MCN: Postpartum

The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective? A) "If the drainage changes from clear to bright red, I am to call the doctor." B) "I will have large amount of vaginal drainage for at least several months." C) "An elevated temperature is normal during the first few weeks after delivery." D) "My drainage will fluctuate between bright red and dark red for several weeks."

A) "If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the patient is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. The patient will not have large amounts of drainage for several months. An elevated temperature indicates an infection. The drainage should not fluctuate between bright and dark red and could indicate retained placental fragments.

A postpartum patient has a swollen area of purplish discoloration in the perineal area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this patient? A) Acute pain B) Risk for injury C) Risk for infection D) Ineffective peripheral tissue perfusion

A) Acute pain The nursing diagnosis of acute pain would be appropriate because of a collection of blood in traumatized tissue secondary to birth trauma. Risk for injury would be appropriate if the patient was demonstrating signs of postpartum depression or psychosis. Risk for infection would be appropriate if the patient had an elevated temperature. Ineffective peripheral tissue perfusion would be appropriate if the patient was demonstrating signs of thrombophlebitis.

Which assessment would lead the nurse to believe a postpartal 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. Postpartal women who void in small amounts may be experiencing bladder overflow from retention.

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time? A) Breast-feeding can continue. B) The baby will need weekly blood work. C) The effect of anticoagulants is counteracted by infant gastric juices. D) All anticoagulants pass in breast milk so breastfeeding will have to stop.

A) Breast-feeding can continue. A patient can continue to breast-feed while receiving heparin. The baby is not going to need weekly blood work. Infant gastric juices do not impact the effect of anticoagulants. Medications do affect breast milk; however, breast-feeding can continue while receiving heparin.

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period? A) Encourage to continue breast-feeding. B) Suggest breastfeeding be discontinued. C) Instruct on supplementing feedings with formula. D) Explain how breastfeeding will weaken the patient's condition.

A) Encourage to continue breast-feeding. The postpartal period is a time when patients are susceptible to complications and may choose not to breastfeed. Nurses can help the nation achieve the 2020 National Health Goals by encouraging women to breast-feed even in the face of a postpartal complication. Suggesting that breast-feeding be discontinued or using supplemental feedings will not support the national goals. Breast-feeding is not known to weaken the patient's condition while being treated for a complication.

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? A) Endometritis B) Endometriosis C) Salpingitis D) Pelvic thrombophlebitis

A) Endometritis Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes.

During a home visit, a postpartum patient is complaining of a painful area on one breast. The nurse notes a local area on one breast to be red and warm to touch. For which health problem should the nurse plan care for this patient? A) Mastitis B) Breast cancer C) Engorgement D) Plugged milk duct

A) Mastitis Mastitis is usually unilateral and the affected breast feels painful, appears swollen, and reddened. The patient is postpartum and is breastfeeding. The nurse has no way of knowing if the patient has breast cancer. Engorgement would affect both breasts equally. Further diagnostic testing would be needed to diagnose a plugged milk duct.

The nurse is concerned that a postpartum patient with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this patient? A) Weak and rapid pulse B) Warm and flushed skin C) Elevated blood pressure D) Decreased respiratory rate

A) Weak and rapid pulse If the loss of blood is extremely copious, a woman will quickly begin to exhibit symptoms of hypovolemic shock such as a weak and rapid pulse. The skin will be pale and clammy, and the blood pressure will fall. Respiratory rate will be increased and shallow.

After delivery, a patient is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this patient? Select all that apply. A) Maintain on bed rest. B) Monitor urine output. C) Instruct on the purpose of a fluid restriction D) Administer magnesium sulfate as prescribed. E) Administer antihypertensive medication as prescribed.

A, B, D, E Treatment for postpartal gestational hypertension includes bed rest, monitoring of urine output, and administration of magnesium sulfate or an antihypertensive agent. Fluid restriction is not indicated for postpartal gestational hypertension.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? A) 99.6° F (37.5° C) B) 100.4° F (38° C) C) 102.4° F (39.1° C) D) 104.2° F (40.1° C)

B) 100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing? A) Providing a sitz bath B) Administering an enema C) Urging to drink all the milk provided during meals D) Administering acetaminophen and codeine for pain

B) Administering an enema A fourth-degree perineal laceration involves the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum. Any patient who has a fourth-degree laceration should not have an enema prescribed because the hard tips of equipment could open sutures near to or including those of the rectal sphincter.

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? A) Assess vital signs. B) Assess the fundus. C) Notify the health care provider. D) Begin an IV infusion of Ringer's lactate solution.

B) Assess the fundus. The best safeguard against uterine atony is to palpate the fundus at frequent intervals to be assured that the uterus is remaining contracted. If bleeding persists, then vital signs assessment and notification to the health care provider may be indicated. An intravenous infusion might be prescribed if bleeding continues.

Why are postpartal women prone to urinary retention? A) Catheterization at the time of delivery reduces bladder tonicity. B) Decreased bladder sensation results from edema because of pressure of birth. C) Frequent partial voidings never relieve the bladder pressure. D) Mild dehydration causes a concentrated urine volume in the bladder.

B) Decreased bladder sensation results from edema because of pressure of birth. As the fetal head passes behind the bladder, bladder edema with loss of sensation can result.

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication? A) Her urine output is over 50 mL/h. B) Her blood pressure is below 140/90 mm Hg. C) She can walk without experiencing dizziness. D) Her hematocrit level is over 45%.

B) Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

A postpartum patient is diagnosed with a vaginal laceration. What intervention will the nurse provide to the patient at this time? A) Monitor vital signs every 30 minutes. B) Insert an indwelling urinary catheter. C) Provide stool softeners as prescribed. D) Weigh vaginal packing to estimate blood loss.

B) Insert an indwelling urinary catheter. An indwelling urinary catheter may be placed following a vaginal repair because the packing causes such pressure on the urethra it can interfere with voiding. Vital signs do not need to be monitored every 30 minutes. Stool softeners are not indicated for this type of laceration. The packing is not removed for 24 to 48 hours.

A postpartum client with thrombophlebitis states that her leg is very painful. Which nursing instruction is most appropriate to decrease the pain? A) Massage the calf of her leg. B) Keep covers off the leg. C) Apply ice above the knee. D) Encourage ambulation every two hours.

B) Keep covers off the leg. Any restriction including tight fitting clothes or blankets on the leg can interfere with blood circulation. Uncovering or removing the constriction relieves the pain. Ice impairs circulation further exacerbating pain. Massaging the leg or encouraging ambulation could cause a clot to move and become a pulmonary embolus.

A postpartal patient is being treated for a separated symphysis pubis. Which outcome should the nurse identify when planning care for this patient? A) Patient plans to return to work in 2 weeks. B) Patient has coordinated child care assistance. C) Patient picks up the infant from the bassinette. D) Patient has a urine output of 30 ml per hour or greater.

B) Patient has coordinated child care assistance. With a separated symphysis pubis, bed rest and the application of a snug pelvic binder to immobilize the joint may be necessary to relieve pain and allow healing. A 4- to 6-week period is necessary for healing to be complete. During this time, the patient should avoid heavy lifting and may need to arrange for a person to help with child care at home. The patient should not be lifting the baby. The patient needs at least 4 to 6 weeks to heal before returning to work. Urine output is not a measurement for a separated symphysis pubis.

While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? A) Calcium gluconate B) Protamine sulfate C) Methylergonovine (Methergine) D) Nitrofurantoin (Macrodantin)

B) Protamine sulfate

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? A) In the milk ducts B) Up the reproductive tract C) In the urinary bladder D) Within the blood stream

B) Up the reproductive tract The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of clients.

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.

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? A) warm and flushed skin B) weak and rapid pulse C) elevated blood pressure D) decreased respiratory rate

B) weak and rapid pulse The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A) Feeding the neonate a maximum of 5 minutes per side on the first day. B) Wearing a supportive brassiere with nipple shields. C) Breastfeeding the neonate at frequent intervals. D) Decreasing fluid intake for the first 24 to 48 hours.

C) Breastfeeding the neonate at frequent intervals. Prevention of breast engorgement is key. The best technique is to empty the breast regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in single room maternity care continuous rooming in, because nursing can be done conveniently to meet the neonate's and mother's needs.

Which assessment on the third postpartal day would make the nurse evaluate a woman as having 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 postpartal day, it is normally three finger widths below the umbilicus.

A postpartum patient is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient? A) Assess ambulation. B) Measure urine output. C) Measure blood pressure. D) Evaluate current hematocrit level.

C) Measure blood pressure. Methylergonovine can increase blood pressure and must be used with caution in patients with hypertension. The nurse should assess the blood pressure prior to administrating and about 15 minutes afterward to detect this side effect. Methylergonovine does not affect ambulation, urine output, or hematocrit level.

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective? A) Patient complains of fatigue. B) Patient appears disheveled and listless. C) Patient is chatting on the telephone with a friend. D) Patient is cleaning the kitchen while the baby naps.

C) Patient is chatting on the telephone with a friend. Chatting on the phone with friends indicates that the patient is not becoming isolated with baby care. This will help prevent the onset of postpartum depression. Fatigue, listlessness, and trying to be perfect with cleaning are observations that could indicate postpartum depression.

Forty eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? A) Taking in B) Letting go C) Taking hold D. Resolution

C) Taking hold Beginning after completion of the taking-in phase, the taking hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs? 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.

The nurse is planning interventions to prevent the onset of urinary retention in a postpartum patient. Why are these interventions needed? A) Frequent partial voiding never relieves the bladder pressure. B) Catheterization at the time of delivery reduces bladder tonicity. C) Mild dehydration causes a concentrated urine volume in the bladder. D) Decreased bladder sensation results from edema because of pressure of birth.

D) Decreased bladder sensation results from edema because of pressure of birth. Urinary retention occurs when there is inadequate bladder emptying. After childbirth, bladder sensation for voiding is decreased because of bladder edema caused by the pressure of birth. Frequent partial voiding can lead to bladder overdistention. Catheterization at the time of delivery will not reduce bladder tone. Dehydration will not cause urinary retention but an overall reduction in urine volume.

postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question? A) Urging her to drink all the milk on her tray B) Administration of acetaminophen and codeine for pain C) Administration of a sitz bath D) Administration of an enema

D) Administration of an enema A fourth-degree perineal laceration involves the anus; a hard object, such as an enema tip, could tear a suture.

A postpartal 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.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? A) Begin an IV infusion of Ringer's lactate solution. 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. To have a suggested idea of the location of the bleeding, the nurse would need to assess the fundus of the client first.

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A) Turn the neonate every 6 hours. B) Encourage the mother to discontinue breadtfeeding. C) Notify the physician if the skin becomes bronze in color. D) Check the vital signs every 2 to 4 hours.

D) Check the vital signs every 2 to 4 hours. While caring for an infant receiving phototherapy for tx. of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

A postpartal woman is prescribed an antibiotic because of endometritis. Her breast-fed infant should be observed particularly for which of the following? A) Decreased sleep levels and increased appetite B) Jaundice that does not respond to phototherapy C) Irritability and loss of appetite D) Signs of thrush and easy bruising

D) Signs of thrush and easy bruising An antibiotic can lead to overgrowth of fungal organisms; it can also lead to underproduction of vitamin K and difficulty with blood clotting.

A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding? A) Jaundice B) Irritability C) Decreased sleep levels D) White plaques in the mouth

D) White plaques in the mouth The patient who is breast-feeding should not be prescribed antibiotics that are incompatible with breast-feeding. The patient should be instructed to observe for problems in their infant, such as white plaques or thrush in their infant's mouth that can occur when a portion of the maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant. Antibiotics will not typically cause jaundice. Irritability may or may not be because of the mother taking antibiotics. Decreased sleep levels are not typically associated with maternal antibiotic use.

A postpartal woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breast-feeding. The nurse's best response would be that: A) all anticoagulants pass in breast milk, so she will have to stop. B) anticoagulants pass in breast milk, but not in amounts great enough to cause harm. C) the effect of anticoagulants is counteracted by infant gastric juices. D) it depends on the type of anticoagulant she is taking.

D) it depends on the type of anticoagulant she is taking. Advice will differ based on the drug prescribed. Heparin, for example, does not pass into breast milk, yet warfarin does.