Chapter 15: Postpartum Adaptations
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
"It takes about 3 days after birth for milk to begin forming." Explanation: The formation of breast milk (lactation) begins in a postpartal woman regardless of her plans for feeding. For the first 2 days after birth, an average woman notices little change in her breasts from the way they were during pregnancy, since midway through pregnancy she has been secreting colostrum, a thin, watery, prelactation secretion. On the third day postpartum, her breasts become full and feel tense or tender as milk forms within breast ducts and replaces colostrum. There is no need to recommend formula feeding to the mother. Mastitis is inflammation of the lactiferous (milk-producing) glands of the breast; there is no indication that the client has this condition. Lactational amenorrhea is the absence of menstrual flow that occurs in many women during the lactation period.
A 2-day old newborn is crying after being circumcised and the mother is attempting to comfort the infant but he continues to be fussy. Which statement by the nurse would best support the mother's actions?
"Many mothers find that offering a nipple dipped in sugar water helps soothe a baby after a painful procedure." Explanation: Parents need support when trying to care for their newborn infants. By offering positive phrases and encouraging the mother in her caretaking, the nurse conveys acceptance and confirms the mother's abilities.
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
"Ovulation may return as soon as 3 weeks after birth." Explanation: Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.
A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort." Explanation: Discomfort during sex and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus Explanation: The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.
A nurse notes a woman's prelabor vital signs were: temperature 98.8° F (37.1° C); blood pressure 120/70 mm Hg; heart rate 80 beats/min; and respirations 20 breaths/min. Which assessment findings during the early postpartum period should the nurse prioritize?
BP 90/50 mm Hg, heart rate 120 bpm, respirations 24 breaths/min. Explanation: The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normal from birth and need to be reported immediately. Shaking chills can occur due to stress on the body and is considered a normal finding. A fever of 100.4° F (38° C) or higher should be reported. The other options are considered to be within normal limits after giving birth to a baby.
A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client?
Body secreting the excess fluids from pregnancy Explanation: Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.
The nurse is conducting a breast exam on a postpartum client on the second day following birth. What finding(s) does the nurse determine to be normal? Select all that apply.
Breasts feel slightly firm. The nipple on the right breast is flattened. Breasts are not painful. Normal findings for a breast exam in a Day 2 postpartum client should include nonpainful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?
Engorgement Explanation: The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.
A nurse is developing a plan of care for a postpartum woman, newborn, and partner to facilitate the attachment process. Which intervention would be appropriate for the nurse to include in the plan?
Ensure early and frequent parent-newborn interactions. Explanation: Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and their partners to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breastfeeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care. Eye contact and interacting with the newborn during feeding helps to promote attachment and bonding.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding Explanation: Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours. Explanation: The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed?
Harm to self Explanation: When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed.
A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue?
Hold the baby frequently. Explanation: The nurse should suggest that the father care for the newborn by holding and talking to the child. Reading up on parental care and speaking to his friends or the primary care provider will not help the father resolve his fears about caring for the child.
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution Explanation: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." Explanation: A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
Which assessment finding 1 hour after birth should be reported to the health care provider?
Lochia rubra is saturating a pad every 45 to 60 minutes. Explanation: The nurse should ask the woman to turn over so her buttocks can be inspected in order to ensure that blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or the woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her health care provider to be certain there is no cervical or vaginal tear, or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is a normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist the client in emptying the bladder. The health care provider should be notified if a catheter needs to be inserted and there are no standing prescriptions for an in-and-out cath following birth.
What two elements play the biggest role in becoming a mother after delivery of her newborn?
Love and attachment to the child and engagement with the child Explanation: A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.
A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints?
Maintain correct posture and positioning. Explanation: The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant. Explanation: A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with postpartum blues.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. As long as there is a prescription, what intervention would the nurse perform next?
Perform urinary catheterization. Explanation: Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The health care provider would be notified if no other interventions help the client.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack. Explanation: The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.
The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?
Risk for injury: postpartum hemorrhage related to uterine atony Explanation: The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.
Which action would most make the nurse believe that a postpartum woman is accepting a child well?
She turns her face to meet the infant's eyes when she holds her. Explanation: An "enface" position is a mark of a woman who is interacting warmly with a newborn.
Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply.
Teach proper positioning of the infant for breastfeeding. Encourage intake of fluids following delivery and after discharge. Wash her hands before and after caring for the client. To reduce the incidence of postpartum infection, the nurse would always wash her hands before and after caring for the client or her infant. The nurse should also recommend adequate fluid intake to encourage urination and prevent urinary retention, which can lead to a UTI. By teaching proper positioning of the infant for breastfeeding, the frequency of cracked nipples is reduced and cracked nipples can cause mastitis. Peripads are changed more frequently than every 12 hours and perineal care is provided. Early ambulation, rather than little activity, is recommended to strengthen the mother's immune system.
A nurse is caring for a client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. What should the nurse do next?
Tell the client to take an NSAID orally. Explanation: The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.
A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?
Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby. Explanation: Negative comments are often made by mothers who lack confidence in their mothering abilities and are experiencing hormonal fluctuations. The best response by the nurse is to acknowledge the mother's concerns and be accepting and supportive to her. Trying to force attachment will only make the situation worse. The mother does not need psychological counseling nor should the nurse dismiss the mother's concerns.
Which reason explains why women should be encouraged to perform Kegel exercises after birth?
They promote blood flow, enabling healing and muscle strengthening. Explanation: Exercising the pubococcygeal muscle increases blood flow to the area. The increased blood flow brings oxygen and other nutrients to the perineal area to aid in healing. Additionally, these exercises help strengthen the musculature, thereby decreasing the risk of future complications, such as incontinence and uterine prolapse. Performing Kegel exercises may assist with lochia removal, but that isn't their main purpose. Bowel function is not influenced by Kegel exercises. Kegel exercises do not generate sufficient energy expenditure to burn many calories.
Which body system is most vulnerable to infection during the postpartum period?
Urinary Explanation: The urinary system must handle an increased workload in the early postpartum period and the renal system is altered by hydronephrosis, a normal change with pregnancy. The hydronephrosis and urinary stasis often lead to urinary tract infections.
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching?
Wear a tight, supportive bra. Explanation: The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra. Explanation: The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?
You should not lift anything heavier than your infant in its carrier. Explanation: New mothers need their rest. They should focus on caring for their newborn and themselves. Nurses should suggest that the mother not overexert herself and limit any heavy lifting. However, mild exercise can be resumed within 1 week after delivery if approved by the physician. Performing postpartum exercises to strengthen muscle groups and walking are good exercises to begin with.
The postpartum nurse is assessing clients, and all have given birth within the past 24 hours. Which client assessment leads the nurse to suspect the woman is experiencing postpartum blues?
a 30-year-old woman who is teary-eyed when asked how she and the baby are doing with breastfeeding Explanation: During the postpartum period, many women experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The teenage mom is holding the baby in en face position, which is normal. The 29-year-old woman has a supportive, close family and there is no indication she is experiencing postpartum blues. The 38-year-old mother is in a normal phase after birth and is exploring the infant's body, a part of the taking-in phase that occurs 1 to 3 days after birth.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra Explanation: The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Lastly, the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased. Explanation: Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.
An adolescent primipara was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with the baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as:
attachment. Explanation: When a woman has successfully linked with her newborn it is termed attachment or bonding. Although a woman carried the child inside her for 9 months, she often approaches her newborn not as someone she loves but more as she would approach a stranger. The first time she holds the infant, she may touch only the blanket. Gradually, as a woman holds her child more, she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smooths the baby's hair, brushes a cheek, plays with toes, and lets the baby's fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby's or kiss the infant's nose; she has successfully bonded or become a mother tending to her child. Engrossment describes the action of new fathers when they stare at their newborn for long intervals. Involution is the process whereby the reproductive organs return to their nonpregnant state. Engorgement is the tension in the breasts as they begin to fill with milk.
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?
difficult to separate clots Explanation: If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.
The nurse is assessing a client at a postpartum visit who reports constipation. The nurse should point out this is likely related to which factor?
discomfort due to hemorrhoids Explanation: The nurse should inform the client that the pain of hemorrhoids can contribute to constipation postpartum. Distention of abdominal muscles, separation of rectus muscles, and relaxation of abdominal muscles are pregnancy-related developments and take time to heal; however, they are not related to constipation.
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
hemorrhage Explanation: The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?
hypovolemia Explanation: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?
increased heart rate Explanation: Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.
The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation?
lochia rubra Explanation: Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
The nurse is preparing a new mother to be discharged home after an uncomplicated delivery. During discharge education, which type of lochia pattern should the nurse tell the woman is abnormal and needs to be reported to her health care provider immediately?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Explanation: Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the health care provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding. Lochia progressing from rubra to serosa to alba within 10 days of delivery is a normal finding. Moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5 is a normal finding.
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains?
oxytocin Explanation: Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post-cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?
perineum Explanation: Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis Explanation: The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breastfeeding, the nurse would identify which hormone that is responsible for milk production?
prolactin Explanation: Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.
Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?
redness in lower legs Explanation: The nurse should identify redness, swelling, or warmth in the lower legs as early signs of thrombophlebitis. Edema in the perineal area usually accompanies an episiotomy. Diaphoresis is a normal finding in the immediate postpartum period. Increased lochia could be due to uterine atony.
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
showing increased confidence when caring for the newborn Explanation: Showing increased confidence when caring for the newborn is an important aspect of the taking-hold phase. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.
A client gave birth 1 day ago and the nurse is monitoring the client's blood pressure. In which position will the nurse place the client to get the most accurate reading?
sitting on the side of the bed for 2 minutes Explanation: To get the most accurate reading on a 1-day postpartum client's blood pressure, it is advised to have the client sit up on the side of the bed for several minutes to prevent orthostatic hypotension and a falsely low blood pressure.
A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?
taking-in phase Explanation: During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go. Explanation: The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?
touching Explanation: Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?
white blood cell count 14,000/mm3 (14 ×109/L) Explanation: The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.