Postpartum Physiological Assessments and Nursing Care CH 12 Durham EXAM 1

On examining a woman in the postpartum period, the nurse learns that the patient is experiencing constipation. Which of the following instructions should the nurse give the patient that will help alleviate this condition? 1. Move slowly when rising to a standing position 2. Increase fluid and fiber intake 3. Tighten the gluteal muscles before sitting down 4. Engage in ambulation 5. Take a stool softener, per the primary care provider's orders

1,2,4,5 Feedback 1: Orthostatic hypotension, a sudden drop in the blood pressure when the woman stands up, is a common risk in the postpartum period and may be prevented by moving slowly when rising to a standing position. However, this does nothing to alleviate constipation. Feedback 2: Increasing fluid and fiber intake promotes intestinal peristalsis and can alleviate constipation. Feedback 3: Tightening the gluteal muscles as one sits down helps cushion the perineum and increase comfort when assuming a sitting position. However, this does nothing to alleviate constipation. Feedback 4: Ambulation promotes intestinal peristalsis and can alleviate constipation. Feedback 5: Stool softeners prevent constipation by increasing water in the stool, promoting stool softening and elimination.

At her first postpartum follow-up appointment, a woman complains of profuse sweating at night. The nurse takes her temperature but finds it normal. Which of the following conditions should the nurse suspect in this case? 1. Diaphoresis 2. Diastasis recti abdominis 3. Mastitis 4. Metritis

1. Diaphoresis Diaphoresis is profuse sweating that occurs during the first few postpartum weeks in response to the decreased estrogen levels. It often occurs at night and assists the body in excreting the increased fluid accumulated during pregnancy.

A laboring woman has just delivered her placenta and entered the fourth stage of labor. At this point, how often should the nurse assess the woman's uterus? 1. Every 15 minutes 2. Every 30 minutes 3. Every hour 4. Every 4 hours

1. Every 15 minutes After the third stage of labor, the nurse should assess the uterus every 15 minutes for the first hour, every 30 minutes for the second hour, every 4 hours for the next 22 hours, and every shift after the first 24 hours or as stated in hospital/unit protocols.

When inspecting a woman's lochia several hours after birth, the nurse detects a foul odor. Which of the following complications should the nurse most suspect based on this finding? 1. Metritis 2. Secondary hemorrhage 3. A boggy uterus 4. Urinary incontinence

1. Metritis Foul-smelling lochia could indicate the development of an infection. A primary complication of the postpartum period is metritis, which is an infection of the endometrial tissue.

After a postpartum examination, as the patient is about to rise from the table, the nurse instructs her to move slowly. Which of the following is the best rationale for this instruction? 1. Prevention of orthostatic hypotension 2. Reduction in the risk of venous thrombosis 3. Reduction in the risk of hemorrhage 4. Prevention of mastitis

1. Prevention of orthostatic hypotension Orthostatic hypotension, a sudden drop in the blood pressure when the woman stands up, is a common risk in the postpartum period and may be prevented by moving slowly when rising to a standing position.

A patient is on day 10 of the postpartum period, and the nurse is inspecting her lochia in an office visit. Which of the following are expected findings at this stage of the postpartum period, indicating a healthy recovery in the woman? 1. Small clots 2. Yellow to white lochia 3. Scant amount 4. Fleshy odor 5. Bright red bleeding

2,3,4 Feedback 1: Small clots are an expected finding in the first 3 days postpartum but would be a deviation from normal on day 10 postpartum. Feedback 2: The lochia on day 10 postpartum should be yellow to white. Feedback 3: The lochia on day 10 postpartum should be scant in amount. Feedback 4: The lochia on day 10 postpartum should have a fleshy odor. Feedback 5: Bright red bleeding on day 10 postpartum would be a deviation from normal, possibly indicating late postpartum hemorrhage.

At a postpartum appointment, a nurse performs a Coombs' test on an Rh-negative woman who gave birth to an Rh-positive newborn and finds that she is negative for this test. Based on this result, which intervention should the nurse expect to perform next? 1. Arrange for a transfusion of Rh-negative blood 2. Administer an injection of Rho immune globulin 3. Nothing, as the test is negative 4. Administer rubella immunization

2. Administer an injection of Rho immune globulin Rh isoimmunization occurs when an Rh-negative woman develops antibodies to Rh-positive blood related to exposure to Rh-positive blood either by blood transfusion or during pregnancy with an Rh-positive fetus. Rho immune globulin is given to Rh-negative women at 28 weeks' gestation. Rh-negative women who gave birth to an Rh-positive neonate are screened for anti-Rh antibodies (Coombs' test). A second injection of Rho immune globulin is given to the woman if she is Coombs' negative.

A new mother complains to her nurse that she has trouble getting her breast milk to flow at first each time she breastfeeds her newborn. Which of the following instructions should the nurse give this patient to facilitate milk flow? 1. Wear a supportive bra 2. Apply warm compresses to the breast 3. Take an analgesic 4. Apply ice packs to the breast

2. Apply warm compresses to the breast Applying warm compresses to the breast and performing breast massage will help facilitate the flow of milk prior to feeding sessions.

When assessing the fundus of a postpartum woman's uterus, the nurse feels a separation in the muscle overlying this area. Which of the following conditions should the nurse suspect in this case? 1. Diaphoresis 2. Diastasis recti abdominis 3. Mastitis 4. Metritis

2. Diastasis recti abdominis Diastasis recti abdominis is a condition in which there is a separation of the rectus muscle as a result of the reduction of tone after birth.

As the nurse is assessing a woman's uterus in the first hour following delivery of the placenta, the nurse notices that the patient's uterus is boggy, or soft. Which of the following interventions should the nurse perform next? 1. Instruct the woman to void 2. Massage the fundus with the palm of the hand 3. Document the stage and amount of lochia 4. Apply ice to the perineum

2. Massage the fundus with the palm of the hand A boggy uterus indicates that the uterus is not contracting and places the woman at risk for excessive blood loss. If the uterus is boggy, the nurse should massage the fundus with the palm of the hand, give oxytocin as per the physician's or midwife's orders, and notify the physician or midwife if the uterus does not respond to massage.

A nurse is measuring the most recent voiding of a woman who is about 12 hours postpartum. The voiding is about 100 mL. Based on this finding, which of the following interventions should the nurse make next? 1. Record the result in the patient's record as normal 2. Palpate for signs of bladder distention 3. Insert a Foley catheter 4. Instruct the woman to increase fluid intake to at least 8 glasses per day

2. Palpate for signs of bladder distention The nurse should measure the patient's voidings during the first 24 hours post-birth. If the voiding is less than 150 mL, the nurse needs to palpate for bladder distention. Signs of bladder distention include uterine atony, displacement of the uterus above the umbilicus to the right, increased lochia, and fullness in the suprapubic area.

A nurse is providing discharge instructions to a patient following birth. The nurse urges the patient to report blurry vision and severe headaches to the physician. The nurse recognizes that these are signs of which of the following conditions? 1. Infection 2. Cystitis 3. Pre-eclampsia 4. Venous thrombosis

3. Pre-eclampsia Blurry vision and severe headaches are signs of possible pre-eclampsia.

A nurse is assessing a woman in the postpartum period who received oxytocin and large amounts of intravenous fluids during labor and delivery. Which respiratory complication is this patient at increased risk for? 1. Pneumonia 2. Asthma 3. Pulmonary edema 4. Chronic obstructive pulmonary disorder

3. Pulmonary edema Women who received oxytocin, large amounts of intravenous fluids, or tocolytics, such as magnesium sulfate or terbutaline, had a multiple birth, an infection, or pre-eclampsia, or were on bed rest are at risk for pulmonary edema.

A nurse is providing discharge instructions to a woman who is recovering from a vaginal birth. Which of the following instructions should the nurse give the patient to reduce the risk for infection? 1. Apply ice to the perineum 2. Lie on your side 3. Tighten your gluteal muscles as you sit down 4. Use a peri-bottle with warm water to rinse the perineum after elimination

4. Use a peri-bottle with warm water to rinse the perineum after elimination To reduce the risk of infection, the nurse should instruct the woman to use a peri-bottle with warm water to rinse the perineum after elimination.

A nurse is providing discharge instructions to a patient following birth. The nurse urges the patient to report leg pain to the physician. The nurse recognizes that this is a possible sign of which of the following conditions? 1. Infection 2. Cystitis 3. Pre-eclampsia 4. Venous thrombosis

4. Venous thrombosis Leg pain may indicate venous thrombosis.