Ch 16: Nursing Management During the Postpartum Period

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount? A) moderate B) heavy C) light D) scant

A) moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? A) when the elevated temperature exceeds 100.4º F (38º C) B) during the first 24 hours after birth owing to dehydration from exertion C) after any period of decreased intake D) when the white blood cell count is less than 10,000/mm³

B) during the first 24 hours after birth owing to dehydration from exertion Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain? A) nothing—it is normal B) hematoma C) infection D) DVT

B) hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval? A) 4 weeks B) 5 weeks C) 2 weeks D) 3 weeks

C) 2 weeks The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A) The flow contains large clots. B) The flow is over 500 mL. C) The color of the flow is red. D) Her uterus is soft to your touch.

C) The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? A) 1 week B) 4 weeks C) 3 weeks D) 2 weeks

D) 2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? A) infection B) hemorrhage C) normal involution D) atony

D) atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: A) the client will show no signs of infection. B) discuss methods that the woman will use to prevent infection. C) list signs of infection that she will report to her health care provider. D) maintain previous household routines to prevent infection.

D) maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and: A) consistency. B) odor. C) specific gravity. D) pH.

B) odor. The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing? A) hemorrhage B) pulmonary emboli C) infection D) depression

C) infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.