NU143- Chapter 22: Nursing Management of the Postpartum Woman at Risk

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed

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?

"How much blood was on the two pads?"

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema.

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.

"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider."

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis?

"Try applying warm compresses to your breasts to encourage the milk to be released."

A nurse is assessing the perineum of a postpartum woman using the REEDA scale. The woman is one day postpartum. The nurse notes that the woman has serous discharge. Which score would the nurse assign this finding?

1

REEDA (perineum assessment)

1. Redness—area may also feel warm to touch. 2. Edema—may indicate infection or a hematoma. 3. Ecchymosis—may indicate vaginal trauma. 4. Discharge—should follow the expected lochia pattern. 5. Approximation of skin edges—should be well aligned without gaps.

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?

Assess the woman's fundus.

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 rubra.

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.

A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the full course of antibiotic prescribed, even if you begins to feel better.

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?

Infection

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate?

Instruct the client to empty her bladder before the examination.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate.

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?

Staphylococcus aureus

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

Uterine atony

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

a client who had a nonelective cesarean birth

Postpartum hemorrhage (PPH)

a potentially life-threatening complication that can occur after both vaginal and cesarean births

A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby." The clinic nurse interprets these findings as suggesting postpartum a. psychosis. b. anxiety disorder. c. depression. d. blues.

a. psychosis

metritis

an infectious condition that involves the endometrium, decidua, and adjacent myometrium of the uterus

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice

Which of the following factors in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection? a. Hemoglobin of 12 mg/dL b. Manually extracted placenta c. Labor of 10 hours length d. Multiparity of 5 pregnancies

b. Manually extracted placenta

Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. Stop breast-feeding and apply lanolin. b. Administer analgesics and bind both breasts. c. Apply warm or cold compresses and administer analgesics. d. Remove the nursing bra and expose the breast to fresh air.

c. Apply warm or cold compresses and administer analgesics

uterine atony

failure of the uterus to contract and retract after birth

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?

family and social support system

postpartum depression (PPD)

form of clinical depression that can affect women, and less frequently men, after childbirth

subinvolution

incomplete involution of the uterus or failure to return to its normal size and condition after birth

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly

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."

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/96 mmHg

d. Blood pressure of 158/96 mmHg

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?

Blood pressure, pulse, reports of dizziness

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. Assessing vital signs immediately b. Measuring her next urinary output c. Massaging her fundus d. Notifying the woman's obstetrician

c. Massaging her fundus

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?

Bladder distention

A woman is experiencing a postpartum hemorrhage due to uterine atony. Which risk factor would the nurse recognize as contributory to this specific problem?

multiparity

venous thromboembolism

one of the leading causes of maternal mortality and morbidity with an annual incidence of one per 1,000 pregnancies, a ten times higher risk than the nonpregnant population

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 frequently assessing uterine involution

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?

"You need to avoid medications which contain acetylsalicylic acid."

the causes of postpartum hemorrhage (4 Ts)

1. Tone: uterine atony, distended bladder 2. Tissue: retained placenta and clots; uterine subinvolution 3. Trauma: lacerations, hematoma, inversion, rupture 4. Thrombin: coagulopathy (preexisting or acquired)

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?

Impaired urinary elimination

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 psychosis

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

Symptoms include fever, chills, malaise, and localized breast tenderness.

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?

The client has a history of epidural anesthesia.

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. Call the client's health care provider immediately. b. Immediately set up an intravenous infusion of magnesium sulfate. c. Assess the fundus and ask her about her voiding status. d. Reassure the mother that this is a normal finding after childbirth.

c. Assess the fundus and ask her about her voiding status

Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication? a. Moderate lochia rubra for the first 24 hours b. Clear lung sounds upon auscultation c. Temperature of 100 degrees F d. Chest pain experienced when ambulating

d. Chest pain experienced when ambulating

When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. Deep venous thrombosis b. Postpartum psychosis c. Uterine infection d. Postpartum hemorrhage

d. Postpartum hemorrhage

mastitis

inflammation of the mammary gland

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:

postpartum depression.

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.

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 should brush my teeth vigorously to stimulate the gums."

A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg.