother to drink around​ 2,000 mL of fluid per day. The nurse should ask the client if she prefers to drink hot or cold beverages. Some cultures prefer warm fluids due to cultural beliefs. The nurse would not recommend drinking only cold water. Breastfeeding mothers​ need, on​ average, an extra 500​ kcal/day.

In preparation for​ discharge, the nurse discusses sexual issues with a primiparous client who had a routine vaginal delivery with a midline episiotomy. What would the nurse explain to the client as the most appropriate time for resuming sexual​ intercourse? After the postpartum​ follow-up visit with the healthcare provider

Nurses should counsel women on​ "pelvic rest," which refers to refraining from sexual​ activity, until they are seen at their 4dash-​6-week ​follow-up visit. This allows the complete healing of the​ cervix, uterus, and episiotomy. Lochia flow can stop as early as 3​ weeks, and although the pain from the episiotomy may have​ stopped, the episiotomy may not have completely​ healed, so sexual intercourse may be painful.​ Typically, new mothers are exhausted and may not feel amorous or desirable for quite a while.

The nurse is teaching a postpartum client who is 4 days postvaginal delivery about​ self-care after she is discharged home. Which statement by the client indicates that more teaching is ​needed? I can strengthen my abdominal muscles by holding my urine for as long as I can stand it.

Postpartum women should be encouraged to keep the bladder empty by voiding every 2 hr. Holding the urine for too long can result in urinary tract infection. Lochia should be pale pink by​ now, and change to​ cream-colored discharge that lasts up to 6 more weeks. Red lochia could indicate uterine problems and should be reported to the healthcare provider immediately. Eating leafy green and fibrous vegetables can help avoid constipation. The postpartum woman should rinse the vulva and perineal area with warm water every time after voiding or eliminating to avoid infection.

The nurse is assessing a breastfeeding mother with engorged breasts. Which intervention should the nurse teach the breastfeeding​ mother? Teaching how to express her breasts in a warm shower

Teaching the client how to express her breasts in a warm shower aids with letdown and will give the breastfeeding client temporary relief without interfering with milk production. Applying ice can promote comfort by decreasing blood​ flow, numbing, and discouraging further letdown of milk. This is not an appropriate intervention for a breastfeeding client. Breast binders are not effective in relieving discomforts of engorgement.​ Bromocriptine is no longer indicated for lactation suppression.

A postpartum client who is​ Rh-negative delivers a newborn who is​ Rh-positive. The nurse anticipates which order will come from the healthcare​ provider? Administer RhoGAM 300 ​µg intramuscularly.

The nurse administers RhoGam to the​ Rh-negative postpartum client if she delivers a baby who is​ Rh-positive. This is given to prevent Rh sensitization in the mother. It is not reasonable for the nurse to anticipate administering blood products to the​ Rh-negative mother, unless there has been significant blood loss during delivery. The nurse would not anticipate the need to prepare and send the placenta for pathological examination. The nurse does not anticipate the need to administer rubella based on the client​'s Rh status.

The nurse is caring for four postpartum clients. The nurse would question a provider​'s order for administering the rubella vaccine to which​ client? Vaginal​ delivery, HIV-positive

The nurse administers rubella vaccine to clients who are nonimmune to rubella. This live vaccine is harmful to clients who have a compromised immune system. The nurse should question the provider​'s order to administer the rubella vaccine to a client who is​ HIV-positive because the vaccine is harmful to immunocompromised individuals. The rubella vaccine does not pass through breast milk to the fetus. The nurse may administer this vaccination to a breastfeeding mother. Receiving blood products after a cesarean section delivery is not a contraindication to rubella vaccination. The nurse would administer the rubella vaccine to a client who has a negative rubella titer.

A client who had a cesarean section asks the nurse why she needs to ambulate. Which response by the nurse is the most​ appropriate? ​"Walking will help prevent blood clots in your​ legs."

The nurse encourages ambulation in the postpartum client to prevent deep vein thrombosis. The nurse is avoiding answering the client​'s question by stating that the doctor ordered this. The client may benefit from​ walking, but this answer is not the most appropriate and does not address the reason for ambulating. The nurse should answer the client​'s question. This is not an appropriate question to refer to the healthcare provider.