Maternity Chapter 22

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? drop in estrogen and progesterone levels after birth preexisting conditions in the client medications used during labor and birth lack of social support from family or friends

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

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

D 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.

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

D 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 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? Weak and rapid pulse Decreased respiratory rate Warm and flushed skin Elevated blood pressure

A 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.

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? Degree of responsiveness, respiratory rate, fundus location Blood pressure, pulse, reports of dizziness Attachment, lochia color, complete blood cell count Height, level of orientation, support systems

B 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.

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

A 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.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: maladjustment to parenting. postpartum blues. postpartum depression. lack of partner support.

C Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

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

C 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.

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

A 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.

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

A 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.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "How much blood was on the two pads?" "When did you last void?" "Are you in any pain with your bleeding?"

B The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

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? Klebsiella pneumoniae Gardnerella vaginalis Escherichia coli Staphylococcus aureus

C 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.

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? Risk for impaired breastfeeding related to development of mastitis Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis Risk for infection related to microorganism invasion of episiotomy Risk for fatigue related to chronic bleeding due to subinvolution

D 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.

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? Call the woman's health care provider. Assess the woman's vital signs. Initiate Ringer's lactate infusion. Assess the woman's fundus.

D 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.

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

A 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.

A postpartum woman is being treated for hemorrhage and is to receive a blood transfusion. The nurse understands that this treatment is being instituted based on which amount of estimated blood loss? 1,500 ml 750 ml 1,250 ml 1000 ml

A Once estimates of blood loss reach 1,500 ml to 2000 ml, transfusion of blood products should be instituted immediately.

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. inability to concentrate decreased interest in life loss of confidence bizarre behavior manifestations of mania

ABC 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.

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? Assess her blood pressure. Palpate her fundus. Have her turn to her left side. Assess her perineum.

B 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.

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

B Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

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? The uterus is filling up with blood. The bladder is distended. The uterine placement is normal. There is an infection inside the uterus.

B 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.

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

B Postpartum hemorrhage involves blood loss in excess of 1,000 mL within the first 24 hours of delivery.

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

B 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.

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

C 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.

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

C Postpartum hemorrhage involves blood loss in excess of 1,000 mL within the first 24 hours of delivery.

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? "I will stop breastfeeding until I finish my antibiotics." "When breastfeeding, it is recommended to begin nursing on the infected breast first." "I am able to pump my breast milk for my baby and throw away the milk." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

D 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.

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? "I need to avoid using any aspirin-containing products." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "If my lochia increases, I need to call my health care provider." "I should brush my teeth vigorously to stimulate the gums."

D 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.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client? Call her caregiver if lochia moves from serosa to alba. Call her caregiver if lochia moves from serosa to rubra. Call her caregiver if amount of lochia decreases. Call her caregiver if lochia moves from rubra to serosa.

B Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

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

A 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.

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? Complete emptying of the breast Use of breast pumps Pierced nipple Frequent feeding

C 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.

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? Postpartum blues Postpartum depression Postpartum psychosis Maladjustment

C Explanation: 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.

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

C 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.

Methylergonovine is prescribed for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which adverse effects? uterine hyperstimulation headache seizures flushing

C Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

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? Dehydration Normal vital signs Infection Shock

C 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.

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? by monitoring hCG titers by assessing skin turgor by frequently assessing uterine involution by assessing blood pressure

C 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.

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? Discussing her birth with another new mom Talking to the infant and rocking the infant Breast-feeding the infant in public Not responding to the infant crying

D 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.

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

C 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.