Postpartum period
A nurse is caring for a client who gave birth yesterday and had a right mediolateral episotomy performed. The client asks the nurse, "What can I do to get pain relief from my episiotomy?" Which response by the nurse would be most appropriate? -"Apply a cold pack to your perineum." -"Take a nice warm sitz bath every 4 hours." -"Perform perineal care after voiding or a bowel movement." -"Stay hydrated to keep the pain at a low level."
"Apply a cold pack to your perineum." Explanation: Applying a cold pack to an episiotomy during the first 24 hours after birth may reduce edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may reduce discomfort by promoting circulation and healing. Although perineal care should be performed after each voiding and bowel movement, its purpose is to prevent infection, not reduce discomfort. Drinking plenty of fluids is also important, especially for breast-feeding clients, but it does not relieve perineal discomfort.
A 24-year-old multigravida client who had an uncomplicated, spontaneous vaginal delivery 7 hours ago is uninterested in her baby and wants to sleep. The student nurse assigned to care for the client is concerned and tells the licensed practical nurse (LPN) who's also assigned to her care. Which response by the LPN is most effective in educating the student nurse? -"It's important to observe these types of behaviors and make necessary referrals to the social worker." -"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience." -"Make sure you don't assume the care for the baby. Encourage the mother to change change diapers and take responsibility for feeding." -"It's sad that some women don't seem to appreciate the gift of a healthy baby."
"Extreme fatigue from the delivery is common, and new mothers initially focus on recovery and taking in the birth experience." Explanation: Postpartum fatigue is common and many clients go home with a sleep deficit. A multigravida client has already experienced the challenges of sleep deprivation with a newborn and understands the need to recuperate. In Rubin's taking-in phase, the mother is commonly focused on her own needs and is only passively involved with the infant for 1 to 2 days postpartum. As the mother integrates her birth experience, she'll start the taking-hold phase and will increasingly shift her attention to the infant. Referral to a social worker is premature at this time. Although nurses need to allow mothers to care for their infants as much as possible, rest for the mother is also important.
A new mother who's breast-feeding asks how she can quickly lose the 40 lb she gained during pregnancy. Which response by the nurse is best? "The extra calories expended during breast-feeding will allow you to lose the weight gradually and effortlessly over the next few months." -"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended." -"Breast-feeding mothers should diet until their babies are weaned." -"Relax and enjoy your infant. You shouldn't be worrying about your weight."
"It's important to avoid dieting while your milk supply is being established; a well-balanced diet with gradual weight loss is recommended." Explanation: Postponing dieting for at least 3 weeks allows the client to recover from childbirth and establish her milk supply. Weight loss should be gradual (no more than 1 lb per week), using moderate exercise and a well-balanced diet to avoid affecting infant growth. Breast-feeding doesn't necessarily result in weight loss, although many mothers will lose weight without dieting. With a safe and sensible approach, the client doesn't have to wait until the baby is weaned. Telling a client not to worry doesn't address her concerns and is an example of nontherapeutic communication.
The nurse is teaching a client about oral contraceptive therapy. The client reports missing three doses of the scheduled medication. Which statement made by the client indicates understanding of the teaching regarding oral contraceptives? -"If I miss any doses, I will take all the missed doses as soon as I notice the oversight." -"I will take two pills for the next 2 days and use an alternative contraceptive method until the next cycle." -"I will take three pills for the next 3 days and use an alternative contraceptive method until the next cycle." -"I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule."
-"I will discard the pack, use an alternative contraceptive method until my menses begins, and start a new pack on the regular schedule." Explanation: A client who misses three or more pills in a row should discard the pack, use an alternative contraceptive method until her menses begins, and start a new pack on the regular schedule. The other options listed don't assure effectiveness and also increase the risk of adverse reactions.
The nurse is preparing to perform a fundal massage on a client who is 2 hours postpartum. Order the sequence of events for performing this procedure. Use all of the options. -Ask the client to void. -Place the client in supine position. -Gently press the fundus between the hands using slight downward pressure. -Place one hand on the abdomen just above the symphysis pubis. -Place one hand around the top of the fundus. -Rotate the upper hand to massage the uterus until firm.
-Ask the client to void. -Place the client in supine position. -Place one hand on the abdomen just above the symphysis pubis. -Place one hand around the top of the fundus. -Rotate the upper hand to massage the uterus until firm. -Gently press the fundus between the hands using slight downward pressure. Explanation: Fundal massage is performed to promote uterine tone and consistency and to minimize the risk of hemorrhage. First, have the client void to prevent displacement of the bladder and allow an accurate assessment of uterine tone. Then, place the client in proper supine positioning to allow for good visualization. To anchor the lower part of the uterus, place one hand on the abdomen just above the symphysis pubis and then place the other hand around the top of the fundus. Next, rotate the upper hand to massage the uterus until it is firm. Finally, when the uterus is firm, push gently on the fundus, using slight downward pressure against the lower hand.
A nurse is assisting a postpartum woman with breast-feeding her newborn. Which action would the nurse recommend to help the new mother breast-feed? Select all that apply. -suggesting the mother cuddle and caress the infant while feeding him -reminding her that breast-feeding is a natural skill -encouraging her to breast-feed when the infant is alert and hungry -showing her the different positions for holding the infant for feeding -reminding her to limit feedings to about 5 to 10 minutes each time
-suggesting the mother cuddle and caress the infant while feeding him -encouraging her to breast-feed when the infant is alert and hungry -showing her the different positions for holding the infant for feeding Explanation: Breast-feeding is a learned skill, and some newborns are able to adapt immediately while others take more time. The nurse should suggest that the mother cuddle and caress the infant during feedings, making sure that the infant is alert and awake and showing signs of hunger. In addition, the nurse should show the mother different positions that can be used for feeding and encourage her to allow sufficient time to enjoy each other in an unhurried atmosphere.
A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary health care provider? -Breast tenderness -Breakthrough bleeding within first 3 months of use -Decreased menstrual flow -Blurred vision and headache
Blurred vision and headache Explanation: Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the health care provider. Because these two effects in particular may result in cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.
When caring for a client who has had a cesarean section, which of the following actions is appropriate? -Removing the initial dressing for incision inspection -Monitoring pain status and providing necessary relief -Monitoring vital signs hourly until the client is stable -Feeding and caring for the neonate for the first day so the mother can rest
Monitoring pain status and providing necessary relief Explanation: The nurse should monitor the client's pain status and provide relief as needed. Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The nurse should monitor vital signs every 15 minutes until the client is stable. Breast-feeding should be initiated as soon as the mother feels like trying. The nurse shouldn't begin bottle- feeding the baby unless the mother is physically unable to breast-feed.
A client is diagnosed with disseminated intravascular coagulation (DIC) postpartum. The nurse recognizes that DIC may be related to which antepartum complication? -severe pre-eclampsia -urinary retention -Rhogam administration -fetal decelerations
severe pre-eclampsia Explanation: DIC is a life-threatening defect in coagulation that may occur in several complications of pregnancy (abruption placenta, pre-eclampsia, HELLP syndrome, sepsis). While anticoagulation is occurring, inappropriate coagulation also is occurring in the microcirculation. DIC can result in time clot formation in small blood vessels which block blood flow to organs and cause ischemia. Urinary retention, Rhogam administration, or fetal decelerations do not increase the risk of DIC.
