Chapter 22: Nursing Management of the Postpartum Woman at Risk

The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage? A. 24 to 48 hours after birth B. 24 hours to 12 weeks after birth C. 6 weeks to 3 months after birth D. 6 weeks to 6 months after birth

B. 24 hours to 12 weeks after birth Mothers who give birth to twins are instructed on postpartum hemorrhage at the same time as a mother with a single newborn. Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 809

It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? A. Client's temperature remains below 100.4°F (38.8°C) orally. B. Fundus remains firm and midline with progressive descent. C. Client maintains a urinary output greater than 30 ml per hour. D. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.

A. Client's temperature remains below 100.4°F (38.8°C) orally. As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? A. "Postpartum blues usually resolves by the 4th or 5th postpartum day." B. "Postpartum psychosis usually appears soon after the woman comes home." C. "Postpartum depression develops gradually, appearing within the first 6 weeks." D. "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

C. "Postpartum depression develops gradually, appearing within the first 6 weeks." Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 826-827

The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? A. Calf pain B. Pyrexia C. Edema D. Dyspnea

D. Dyspnea A DVT is often suspected when an individual with an increased risk develops calf pain, pyrexia, and edema in one lower extremity. After the individual has been positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible pulmonary embolism and should be handled as an emergency. The RN and/or primary care provider should be notified immediately so emergent care can be started, as this is often fatal. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? A. She feels like eating all the time. B. lack of pleasure C. She is over her interest in her baby. D. extreme periods of elation

B. lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 828-829

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? A. Content, lochia, place B. Location, shape, and content C. Consistency, shape, and location D. Consistency, location, and place

C. Consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 813

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? A. Warm and flushed skin B. Weak and rapid pulse C. Elevated blood pressure D. Decreased respiratory rate

B. Weak and rapid pulse Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 818

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? A. Dehydration B. Normal vital signs C. Infection D. Shock

C. Infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? A. She should stop breastfeeding until completing the antibiotic. B. She should supplement feeding with formula until the infection resolves. C. She should not use analgesics because they are not compatible with breastfeeding. D. She should continue to breastfeed; mastitis will not infect the neonate.

D. She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition? A. femoral thrombophlebitis B. uterine atony C. mastitis D. subinvolution

A. femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question? A. Wear compression stockings. B. Plan long rest periods throughout the day. C. Take aspirin as needed. D. Take an oral contraceptive pill daily.

D. Take an oral contraceptive pill daily. When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptive pills, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 820

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? A. drop in estrogen and progesterone levels after birth B. lack of social support from family or friends C. medications used during labor and birth D. preexisting conditions in the client

A. drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 826,828

A nurse is assessing a client with postpartum hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. A. Assess the client's uterine tone. B. Monitor the client's vital signs. C. Assess the client's skin turgor. D. Get a pad count. E. Assess deep tendon reflexes.

A. Assess the client's uterine tone. B. Monitor the client's vital signs. D. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816

A nurse is caring for a client with a postpartum laceration. Which nursing diagnoses would be most appropriate? Select all that apply. A. Ineffective tissue perfusion B. Ineffective thermoregulation C. Risk for injury D. Risk for disuse syndrome E. Impaired tissue integrity

A. Ineffective tissue perfusion C. Risk for injury E. Impaired tissue integrity

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client? A. temperature of 38°C (100.4°F) or higher after the first 24 hours after birth B. temperature of 37.5°C (99.5°F) or higher after the first 12 hours after birth C. temperature of 39°C (102.2°F) or higher after the first 48 hours after birth D. temperature of 38.5°C (101.3°F) or higher after the first 36 hours after birth

A. temperature of 38°C (100.4°F) or higher after the first 24 hours after birth Postpartum infection is defined as a fever of 38°C or 100.4°F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? A. Postpartum blues B. Postpartum depression C. Postpartum psychosis D. Maladjustment

C. Postpartum psychosis Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 830

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? A. Bend her knee, and palpate her calf for pain. B. Ask her to raise her foot and draw a circle. C. Blanch a toe, and count the seconds it takes to color again. D. Assess for pedal edema.

D. Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection? A. length of labor B. maternal Rh status C. method of birth D. size of the neonate

A. length of labor The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 826

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? A. massaging the fundus firmly B. performing bimanual compressions C. administering ergonovine D. notifying the primary care provider

A. massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergonovine maleate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem? A. fetal demise B. placenta accreta C. preeclampsia D. multiparity

D. multiparity Risk factors for postpartum hemorrhage due to uterine atony include many factors, including multiparity. Placenta accreta is associated with placental issues, preeclampsia is seen in disruption of maternal clotting factors, and fetal demise can cause a disruption in maternal clotting factors, but not uterine atony. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply. A. Assess for redness and warmth in the affected leg. B. Ask if her pain that is relieved with walking. C. Assess for edema in the affected leg. D. Assess for a low-grade fever.

A. Assess for redness and warmth in the affected leg. C. Assess for edema in the affected leg. D. Assess for a low-grade fever. The nurse should ask the woman if she has pain or tenderness in the lower extremities when ambulating and if that pain is relieved by rest and elevation. Also assess for redness, warmth, and edema as well as a low-grade fever. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? A. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. B. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. C. She says she is extremely thirsty. D. Her perineum is obviously edematous on inspection.

A. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Postpartum women who void in small amounts may be experiencing bladder overflow from retention. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 824

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? A. Check the lochia. B. Assess the temperature. C. Monitor the pain level. D. Assess the fundal height.

A. Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 811

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? A. uterine atony B. uterine prolapse C. uterine subinvolution D. uterine contraction

A. uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 815

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? A. sudden change in mental status B. difficulty in breathing C. calf swelling D. sudden chest pain

C. calf swelling The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The priority actions of the nurse should be to first A. obtain a culture, recheck the client's temperature, administer antibiotics___________________ followed by B. ________ initiate antibiotics, recheck the client's temperature, administer nonsteroidal anti-inflammatory drug (NSAID), encourage intake of fluids

a. obtain a culture b. initiate antibiotics The nurse should first obtain a culture for sensitivity before administering antibiotics. Once the culture has been obtained, the nurse should administer a broad-spectrum antibiotic per provider prescription. Rechecking the client's temperature is not necessary. An antibiotic should not be administered until a culture has been obtained. The priorities for this client would be to first obtain a culture, then administer a broad-spectrum antibiotic. The nurse will encourage fluid intake, but this is not the priority. A nonsteroidal anti-inflammatory drugs (NSAID) can be administered for fever, but the priority is to obtain a culture and start the client on a broad-spectrum antibiotic to start treating the infection. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 822

The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? A. deep venous thrombosis B. uterine atony C. postpartum hemorrhage D. metritis

A. deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 818-819

The nurse is working with several clients who have recently delivered healthy newborns. Which statement by a mother would alert the nurse to further assess the mother for postpartum depression? A. "The first few days I was home, I was overwhelmed." B. "I seem to cry more each and every day that goes by." C. "I am hearing voices and sometimes want to harm myself and my newborn." D. "Life sure has changed since I had the newborn....I am so tired but it is worth it."

B. "I seem to cry more each and every day that goes by." The symptoms of postpartum depression are similar to the "baby blues" but worsen over time and do not lighten, so the nurse would further assess the mother who states she is crying more, not less. If the mother is in danger of harming herself or her newborn and hearing voices, she is likely experiencing postpartum psychosis, which is a psychiatric emergency. The mother who speaks of being tired and the mother who felt overwhelmed in the beginning are likely experiencing "baby blues." Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 828

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? A. Staphylococcus aureus B. Escherichia coli C. Gardnerella vaginalis D. Klebsiella pneumoniae

B. Escherichia coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider? A. "It has been hard getting enough sleep with the infant waking up during the night." B. "I am so angry with myself, I just want to give up my life right now." C. "I get tearful every so often and then suddenly I am all smiles." D. "I feel really restless and sad, nothing seems to make me happy."

B. "I am so angry with myself, I just want to give up my life right now." The client's statement about being angry at herself and wanting to give up suggests postpartum psychosis. This information would need to be reported, because there is a threat to the mother's safety and possibly the infant's safety. The nurse should not leave the client alone. Postpartum psychosis generally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant. The statement about not getting sleep may or may not be related to an affective disorder. It may be an indication of the mother attempting to adapt to the maternal role. The statement about getting tearful and then happy suggests emotional lability typically associated with postpartum blues; the statement about feeling restless and sad and lacking happiness suggest postpartal depression. Although these need to be reported and the nurse should continue to monitor the client, the statement about wanting to give up is of the utmost urgency. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 830

A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client? A. Encourage an oral intake of 2 to 3 liters per day. B. Keep the environment quiet to encourage rest. C. Change her perineal pads frequently. D. Take analgesics for uterine pain.

A. Encourage an oral intake of 2 to 3 liters per day. Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 826

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? A. Oxytocin B. Magnesium sulfate C. Domperidone D. Calcium gluconate

A. Oxytocin Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816

A client who is diagnosed with septic pelvic thrombophlebitis is prescribed heparin therapy by the health care provider. Which nursing assessment(s) should the nurse prioritize to begin each nursing shift? Select all that apply. A. pain B. platelet count C. clotting profiles D. fluid status E. evidence of bleeding

A. pain B. platelet count C. clotting profiles E. evidence of bleeding Thrombophlebitis interrupts blood flow causing pain. A pain assessment is needed every shift. The nurse should also monitor platelet counts and clotting profiles and assess bleeding in the client prescribed heparin therapy, an anticoagulant. Monitoring fluid status would be important for any client. This assessment would not specifically reveal complications or concerns related to the client receiving heparin therapy. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? A. "If my lochia increases, I need to call my health care provider." B. "I should brush my teeth vigorously to stimulate the gums." C. "I need to avoid using any aspirin-containing products." D. "If I get a cut, I need to apply direct pressure for about 5 minutes or more."

B. "I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? A. soft and boggy uterus that deviates from the midline B. firm uterus with trickle of bright red blood in perineum C. firm uterus with a steady stream of bright red blood D. Large uterus with painless dark red blood mixed with clots

D. Large uterus with painless dark red blood mixed with clots The presence of a large uterus with painless dark red blood mixed with clots indicates retained placental fragments in the uterus. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. A firm uterus with a trickle or steady stream of bright red blood in the perineum indicates bleeding from trauma. A soft and boggy uterus that deviates from the midline indicates a full bladder, interfering with uterine involution. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 815

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain? A. Flat in bed B. On her left side C. Trendelenburg D. Semi-Fowler

D. Semi-Fowler A semi-Fowler position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would not accomplish this goal and could result in the infection spreading to other parts of the body. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 827

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? A. The most common pathogen is group A streptococcus (GAS). B. A breast abscess is a common complication of mastitis. C. Mastitis usually develops in both breasts of a breastfeeding client. D. Symptoms include fever, chills, malaise, and localized breast tenderness.

D. Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 824

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination? A. The client is receiving oral pain medications. B. The client had an episiotomy. C. The client has a distended bladder. D. The client has a history of epidural anesthesia.

D. The client has a history of epidural anesthesia. If a client has an epidural, her sensation of pain is decreased, so nurses cannot rely on client reports of pain as a symptom of a perineal hematoma. The nurse should always inspect the perineum to determine if there is a hematoma present. Having an episiotomy, having a distended bladder, or taking oral pain medications would have no effect on a perineal hematoma. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 814

A woman arrives at the office for her 4-week postpartum visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client? A. Risk for fatigue related to chronic bleeding due to subinvolution B. Risk for infection related to microorganism invasion of episiotomy C. Risk for impaired breastfeeding related to development of mastitis D. Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

A. Risk for fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 810-811

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and they frequently indulge in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? A. postpartum psychosis B. postpartum blues C. postpartum depression D. postpartum panic disorder

A. postpartum psychosis The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 832

A nurse is assessing the perineum of several postpartum clients using the REEDA score. The nurse initiates interventions to minimize the risk for postpartum infection for the client with which score? A. 3 B. 5 C. 7 D. 9

D. 9 The nurse would implement measures to minimize the risk for postpartal infection for the woman with a REEDA score of 9. The acronym REEDA is frequently used for assessing a woman's perineum status. It is derived from five components that have been identified to be associated with the healing process of the perineum. These include: redness, edema, ecchymosis, discharge and approximation of skin edges. Each category is assessed and a number assigned (0 to 3 points, with 0 indicating none or intact and 3 indicating more significant problems). The total REEDA score ranges from 0 to 15. Higher scores indicate increased tissue trauma predisposing the woman to an increased risk for infection and a greater risk for postpartal hemorrhage. Therefore the woman with a total score of 9 is at greatest risk for problems. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A. a client who had a nonelective cesarean birth B. a primiparous client who had a vaginal birth C. a client who had an 8-hour labor D. a client who conceived following fertility treatments

A. a client who had a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

A client presents to the clinic with a 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101.8°F (38.8°C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client? A. Complete the full course of antibiotic prescribed, even if you begin to feel better. B. Use NSAIDs, warm showers, and warm compresses to relieve discomfort. C. Breastfeed or otherwise empty your breasts at least every 3 hours. D. Increase your fluid intake to ensure that you will continue to produce adequate milk.

A. Complete the full course of antibiotic prescribed, even if you begin to feel better. Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis, and administering antibiotics for a full 10 to 14 days. The client should empty the breasts every 1.5 to 2 hours to help prevent milk stasis and limit the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing the fluid intake will keep the client well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? A. applying ice B. restricting fluids C. applying warm compresses D. administering bromocriptine

A. applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes the client's history of asthma. Which medication if prescribed would the nurse question? A. carboprost B. oxytocin C. dinoprostone D. methylergonovine

A. carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, and methylergonovine should not be given to a woman who is hypertensive. Dinoprostone and methylergonovine can be used in pregnant clients with asthma, although should be used cautiously. Dinoprostone may cause hypotension, nausea/vomiting, diarrhea and temperature elevation. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first? A. coagulation studies B. STI status C. urinalysis results D. HIV status

A. coagulation studies Coagulation studies should be obtained immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status and urinalysis results, although important, are not necessary emergently. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 811

The mental health clinical nurse specialist is teaching a postpartum nurse how to use the Postpartum Depression Predictor Scale (PDSS) to assess for postpartum depression. The nurse specialist determines the need for additional teaching when the nurse identifies which component as being screened with the scale? A. family and social support system B. emotional lability C. guilt D. cognitive impairment

A. family and social support system The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance; emotional lability; loss of self-esteem; guilt/shame; cognitive impairment; and suicidal thoughts. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 828-829

Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection? A. foul-smelling vaginal discharge B. sudden onset of shortness of breath C. pain in the lower leg D. apprehension and diaphoresis

A. foul-smelling vaginal discharge The nurse should monitor for foul-smelling vaginal discharge to verify the presence of an episiotomy infection. Sudden onset of shortness of breath, along with apprehension and diaphoresis, are signs of pulmonary embolism and do not indicate episiotomy infection. Pain in the lower leg is indicative of a thrombosis. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. A. inability to concentrate B. loss of confidence C. manifestations of mania D. decreased interest in life E. bizarre behavior

A. inability to concentrate B. B. loss of confidence D. decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 832

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor? A. increased vaginal acidity leading to growth of bacteria B. loss of protection with premature rupture of membranes C. prolonged labor with multiple vaginal examinations to evaluate progress D. retained placental fragments

A. increased vaginal acidity leading to growth of bacteria Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? A. meticulous handwashing B. use of clean gloves for invasive procedures C. unlimited visitation from family and friends D. fluid intake limitations

A. meticulous handwashing Meticulous handwashing is essential for preventing postpartum infections, including before and after each client care activity. Aseptic technique, not clean gloves, are needed when performing invasive procedures. All visitors should be screened for any signs of active infection to reduce the risk for exposure. Adequate hydration, not fluid limitations, would be appropriate. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? A. oxytocin agent B. magnesium sulfate C. indomethacin D. nifedipine

A. oxytocin agent The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816`

The nurse is performing a focused assessment on a client who is 2 days postpartum. The client reports pelvic pain, chills, profuse dark, foul-smelling lochia with blood clots. The client states, "my bleeding before was light and now it is heavy." Vital signs: temperature, 99.5°F (37.5°C); heart rate, 102 beats/min; blood pressure, 100/66 mm Hg. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client has _____________ A. retained fragments of placenta, urinary tract infection (UTI), puerperal infection as evidenced by _______________ B. pelvic pain, heart rate 102 beats/min, temperature 99.5°F (37.5°C) and _______________ C. profuse dark lochia with blood clots, blood pressure 100/66 mm Hg, decreased appetite

A. retained fragments of placenta B. pelvic pain C. profuse dark lochia with blood clots Endometritis is an infection of the uterine lining that may occur on the second to the fifth day postpartum. Signs and symptoms of endometritis include pelvic pain; malodorous dark, profuse lochia; and a low-grade fever. Retained fragments of the placenta can occur when the placenta does not come out whole. The symptoms of retained pieces are delayed and heavy bleeding with clots, foul-smelling vaginal discharge, fever, chills, and feeling sick or flulike. The client would have had severe symptoms 2 days postpartum. Pelvic pain 2 days postpartum may indicate retained fragments of placenta. Foul-smelling lochia 2 days postpartum is a sign of retained fragments of placenta. Signs and symptoms of urinary tract infection (UTI) include dysuria, pelvic pain (cystitis), or costovertebral pain if the infection is in the kidney (pyelonephritis). Signs and symptoms of puerperal infections include flulike symptoms such as high fevers, chills, malaise, and anorexia. A heart rate of 102 beats/min is slightly above average, most likely due to the low-grade fever. Although a temperature of 99.5°F (37.5°C) is a low-grade fever that may occur in endometritis, this is not the best answer. A blood pressure of 100/66 mm Hg has nothing to do with retained placenta fragments. Decreased appetite has nothing to do with retained placenta fragments. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 813-817

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? A. "If you don't attempt to void, I'll need to catheterize you." B. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." C. "I'll contact your health care provider." D. "I'll check on you in a few hours."

B. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 824

The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client? A. NSAIDS B. Anticoagulants C. Opioid analgesics D. Beta-blockers

B. Anticoagulants The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Opioid analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? A. Avoid iron replacement therapy. B. Avoid over-the-counter (OTC) salicylates. C. Wear knee-high stockings when possible. D. Shortness of breath is a common adverse effect of the medication.

B. Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? A. Attachment, lochia color, complete blood cell count B. Blood pressure, pulse, reports of dizziness C. Degree of responsiveness, respiratory rate, fundus location D. Height, level of orientation, support systems

B. Blood pressure, pulse, reports of dizziness Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 817

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next? A. Perform vigorous fundal massage for the client. B. Check for bladder distention, while encouraging the client to void. C. Use semi-Fowler position to encourage uterine drainage. D. Offer analgesics prescribed by health care provider.

B. Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 817

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? A. Mastitis B. Endometritis C. Subinvolution D. Episiotomy infection

B. Endometritis The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.3°C], possibly as high as 104°F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 824

The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady trickle of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider? A. Uterine atony B. Laceration C. Perineal hematoma D. Infection of the uterus

B. Laceration A steady trickle of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 814

The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider? A. Talking to the infant and rocking the infant B. Not responding to the infant crying C. Discussing her birth with another new mom D. Breast-feeding the infant in public

B. Not responding to the infant crying When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. The other options are normal activities for a new mother who is 2 weeks postpartum. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 832

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? A. Assess her blood pressure. B. Palpate her fundus. C. Have her turn to her left side. D. Assess her perineum.

B. Palpate her fundus. The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 813

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? A. Use of breast pumps B. Pierced nipple C. Complete emptying of the breast D. Frequent feeding

B. Pierced nipple Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 822

Which situation should concern the nurse treating a postpartum client within a few days of birth? A. The client is nervous about taking the baby home. B. The client feels empty since she gave birth to the neonate. C. The client would like to watch the nurse give the baby her first bath. D. The client would like the nurse to take her baby to the nursery so she can sleep.

B. The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 826

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? A. scheduling electroconvulsive therapy B. administrating a selective serotonin reuptake inhibitor C. talking to the client and reassuring her that she will feel better soon D. telling the client that she has no need to be depressed

B. administrating a selective serotonin reuptake inhibitor. Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 829

Which measurement best describes postpartum hemorrhage? A. blood loss of 400 ml, occurring at least 24 hours after birth B. blood loss of 1,000 ml, occurring at least 24 hours after birth C. blood loss of 800 ml, occurring at least 24 hours after birth D. blood loss of 600 ml, occurring at least 24 hours after birth

B. blood loss of 1,000 ml, occurring at least 24 hours after birth Postpartum hemorrhage involves blood loss in excess of 1,000 mL within the first 24 hours of delivery. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 809

The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication? A. if urine output is higher than 50 ml/h B. if blood pressure is lower than 140/90 mm Hg C. if the client can walk without experiencing dizziness D. if hematocrit level is higher than 45%

B. if blood pressure is lower than 140/90 mm Hg Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 816

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? A. hematoma B. laceration C. uterine inversion D. uterine atony

B. laceration Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? A. breast yeast B. mastitis C. plugged milk duct D. engorgement

B. mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 822

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? A. hemoglobin level of 12 g/dl (120 g/L) B. uterine atony C. thrombophlebitis D. moderate amount of lochia rubra

B. uterine atony Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 809

The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? A. "I will stop breastfeeding until I finish my antibiotics." B. "I am able to pump my breast milk for my baby and throw away the milk." C. "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." D. "When breastfeeding, it is recommended to begin nursing on the infected breast first."

C. "I can continue breastfeeding my infant, but it may be somewhat uncomfortable." Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. A. "I am sad because I am not spending as much time with my toddler now that my newborn is here." B. "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit." C. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." D. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." E. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

C. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." D. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." E. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 830

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? A. "Stop breastfeeding until the pain and swelling subside." B. "You'll need to take this medication to stop the milk from being produced." C. "Try applying warm compresses to your breasts to encourage the milk to be released." D. "Limit the amount of fluid you drink so your breasts don't get much fuller."

C. "Try applying warm compresses to your breasts to encourage the milk to be released." Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 822

The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed? A. "I will change my perineal pad regularly to remove the infected drainage." B. "I will take frequent walks around my home to promote drainage." C. "When I am sleeping or lying in bed, I should lie flat on my back." D. "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor."

C. "When I am sleeping or lying in bed, I should lie flat on my back." With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 827

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client? A. "It is appropriate for you to sit with your legs crossed over each other." B. "It is expected for you to have minimal blood in your urine during therapy." C. "You need to avoid medications which contain acetylsalicylic acid." D. "You can breastfeed your newborn while taking any anticoagulation medication."

C. "You need to avoid medications which contain acetylsalicylic acid." The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? A. 500 ml B. 750 ml C. 1000 ml D. 250 ml

C. 1000 ml Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 809

The nurse notes uterine atony in the postpartum client. Which assessment is completed next? A. Assessment of bowel function B. Assessment of the lung fields C. Assessment of the perineal pad D. Assessment of laboratory data

C. Assessment of the perineal pad Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 809

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? A. Her uterus is 2 cm above the symphysis pubis. B. Her uterus is three finger widths under the umbilicus. C. Her uterus is at the level of the umbilicus. D. She experiences "pulling" pain while breastfeeding.

C. Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartum day, it is normally three finger widths below the umbilicus. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 810

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis? A. Complete blood count B. Vital signs C. Pad count D. Urine volume excreted

C. Pad count The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 815

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? A. Avoid massaging the breast area. B. Avoid frequent breastfeeding. C. Perform handwashing before breastfeeding. D. Apply cold compresses to the breast.

C. Perform handwashing before breastfeeding. As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 821

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? A. Escherichia coli B. group B streptococcus (GBS) C. Staphylococcus aureus D. Streptococcus pyogenes (group A strep)

C. Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 822

The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. The health care provider is concerned the woman may have retained placental tissue. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue? A. The client's blood pressure is 160/78 mm Hg with a base line of 102/62 mm Hg. B. The client reports perineal discomfort and burning pain. C. The client's pulse is 130 beats/min at rest and base line was 98 beat/min. D. The client states being slightly nauseated and having no appetite since giving birth.

C. The client's pulse is 130 beats/min at rest and base line was 98 beat/min. Retained placental fragments (or tissue) is a cause of postpartum hemorrhage. The nurse would assess the client for signs of hemorrhage, including a high pulse rate. The blood pressure would be lower if hemorrhaging. The client's appetite and perineal pain are not indicative of a hemorrhage as stand-alone data. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 810

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother? A. Roll a bath blanket or towel and place it firmly behind the knees. B. Limit oral intake of fluids for the first 24 hours to prevent nausea. C. Assist client in performing leg exercises every 2 hours. D. Ambulate the client as soon as her vital signs are stable.

D. Ambulate the client as soon as her vital signs are stable. The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 820

The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? A. Bend the knee and palpate the calf for pain. B. Ask the client to raise the foot and draw a circle. C. Blanch a toe, and count the seconds it takes to color again. D. Assess for warmth, erythema, and pedal edema.

D. Assess for warmth, erythema, and pedal edema. This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT). Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 819

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? A. Initiate Ringer's lactate infusion. B. Assess the woman's vital signs. C. Call the woman's health care provider. D. Assess the woman's fundus.

D. Assess the woman's fundus. The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 818

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? A. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. B. Drink plenty of fluids to decrease a bladder infection. C. Apply ice to the perineum to decrease pain of a perineal infection. D. Finish all antibiotics to decrease a genital tract infection.

D. Finish all antibiotics to decrease a genital tract infection. A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract. Chapter 22: Nursing Management of the Postpartum Woman at Risk - Page 823