Chapter 16 &15 Postpartum care

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal. Explanation: Expected urinary output for a postpartum woman is at least 150 mL with each void on an hourly basis. Therefore 150 to 200 mL is a normal volume for each void.

A postpartum woman with an episiotomy asks the nurse about perineal care. Which recommendation would the nurse give?

Wash her perineum with her daily shower. Explanation: A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Explanation: Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

A nurse is providing care to a woman who is 6 hours postpartum. The nurse suspects urinary retention based on which finding?

50 to 70 mL urine per void every hour Explanation: Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Frequent voiding of small amounts (less than 150 mL) suggests urinary retention with overflow and a need for catheterization. A uterus at the level of the umbilicus, moderate lochia rubra, and clear yellow urine are normal findings.

A client who had a vaginal birth 2 days ago asks the nurse when she will be able to breathe normally again. Which response by the nurse is accurate?

"Within 1 to 3 weeks, your diaphragm should return to normal, and your breathing will feel like it did before your pregnancy." Explanation: The abdominal organs, including the diaphragm, typically return to prepregnancy state within 1 to 3 weeks after birth. Discomforts such as shortness of breath and rib aches lessen, and tidal volume and vital capacity return to normal values.

A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?

25 to 50 ml Explanation: Typically, the amount of lochia is described as follows: scant: a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad or approximately a 10-ml loss light or small: an approximately 4-in (10-cm) stain or a 10- to 25-ml loss moderate: a 4- to 6-in (10- to 15-cm) stain with an estimated loss of 25 to 50 ml large or heavy: a pad saturated within 1 hour after changing it or over 50-ml loss.

What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply.

Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C) Explanation: The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. Explanation: An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area. Explanation: Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

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.

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum Explanation: Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Opioid pain medication would not be the first choice.

Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. Explanation: This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony Explanation: 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.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used.

commitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Explanation: Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Explanation: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage Explanation: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

encouraging the woman to empty her bladder completely every 2 to 4 hours Explanation: The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

fourth degree Explanation: The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3 to 6 weeks Explanation: There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother?

indirect Coombs test Explanation: The indirect Coombs test is an antibody screen that will indicate whether or not the woman has been sensitized to the Rh-positive blood of her infant. A positive result indicates the sensitization has occurred and this can cause complications for future pregnancies. A CBC with differential provides a count of the various blood cells. The ANA and titer screen both analyze the blood for various antibodies that might be present in the blood. They can be used to check for immunization and autoimmune disorders.

The nurse is assessing a client at a postpartum visit. Which hemodynamic change will the nurse expect the client to exhibit?

rise in hematocrit Explanation: Hemoglobin and erythrocyte values vary during the early postpartum period, but they should approximate or exceed prelabor values within 2 to 6 weeks. As the woman excretes extracellular fluid, hemoconcentration occurs, with a concomitant rise in hematocrit. Puerperal bradycardia, with rates of 50 to 70 beats per minute, is common during the first 6 to 10 days postpartum. Blood volume decreases following placental separation, contraction of the uterus, and increased stroke volume. Cardiac output begins to increase early in pregnancy and peaks at 20 to 24 weeks' gestation at 30% to 50% above prepregnant levels. Cardiac output decreases during the postpartum period following placental separation, contraction of the uterus, and increased stroke volume.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus Explanation: If the bladder is distended, the nurse would most likely palpate a rounded mass at the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4°F (38°C), infection is suggested.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature Explanation: The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus. Explanation: Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

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 Explanation: 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.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

third-degree laceration Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities Explanation: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.

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 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?

2 weeks Explanation: Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.

During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?

6 to 8 weeks after pregnancy Explanation: During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m. Explanation: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?

Ask her questions and observe her caring for the baby. Explanation: The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant. Explanation: "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness. Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual. Reference:

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families. Explanation: To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?

The fundus is located 2 fingerbreadths above the umbilicus. Explanation: The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first

venous duplex ultrasound of the right leg Explanation: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency

While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?

diuresis Explanation: Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.

An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply.

Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any spontaneous abortions (miscarriages) or abortions (elective terminations of pregnancy)? Explanation: An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, spontaneous abortion (miscarriage), abortion (elective termination of pregnancy) or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.

The nurse is caring for a client who underwent a cesarean birth one day ago. After listening to the nurse's discussion about the plan of care, the client indicates that she is in a great deal of pain and does not wish to ambulate until the next day. What response by the nurse is most appropriate?

"Walking is the best way to prevent complications such as blood clots." Explanation: The development of blood clots is a potential complication of a cesarean birth. Early ambulation is key in the prevention of the complication. The client needs to be advised of this complication and the best means of clot prevention. Telling the client that failing to walk will prevent her recovery is threatening and does not provide her the needed information. A delay in walking by even one day can be detrimental to her recovery. Recommending pain medication may help the client in her ability and willingness to ambulate, but it does not provide the needed client education.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. Explanation: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

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 nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply.

urinary stasis denuded endometrial arteries episiotomy Explanation: The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia.

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.