Chapter 22 PrepU

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

A. 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.

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. Pierced nipple B. Frequent feeding C. Use of breast pumps D. Complete emptying of the breast

A. 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.

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? A. by frequently assessing uterine involution B. by assessing skin turgor C. by monitoring hCG titers D. by assessing blood pressure

A. by frequently assessing uterine involution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

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 panic disorder C. postpartum blues D. postpartum depression

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.

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

B. 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.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder? A. Breast yeast B. Engorgement C. Mastitis D. Plugged milk duct

C. Mastitis Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis.

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. 9 B. 3 C. 7 D. 5

*not in ALG A. 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.

A woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed endometritis? Select all that apply. A. hematuria B. flank pain C. odorless lochia D. leukocytosis E. pain on both sides of the abdomen

*not in ALG D. leukocytosis E. pain on both sides of the abdomen Signs and symptoms of endometritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

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. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." B. "I'll check on you in a few hours." "C. I'll contact your health care provider." D. "If you don't attempt to void, I'll need to catheterize you."

A. "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.

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

A. 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.

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

A. 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.

The nurse palpates a postpartum woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? A. The bladder is distended. B. The uterine placement is normal. C. The uterus is filling up with blood. D. There is an infection inside the uterus.

A. The bladder is distended. If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

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. postpartum hemorrhage C. uterine atony 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.

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. preexisting conditions in the client C. medications used during labor and birth D. lack of social support from family or friends

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.

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. loss of confidence B. bizarre behavior C. inability to concentrate D. manifestations of mania E. decreased interest in life

A. loss of confidence C. inability to concentrate E. 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.

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

B. 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.

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

C. 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.

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

C. 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.

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. Call the woman's health care provider. C. Assess the woman's vital signs. 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.