Ch 35: The Postpartum Family at Risk
32. A patient who is hemorrhaging after a vaginal delivery is being considered for a uterine tamponade. What should the nurse instruct the patient about this process? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. A balloon is inserted into the uterus 2. The balloon is kept in place for 12 hours 3. The balloon is inflated with 300 to 500 mL of saline 4. After removal, the uterus is packed with sterile gauze 5. The tube has an open tip to permit bleeding to be visualized
Answer: 1, 3, 5 Explanation: If utero-tonic agents are unsuccessful at correcting uterine atony, the physician may use uterine tamponade. One technique of uterine tamponade is the use of the Bakri balloon, which is inserted into the uterine cavity and inflated with 300-500 mL of isotonic saline to provide pressure against the uterine walls. The tube has an open tip, which permits any continuous bleeding from the uterus to be visualized. If bleeding is controlled, the tamponade is removed after 24 hours and not 12 hours. Packing the uterus with sterile gauze is no longer favored as a method of tamponade. Page Ref: 947
18. The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? A) Purulent, foul-smelling lochia B) Decreased blood pressure C) Flank pain D) Breast is hot and swollen
Answer: A Explanation: A) Assessment findings consistent with endometritis are foul-smelling lochia, fever, uterine tenderness on palpation, lower abdominal pain, tachycardia, and chills. B) Decreased blood pressure is a sign of hemorrhage. C) Flank pain is a symptom of a urinary tract infection. D) The breast being hot and swollen is a symptom of engorgement. Page Ref: 950
22. The postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? A) "Cesarean birth after extended labor with ruptured membranes." B) "Unassisted childbirth and afterbirth." C) "External fetal monitoring used throughout labor." D) "The client has history of pregnancy-induced hypertension."
Answer: A Explanation: A) Cesarean birth is the single most significant risk factor for postpartum endometritis, along with prolonged premature rupture of the amniotic membranes (PPROM). B) Instrument-assisted childbirth (vacuum or forceps) and manual removal of the placenta are risk factors for postpartum endometritis. C) Use of fetal scalp electrode or intrauterine pressure catheter for internal monitoring during labor are risk factors for postpartum endometritis. D) Pregnancy-induced hypertension is not a risk factor for postpartum endometritis. Page Ref: 955
16. The postpartum multipara is breastfeeding her new baby. The client states that she developed mastitis with her first child, and asks whether there is something she can do to prevent mastitis this time. What would the best response of the nurse be? A) "Massage your breasts on a daily basis, and if you find a hardened area, massage it towards the nipple." B) "Most first-time moms experience mastitis. It is really quite unusual for a woman having her second baby to get it again." C) "Apply cabbage leaves to any areas that feel thickened or firm to relieve the swelling." D) "Take your temperature once a day. This will help you to pick up the infection early, before it becomes severe."
Answer: A Explanation: A) If the mother finds that one area of her breast feels distended or lumpy, she can massage the lumpy area toward the nipple as the infant nurses. B) This statement is not accurate. Most first-time moms do not experience mastitis. C) Cabbage leaves are applied to suppress lactation, not prevent mastitis. D) The onset of mastitis is quite rapid, and taking the temperature daily is not likely to be helpful for catching early onset of the infection. Page Ref: 961
28. The client delivered by cesarean birth 3 days ago and is being discharged. Which statement should the nurse include in the discharge teaching? A) "If your incision becomes increasingly painful, call the doctor." B) "It is normal for the incision to ooze greenish discharge in a few days." C) "Increasing redness around the incision is a part of the healing process." D) "A fever is to be expected because you had a surgical delivery."
Answer: A Explanation: A) The client should call the doctor if the incision becomes increasingly painful. After cesarean delivery, wound infection is most often associated with concurrent endometritis. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. Some women have cellulitis without actual purulent drainage. B) Green drainage is not an acceptable symptom. C) The client should call the doctor if the incision becomes increasingly painful. Cesarean wound infections are characterized by increasing redness and tenderness at the margins. D) A fever could be a symptom of infection and this client should call the doctor Page Ref: 955
25. The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? A) Assist the client to the bathroom in 2 hours to void. B) Place a Foley catheter now. C) Apply warm packs to the perineum three times a day. D) Allow the client to rest for the next 8 hours.
Answer: A Explanation: A) This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention. B) A Foley catheter is not indicated at this time. C) Cold packs will help decrease the perineal edema; warm packs would increase the edema. D) Waiting 8 hours to reassess the bladder is too long. Page Ref: 958
4. The client has experienced a hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? A) "Sometimes the uterus relaxes and excessive bleeding occurs." B) "The blood collected in the vagina and poured out when your partner stood up." C) "Bottle-feeding prevents the uterus from getting enough stimulation to contract." D) "The placenta had embedded in the uterine tissue abnormally."
Answer: A Explanation: A) Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases. B) Although blood can pool in the vagina and thus pour out when the client stands, this does not constitute a hemorrhage. C) Although breastfeeding stimulates the release of oxytocin, which causes the uterus to contract, bottle-feeding does not cause hemorrhage. D) Had the placenta embedded abnormally (as in placenta accreta), the hemorrhage would have occurred immediately after the placenta delivered. Page Ref: 946
21. A nurse suspects that a postpartum client has mastitis. Which data support this assessment? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Shooting pain between breastfeedings B) Late onset of nipple pain C) Pink, flaking, pruritic skin of the affected nipple D) Nipple soreness when the infant latches on E) Pain radiating to the underarm area from the breast
Answer: A, B, C Explanation: A) Mastitis is characterized by shooting pain between feedings, often radiating to the chest wall. B) Mastitis is characterized by late-onset nipple pain. C) The skin of the affected breast becomes pink, flaking, and pruritic. D) Nipple soreness when the infant latches on is not a symptom of mastitis. E) The pain from mastitis does not radiate to the underarm area. Page Ref: 960
15. A postpartal client recovering from deep vein thrombosis is being discharged. What areas of teaching on self-care and anticipatory guidance should the nurse discuss with the client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Avoid crossing the legs. B) Avoid prolonged standing or sitting. C) Take frequent walks. D) Take a daily aspirin dose of 650 mg. E) Avoid long car trips.
Answer: A, B, C Explanation: A) Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. B) Women should be taught to avoid prolonged standing or sitting in one position or sitting with legs crossed. C) Women should be advised to avoid a sedentary lifestyle and to exercise as much as possible (walking is ideal). D) Taking a daily aspirin increases anticoagulant activity, and should be avoided if the client is being treated with other anticoagulants. E) Avoiding long car trips is not necessary. The client should be encouraged to take frequent breaks during long car trips and to walk around, thereby preventing prolonged venous stasis. Page Ref: 964
10. Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Redness B) Tender at the margins C) Vaginal bleeding D) Hardened tissue E) Purulent drainage
Answer: A, B, D, E Explanation: A) Redness is a classic sign of a perineal wound infection. B) The wound is typically red, indurated, tender at the margins, and draining purulent exudate. C) Vaginal bleeding is nonspecific to identifying a perineal wound infection. D) The wound is typically red, indurated, tender at the margins, and draining purulent exudate. E) Purulent drainage is a classic sign of a perineal wound infection. Page Ref: 955
26. Risk factors associated with increased risk of thromboembolic disease include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Diabetes mellitus B) Varicose veins C) Hypertension D) Adolescent pregnancy E) Malignancy
Answer: A, B, E Explanation: A) Diabetes mellitus is a risk factor for thromboembolic disease. B) Varicose veins are a risk factor for thromboembolic disease. C) Hypertension is not a risk factor for thromboembolic disease. D) Advanced maternal age, not adolescence, is a risk factor for thromboembolic disease. E) Malignancy is a risk factor for thromboembolic disease. Page Ref: 963
3. A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) Methergine B) Coumadin C) Misoprostol D) Serotonin reuptake inhibitors (SSRIs) E) Nonsteroidal anti-inflammatory drugs
Answer: A, C Explanation: A) Methergine is commonly used orally for postpartum hemorrhage. B) Coumadin (warfarin) is an anticoagulant and is not used for postpartum hemorrhage. C) Misoprostol is commonly used rectally for postpartum hemorrhage. D) Serotonin reuptake inhibitors (SSRIs) are antidepressants and would not be used for postpartum hemorrhage. E) Nonsteroidal anti-inflammatory drugs increase anticoagulant activity and would not be used for postpartum hemorrhage. Page Ref: 949
31. Clinical features of posttraumatic stress disorder (PTSD) include which of the following? A) Difficulty sleeping B) Acute awareness C) Flashbacks D) The need to be constantly around others E) Irritability
Answer: A, C, E Explanation: A) A clinical feature of PTSD is difficulty sleeping. B) Numbness, not acute awareness, is a clinical feature of PTSD. C) A clinical feature of PTSD is intrusive thoughts and flashbacks to the threatening event. D) Avoidance of others is a clinical feature of PTSD. E) A clinical feature of PTSD is irritability. Page Ref: 972
11. A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? A) Decreased bladder capacity B) Inhibited neural control of the bladder following the use of anesthetic agents C) Increased bladder sensitivity D) Abnormal postpartum diuresis
Answer: B Explanation: A) A postpartum woman is at increased risk for developing urinary tract problems because of increased bladder capacity. B) A postpartum woman is at increased risk for developing urinary tract problems because of inhibited neural control of the bladder following the use of anesthetic agents. C) A postpartum woman is at increased risk for developing urinary tract problems because of decreased bladder sensitivity from stretching or trauma. D) A postpartum woman is at increased risk for developing urinary tract problems because of normal postpartum diuresis. Page Ref: 958
14. To prevent the spread of infection, the nurse teaches the postpartum client to do which of the following? A) Address pain early B) Change peri-pads frequently C) Avoid overhydration D) Report symptoms of uterine cramping
Answer: B Explanation: A) Addressing pain early would not be a preventive action for infection. B) Changing peri-pads frequently decreases skin contact with a moist medium that favors bacteria growth. C) Avoiding overhydration actually would increase the risk for infection by not providing adequate fluids to flush the kidneys and bladder. D) Reporting symptoms of uterine cramping would not be a preventive action for infection. Page Ref: 956
2. The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? A) Assist the client to empty her bladder B) Help the client back to bed to check the fundus C) Assess her blood pressure and pulse D) Begin an IV of lactated Ringer's solution
Answer: B Explanation: A) Assisting the client to empty her bladder is not the first action the nurse would take. B) Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts. C) Blood pressure and pulse do not change until 1000 to 2000 mL of blood has been lost. D) An IV might need to be started if the client becomes symptomatic. Page Ref: 947
9. Which of the following would be considered a clinical sign of hemorrhage? A) Increased blood pressure B) Increasing pulse C) Increased urinary output D) Hunger
Answer: B Explanation: A) Decreased blood pressure would be considered a clinical sign of hemorrhage. B) Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage. C) Decreased urinary output would be considered a clinical sign of hemorrhage. D) Thirst, not hunger, would be considered a clinical sign of hemorrhage. Page Ref: 946
13. The nurse is calling clients at 4 weeks postpartum. Which of the following clients should be seen immediately? A) The client who describes feeling sad all the time B) The client who reports hearing voices talking about the baby C) The client who states she has no appetite and wants to sleep all day D) The client who says she needs a refill on her sertraline (Zoloft) next week
Answer: B Explanation: A) Feeling sad is an indication the client is experiencing postpartum blues, and is not the highest priority. B) Hearing voices is an indication the client is experiencing postpartum psychosis, and is the highest priority because the voices might tell her to harm her baby. C) Having no appetite and sleeping all day is an indication the client is experiencing postpartum depression, but is not the highest priority. D) A client on medications needs refills on time, but right now she has medication, and therefore is not a high priority. Page Ref: 970
24. The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. A) High fever B) Frequency C) Suprapubic pain D) Chills E) Nausea and vomiting
Answer: B, C Explanation: A) High fever is not usually present in acute cystitis, although it can appear if the cystitis progresses to pyelonephritis. B) Frequency is characteristic of acute cystitis. C) Suprapubic pain is characteristic of acute cystitis. D) Chills are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis. E) Nausea and vomiting are not usually present in acute cystitis, although they can appear if the cystitis progresses to pyelonephritis. Page Ref: 959
30. The postpartum client who is being discharged from the hospital experienced severe postpartum depression after her last birth. What should the nurse include in the plan of follow-up care for this client? A) One visit from a home care nurse, to take place in 2 days B) Two visits from a public health nurse over the next month C) An appointment with a mental health counselor D) Follow-up with the obstetrician in 6 weeks
Answer: C Explanation: A) A home visit in 2 days will be helpful to assess feeding, but is too early to detect signs of postpartum depression. B) Two home visits in a month are too sporadic to accurately detect postpartum depression. C) Postpartum depression has a high recurrence rate. Women with a history of postpartum psychosis or depression, or other risk factors, may benefit from a referral to a mental health professional for counseling during pregnancy or postpartum. D) Following up with the obstetrician in 6 weeks is too long a wait. Page Ref: 972
20. The postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? A) The client reports she had this condition after her last pregnancy. B) The client develops pain and swelling in her left lower leg. C) The client appears anxious, and describes pressure in her chest. D) The client becomes upset that she cannot go home yet.
Answer: C Explanation: A) A risk factor includes recurrent thromboembolic disease, but this is neither a predictor nor an indication of complications. B) Development of thrombophlebitis is a complication, but not the top priority. C) The most common clinical findings of a pulmonary embolism include dyspnea, pleuritic chest pain, cough with or without hemoptysis, cyanosis, tachypnea and tachycardia, panic, syncope, or sudden hypotension and require immediate intervention. D) Becoming upset is a psychosocial issue and far less important than another finding. Page Ref: 965
6. The postpartum client is concerned about mastitis because she experienced it with her last baby. Preventive measures the nurse can teach include which of the following? A) Wearing a tight-fitting bra B) Limiting breastfeedings C) Frequent breastfeedings D) Restricting fluid intake
Answer: C Explanation: A) Although wearing a supportive bra is recommended, a tight-fitting bra would tend to suppress lactation. B) The woman should continue to breastfeed; in fact, regular drainage of both breasts actually helps by preventing milk stasis and abscess formation. C) Treatment and prevention of mastitis includes frequent and complete emptying of the breasts. D) Supportive measures include increased fluid intake (at least 2 to 2.5 L/day). Page Ref: 960
8. Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? A) Urge ambulation B) Apply ice to the leg C) Elevate the affected limb D) Massage her calf
Answer: C Explanation: A) Ambulation would increase discomfort. B) Applying ice to the leg is contraindicated in thrombophlebitis treatment. Treatment includes application of local heat. C) Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents. D) Massaging the calf is contraindicated because it can cause a breakup of a clot and put the client at risk for a pulmonary embolus. Pulmonary embolism occurs when a thrombus from a lower extremity or the pelvis lodges in the pulmonary vascular bed and restricts circulation to the corresponding area of the lung vasculature. Page Ref: 963
23. The nurse suspects that a client has developed a perineal hematoma. What assessment findings would lead the nurse to this conclusion? A) Facial petechiae B) Large, soft hemorrhoids C) Tense tissues with severe pain D) Elevated temperature
Answer: C Explanation: A) Facial petechiae do not indicate perineal hematoma. B) Large, soft hemorrhoids are not indicative of perineal hematoma. C) Tenseness of tissues that overlie the hematoma is characteristic of perineal hematomas. D) An elevated temperature is not a symptom of a perineal hematoma. Page Ref: 950
19. The client delivered her second child 1 day ago. The client's temperature is 101.4° F, her pulse is 100, and her blood pressure is 110/70. Her lochia is moderate, serosanguinous, and malodorous. She is started on IV antibiotics. The nurse provides education for the client and her partner. Which statement indicates that teaching has been effective? A) "This condition is called parametritis." B) "Gonorrhea is the most common organism that causes this type of infection." C) "My positive Beta-strep culture might have contributed to this problem." D) "If I had walked more yesterday, this probably wouldn't have happened."
Answer: C Explanation: A) Pelvic cellulitis (parametritis) is an infection that has ascended to involve the connective tissue of the broad ligament or, in more severe forms, the connective tissue of all the pelvic structures. B) Gonorrhea is not a common cause of endometritis. C) Clinical findings of endometritis in the initial 24 to 36 hours postpartum tend to be related to group B streptococcus (GBS). D) Walking would prevent deep vein thrombophlebitis, not endometritis. Page Ref: 954
17. The postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? A) Postpartum psychosis B) Postpartum infection C) Postpartum depression D) Postpartum blues
Answer: C Explanation: A) Postpartum psychosis is more severe, and includes hallucinations and irrationality, which are not represented in this situation. B) Postpartum infection is not related to this situation. C) Postpartum depression can impair maternal-infant bonding and can cause developmental and cognitive delays in the child. D) Postpartum blues episodes occur frequently in the week after birth, are associated with hormonal fluctuations, and are typically transient. Page Ref: 970
1. The charge nurse is assessing several postpartum clients. Which client has the greatest risk for postpartum hemorrhage? A) The client who was overdue and delivered vaginally B) The client who delivered by scheduled cesarean delivery C) The client who had oxytocin augmentation of labor D) The client who delivered vaginally at 36 weeks
Answer: C Explanation: A) The client who was overdue and delivered vaginally has a lower risk for postpartum hemorrhage than would another client. B) The client who delivered by scheduled cesarean delivery has a lower risk for postpartum hemorrhage than would another client. C) Uterine atony is a cause of postpartal hemorrhage. A contributing factor to uterine atony is oxytocin augmentation of labor. D) The client who delivered vaginally at 36 weeks has a lower risk for postpartum hemorrhage than would another client. Page Ref: 946
7. A postpartum client reports sharp, shooting pains in her nipple during breastfeeding and flaky, itchy skin on her breasts. Which of the following does the nurse suspect? A) Nipple soreness B) Engorgement C) Mastitis D) Letdown reflex
Answer: C Explanation: A) These are not symptoms of nipple soreness. B) These are not symptoms of engorgement. C) Signs of mastitis include late-onset nipple pain, followed by shooting pain between feedings, often radiating to the chest wall. Eventually, the skin of the affected breast may become pink, flaking, and pruritic. D) These are not symptoms of the letdown reflex. Page Ref: 960
5. A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? A) That the client would be encouraged to ambulate freely B) That the client would be given aspirin 650 mg by mouth C) That the client would be given Methergine IM D) That the client would be placed on bed rest
Answer: D Explanation: A) Ambulation would increase the inflammation. B) Aspirin 650 mg by mouth has anticoagulant properties, but usually is not necessary unless complications occur. C) Methergine is given only for postpartum hemorrhage, and would only cause vasoconstriction of an already inflamed vessel. D) These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose. Page Ref: 964
29. The client delivered her second child yesterday, and is preparing to be discharged. She expresses concern to the nurse because she developed an upper urinary tract infection (UTI) after the birth of her first child. Which statement indicates that the client needs additional teaching about this issue? A) "If I start to have burning with urination, I need to call the doctor." B) "Drinking 8 glasses of water each day will help prevent another UTI." C) "I will remember to wipe from front to back after I move my bowels." D) "Voiding 2 or 3 times per day will help prevent a recurrence."
Answer: D Explanation: A) Burning with urination is a common symptom of a UTI. B) Drinking 8 to 10 8-oz glasses of water daily will help to prevent the development of a UTI. C) Wiping from front to back after bowel movements will help to prevent the development of a UTI. D) Voiding only 2 or 3 times per day is not sufficient to prevent recurrence of a urinary tract infection (UTI). The woman needs to empty her bladder whenever she feels the urge to void, or at least every 2 to 4 hours while awake. Page Ref: 960
27. A postpartum client with endometritis is being discharged home on antibiotic therapy. The new mother plans to breastfeed her baby. What should the nurse's discharge instruction include? A) The client can douche every other day. B) Sexual intercourse can be resumed when the client feels up to it. C) Light housework will provide needed exercise. D) The baby's mouth should be examined for thrush.
Answer: D Explanation: A) Douching is contraindicated for this client. B) Pelvic rest is necessary for this client, and sexual activity should be resumed only when the physician says it is safe. C) The woman with a puerperal infection needs assistance when she is discharged from the hospital. If the family cannot provide this home assistance, a referral to home care services is needed. D) A breastfeeding mother on antibiotics should check her baby's mouth for signs of thrush, which should be reported to the physician. Page Ref: 958
12. Which of the following is a risk factor for urinary retention after childbirth? A) Multiparity B) Precipitous labor C) Unassisted childbirth D) Not sufficiently recovering from the effects of anesthesia
Answer: D Explanation: A) Nulliparity is a risk factor for urinary retention after childbirth. B) Prolonged labor is risk factor for urinary retention after childbirth. C) Instrumental childbirth is a risk factor for urinary retention after childbirth. D) Women who have not sufficiently recovered from the effects of anesthesia and cannot void spontaneously are at risk for urinary retention after childbirth. Page Ref: 958
