Ch 25 PrepU OB

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.

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug?

cardiovascular disease

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

Mastitis

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

applying ice

The nurse is providing education to a postpartal woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed?

"When I am sleeping or lying in bed, I should lie flat on my back."

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus.

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

Teach that adequate hydration helps clear the infection quicker.

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

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

uterine atony

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?"

On completing fundal palpation, the nurse notes that the fundus is situated in the client's left abdomen. Which action is appropriate?

Ask the client to empty her bladder

A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract?

birth of a large newborn

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin.

A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately?

dyspnea, diaphoresis, hypotension, and chest pain

The nurse receives a report on a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware of these complications and knows to monitor the client closely for which of the following?

Postpartum hemorrhage

The nurse is caring for a client within the first four hours after her cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable.

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."

On assessment of a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which actions are immediately initiated? Select all that apply.

Assess the client's vital signs Palpate the client's fundus

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

Consistency, shape, and location

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 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 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

A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern?

sharp stabbing chest pain with shortness of breath

Which condition in a postpartum client may cause fever not caused by infection?

Breast engorgement

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A client is diagnosed with a puerperal infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection.

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

Instruct the client to empty her bladder before the examination.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

Obtain a clean-catch urine specimen

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

A nurse is caring for a client with peritonitis. Which nursing intervention is a priority?

Regulate client's body temperature

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.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Whch sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

Weak and rapid pulse

After presenting an in-service presentation on measures to prevent postpartum hemorrhage, the nurse determines that the teaching was successful when the group identifies which measure to prevent postpartum hemorrhage due to retained placental fragments?

inspecting the placenta after birth for intactness

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony

Over 75% of women who give birth experience postpartum depression.

False

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?

Bladder distention

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

Perform handwashing before breast-feeding.

A nurse is caring for a pregnant client. The client has been diagnosed with uterine fibroids. The nurse knows that which of the following is likely to occur in this client in the postpartum period?

Postpartum hemorrhage

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem?

multiparity

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

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.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness

A nurse is caring for a client with severe hemorrhage who requires an intramuscular injection of carboprost tromethamine. The nurse would monitor the client for which of the following side effects related to the administration of this drug?

Diarrhea

The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?

Encourage fluid intake.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

Escherichia coli

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?

She should continue to breast-feed; mastitis will not infect the neonate.

The nurse observes several interactions between a mother and her new son. Which behaviors by the mother would the nurse identify as evidence of mother-infant attachment? Select all that apply:

Talks and coos to her son Cuddles her son close to her

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

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition?

thrombophlebitis

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