Chapter 19 - Nursing care of the family during the postpartum period EAQS

The nurse helps a postpartum patient ambulate around the patient's bed. What complication is the nurse trying to prevent?

Thromboembolism Thromboembolism is a postpartum complication caused by hormonal imbalances, stress of childbirth, and long periods of immobility. This complication can be prevented by encouraging early ambulation. Ambulation does not help relieve bladder distention, orthostatic hypotension, or postpartum hemorrhage. The first priority in bladder distention is to help her to the bathroom or onto a bedpan if she is unable to ambulate. Orthostatic hypotension can be managed by asking the patient to change positions slowly. Postpartum hemorrhage has multiple causes and is not managed by ambulation

After delivery, the primary health care provider (PHP) prescribes Rh immune globulin to a postpartum patient. The nurse asks the PHP, "What is the purpose of this medication?" Which is the best response by the PHP? "It protects the patient's next baby from:

Being affected by Rh incompatibility Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus that is Rh positive. During pregnancy and at the time of the delivery, some of the baby's Rh-positive blood can enter the maternal circulation, causing the woman's immune system to form antibodies against the Rh-positive blood. The administration of Rh immune globulin prevents the woman from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen. Rh immune globulin suppresses the immune response, so it is not useful to protect the next child from having decreased immunity or infection. Therefore the woman who receives both Rh immune globulin and a live virus immunization such as rubella must be tested in 3 months to see whether she has developed immunity. If not, the woman will need another dose of the vaccine. Physiologic jaundice in newborns is caused by the immaturity of the baby's liver, which leads to the slow processing of bilirubin. It is not caused by the injection of Rh immune globulin.

The nurse is caring for a postpartum patient who has an episiotomy wound. The nurse finds that the patient has soreness at the incision site and lower back pain. What does the nurse tell the patient?

Place a covered ice pack on the affected area Patients with episiotomy may have soreness and back pain. To relieve soreness and back pain, the nurse should advise the patient to place an ice pack on the affected area. This provides comfort and reduces the inflammation and pain. A sitz bath helps relieve lower back pain and discomfort, so the patient should be encouraged to use sitz baths at a temperature of 38° to 40° C (100° to 104° F) at least twice a day to prevent edema. Not cleaning the perineal area may cause infection, so the nurse should advise the patient to clean her perineum frequently. Drinking plenty of water and eating foods such as fresh fruit and vegetables that contain fibers can relieve constipation or hemorrhoids but does not help reduce soreness.

The nurse tells the primary health care provider (PHP) that there is 15 mL of fetal blood in maternal circulation, as detected by Kleihauer-Betke test, in an Rh-negative patient. What does the nurse expect the PHP to prescribe to this patient?

300 mcg of intramuscular Rh immune globulin If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is usually sufficient to prevent maternal sensitization. A dose of 400 mcg of intramuscular Rh immune globulin may result in an overdosage. A dose of 100 mcg or 200 mcg of intramuscular Rh immune globulin is not sufficient to prevent maternal sensitization.

A postpartum patient is being prepared for discharge and is instructed to visit the clinic after 6 weeks for follow-up. When should the nurse discuss contraceptive options with the patient?

At the time of discharge Contraception is an important aspect of patient care. It should be discussed with the patient at the time of discharge. The patient may start to ovulate as early as 1 month postpartum; therefore contraception methods should be explained to the patient at discharge. Waiting for the patient's follow-up visit or for a month or more to educate the patient about contraception may be too late, and the patient may conceive again.

The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation?

Document the findings and continue to monitor Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract.

A nursing student asks the nurse, "Which woman is at greatest risk of bladder distention after a normal vaginal delivery?" Which is the best response by the nurse? A woman who had:

Epidural anesthesia Every woman is at risk for bladder distention after delivery. Therefore the nurse must assess the patient's voiding patterns after childbirth. The biggest risk factor is epidural anesthesia, which affects the sensory nerves. It occurs because the woman is unaware of the need to empty her bladder. Nerve blocks may also affect the motor nerves, making micturition difficult. A midline episiotomy will not promote urinary retention. Intravenous fluids may cause more urine to be produced but would not worsen retention of urine. A labor that lasts 12 hours would not increase the risk of bladder distention.

Which measure would be least effective in preventing postpartum hemorrhage?

Massage the fundus every hour for the first 24 hours following birth Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.

The nurse is caring for a patient with uterine atony. The nurse massages the patient's uterine fundus. The uterus remains boggy even after the blood clots are expelled. What medication would be most beneficial for the patient?

Oxytocin (Pitocin) Oxytocin is the most common drug ordered to increase the uterine tone and control uterine atony. A patient who is allergic to duck eggs can develop a hypersensitivity reaction to the rubella vaccine, and adrenaline is given to such patients. Nonopioid analgesics such as ibuprofen are used for pain management in postpartum breastfeeding women because they do not reduce maternal or infant alertness. Magnesium sulfate is used to treat preeclampsia.

The nurse is caring for a patient who has just given birth. What findings in the patient would indicate that she has postpartum blues?

Periodic crying and insomnia After the baby is born, many new mothers have the "postpartum blues" or "baby blues." Periodic crying and insomnia are characteristics of postpartum blues. It is transient and resolves on its own. It is caused by a number of factors including changes in hormone levels and adjustment to motherhood. Symptoms that last for more than 2 weeks could indicate postpartum depression and warrant treatment. Panic attacks and suicidal thoughts are characteristics of postpartum psychosis; anger toward self and infant and obsessive thoughts and hallucinations are characteristics of postpartum depression.

The nurse finds that a postpartum patient's perineal pad is soaked within 15 minutes. What should the nurse infer from the finding?

Signs of excessive hemorrhage A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient.

The nurse has taught perineal care techniques to a postpartum patient to prevent infections. After the teaching session, the nurse asks the patient to repeat the measures that should be followed to prevent infection. Which statement made by the patient would indicate the need for further teaching?

"I should fill the squeeze bottle with cold water while washing." The squeeze bottle should be filled with warm water. The nurse should inform the patient that the tap water should be heated to 38o C. Washing with warm water will make the patient feel comfortable and provide relief from pain. The patient should wash the perineum with mild soap and squeeze a bottle full of water at least once daily to maintain hygiene and prevent infections. Cleansing from symphysis pubis to anal area ensures proper cleaning and prevents infection. Changing the perineal pad for every 2 to 3 hours helps prevent infections.

The nurse is providing instructions to a postpartum patient who has been diagnosed with mastitis. Which statement made by the patient indicates a need for further teaching?

"I need to stop breastfeeding until this condition resolves." In most cases, the patient can continue to breastfeed. If the affected breast is too sore, the patient can pump the breast gently. Regular emptying of the breast is important to prevent the formation of abscess. Use of a supportive bra suppresses milk production and prevents breast engorgement. Additional supportive measures include ice packs, breast supports, and analgesics. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours.

Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth?

1 Hour Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the Baby-Friendly Hospital Initiative (BFHI) mandates 1 hour. Ideally an infant should go no longer than 2 hours after delivery before being put to breast. This is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

. While assessing a postpartum patient early in the morning, the nurse finds that the patient's perineal pad is completely saturated. What is the first step the nurse should take in this situation?

Ask the patient when she last changed her perineal pad It is likely that when the morning assessment was done, the patient had not been to the bathroom. In this situation, the patient's perineal pad may have been in place all night. Second, the lochia may have pooled during the night, resulting in heavy flow in the morning. Therefore the nurse should ask when the patient last changed the pad. The nurse need not call the (PHP) unless the patient has severe postpartum hemorrhage. Vigorous massage of the fundus is done to increase the tone of the uterine muscles. This would not be recommended until the patient has gone to the bathroom, changed her perineal pad, and emptied her bladder. If the nurse is uncertain, it is appropriate to have another qualified person check the patient, but only after a complete assessment of the patient's status.

Excessive blood loss after childbirth can have several causes; however, the most common is:

failure of the uterine muscle to contract firmly. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects:

hematoma formation Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to:

massage her fundus. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

The nurse has taught a postpartum patient about postpartum blues. Which statement given by the patient indicates effective teaching?

"I might feel like laughing one minute and crying the next" Emotional ability is a common symptom of postpartum blues. The patient may have continuous mood swings and may feel like laughing one minute and crying the next. The patient can call the support line whenever she feels depressed or anxious. The patient should consult the PHP if the symptoms persist for more than 2 weeks. Postpartum blues are usually self-limiting and require no medication.

The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient?

"You should use proper contraception for 1 month after the vaccination." The patient must not become pregnant for 1 month after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common adverse effects of the rubella vaccine.

What intervention does the nurse perform to suppress lactation in a patient who had a stillbirth?

Advise the patient to wear a breast binder for the first 72 hrs after giving birth Suppression of lactation is recommended in cases of neonatal death. To suppress lactation, the nurse should advise the patient to wear a breast binder continuously for the first 72 hours after delivery. Running warm water over the breast stimulates lactation. Mild analgesics can be administered to reduce breast engorgement, but they are not used to suppress lactation. Administration of oral or intravenous fluids may stimulate lactation.

The nurse is caring for a postpartum patient. One day after delivery, the nurse assesses the lochia of the patient and finds that it is red and has a foul-smelling odor. What does the nurse conclude from this assessment?

An infection is present Lochia is vaginal discharge that can be observed after childbirth; it contains blood and mucus. Usually, lochia appears to be dark red during the first 3 days after delivery and has fleshy odor. The presence of foul odor indicates that the patient has an infection. Foul-smelling lochia does not indicate that the patient is healing well. The presence of a moderate amount of lochia would indicate that the patient is healing well. An increase in body temperature would indicate that the patient is dehydrated. Excessive bleeding would indicate internal hemorrhage.

The nurse is reviewing the discharge orders with a postpartum patient. Which action does the nurse implement before discharging the patient?

Breastfed infants should be taken for a pediatric health checkup 3 to 5 days after birth, or 48 to 72 hours after hospital discharge, and again at approximately 2 weeks of age. Breastfed infants should be taken for a pediatric health checkup 3 to 5 days after birth, or 48 to 72 hours after hospital discharge, and again at approximately 2 weeks of age. The nurse should not administer analgesic medications before discharge because the patient is unlikely to be in pain at this time. The nurse can give the patient's hospital documents to her partner after discharge when the assessment findings have been documented and discharge teaching is provided. If the nurse removes the identification band before thoroughly checking the infant and the mother, it may lead to confusion in the identification of the infant.

The nurse is caring for a postpartum patient who gave birth recently. The nurse is evaluating the parent's behavior toward the new baby. Which parent-infant behaviors should the nurse investigate further?

Complete the child care activities silently, without looking at the baby The psychosocial assessment includes evaluating adaptation to parenthood, as evidenced by the parents' reactions to the baby and interactions with the new baby. Good attachment behaviors include seeking eye contact with the baby and talking to the baby during caretaking activities; the nurse should investigate the behaviors when these are not observed. Changing diapers, positioning baby comfortably, and maintaining eye-to-eye contact are appropriate behaviors that increase parent-infant attachment.

The patient who belongs to the Hmong community tells the nurse, "We do not use contraceptives or other birth control methods. We want to have a large family." How should the nurse provide culturally competent care to the patient?

Educate the patient about importance of contraceptives with due respect to the cultural beliefs. Hmong women desire to have large families, so they tend to avoid using birth control methods. However, it's the nurse's duty to educate the patient about various birth control methods without disregarding the patient's cultural beliefs. This approach helps the nurse to provide culturally sensitive care and helps the patient to incorporate these methods into her daily life. The nurse should teach the patient about contraceptives even if the patient does not follow it. The teaching may, however, increase the patient's awareness about contraceptives. The nurse should provide written information about contraceptives to the patient. But this information should be a supplement for the health education given face to face. The nurse should be sensitive to the patient's cultural beliefs but should not promote unhealthy practices.

A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching?

Fatigue may affect interest in sexual activity. Sexual activity can usually be safely resumed by 5 to 6 weeks after birth. Water-soluble lubrication may increase comfort. The female-on-top position may be more comfortable than other positions. Kegel exercises are usually recommended and can strengthen the pubococcygeal muscle. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers. The amount of psychologic energy expended by the mother in child care activities may lead to fatigue and decreased interest in sexual activity. Most women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel or jelly is recommended for lubrication. A position in which the mother has control of the depth of insertion of the penis, such as the female-on-top position may be more comfortable than other positions.

Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum?

Pain in left calf with dorsiflexion of left foot Lochia rubra with foul odor Postural hypotension is an expected finding related to circulatory changes after birth A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. These findings indicate a positive Homans' sign and are suggestive of thrombophlebitis and should be investigated. Lochia with odor may indicate infection.

The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding?

Provide education about newborn care when the father is present. To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn.

The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises?

To strengthen the perineal muscles Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles.

A postpartum patient has chosen not to breastfeed. What instructions should the nurse provide to the patient to prevent discomfort caused by breast engorgement? Select all that apply.

Wear a well-fitted support bra. Use a breast binder. Apply ice packs on the breasts Patients who choose not to breastfeed may experience breast engorgement and related discomfort. The nurse should instruct the patient to wear a well-fitted support bra or use a breast binder to support the breasts, which can relieve discomfort. Applying ice packs with a 15-minutes-on, 45-minutes-off schedule also helps relieve breast engorgement and reduce discomfort. Expressing milk from the breast or performing nipple stimulation may increase milk production and may worsen breast engorgement.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should:

assist the woman to empty her bladder. A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to:

massage the woman's fundus. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman:

uses the peribottle to rinse upward into her vagina. These are all appropriate measures. These are all appropriate measures. These are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

A postpartum patient tells the nurse, "It has been several weeks since I had my baby, and I'm still tired all the time." What advice should the nurse provide to the patient in this situation? Select all that apply.

The mother should sleep when the baby sleeps. Limit visitors and activities. Accept help from others for household work. The patient's responses indicate that she is experiencing postpartum fatigue. It is important to save energy during this period and sleep when the baby sleeps. The nurse should advise the patient and her partner to limit visitors and activities. Fatigue may increase further if the patient provides care and feeding for the newborn and performs other household responsibilities such as preparing meals and doing laundry. Therefore, she should accept help from other family members for household work for at least first 6 weeks after childbirth. The patient is lactating and needs proper nutrition. Therefore the nurse should not ask the patient to skip meals. Because the patient does not report having pain, the nurse need not suggest the use of pain medications.