Ch 19 Postpartum Women at Risk

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?"

The nurse is administering a postpartal woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

The nurse is instructing a postpartum patient on observations to report to the health care provider that could signify retained placental fragments. Which patient statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching?

Avoid over-the-counter (OTC) salicylates

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breast-feeding.

A postpartum client calls the nurse to her room and states that she knows something awful is going to happen to her. What should the nurse do?

Report this immediately to the RN

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?

Risk for fatigue related to chronic bleeding due to subinvolution

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate.

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor

A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis?

delirium

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly

A postpartum client has continuous seepage of blood from the vagina. Upon nursing assessment, the nurse confirms a firm uterus, 1 cm below the umbilicus. The nurse increases her nursing assessment to include assessment for which?

A cervical laceration

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

"I know you are hurting, but you can have another baby in the future."

The nurse is working with several clients who have recently delivered healthy newborns. Which statement by a mother would alert the nurse to further assess the mother for postpartum depression?

"I seem to cry more each and every day that goes by."

A postpartal woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

A woman gave birth to a healthy baby girl 2 days ago. Which observation by the nurse indicates the need for additional assessment and follow up?

The woman tells a friend, referring to her baby, "It just cries all the time."

A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding?

White plaques in the mouth