OB: Chapter 15 Postpartum Adaptations
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
A nurse is providing care to a postpartum client. Which client behavior would indicate to the nurse that she is in the letting-go phase?
shows increased confidence when caring for the newborn During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Independence with self-care is an important aspect of the taking-hold phase.
During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this?
urinary elimination In the early postpartum period, the woman eliminates the additional fluid volume that is present during the pregnancy via the skin and urinary tract and through blood loss.
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?
Perform urinary catheterization. Displacement of the uterus from the midline to the right and frequent voiding of small amounts suggests urinary retention with overflow. Catheterization may be necessary to empty the bladder to restore tone. An IV and oxytocin are indicated if the client experiences hemorrhage due to uterine atony from being displaced. The healthcare provider would be notified if no other interventions help the client.
A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?
"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." The nurse should explain to the client that lochia rubra is a deep red mixture of mucus, tissue debris, and blood. Discharge consisting of leukocytes, decidual tissue, RBCs, and serous fluid is called lochia serosa. Discharge consisting of only RBCs and leukocytes is blood. Discharge consisting of leukocytes and decidual tissue is called lochia alba.
The nurse is monitoring a postpartum client who says she's concerned because she feels mildly depressed. The nurse recognizes that she is most likely experiencing "postpartum blues," and reassures the client that this symptom is experienced by approximately what percentage of women?
85% Postpartum blues, or mild depression during the first 10 days after giving birth, affects up to 85% of women who give birth. More intense depression during this period is referred to as postpartum depression, which affects approximately 10% to 15% of postpartum clients. Postpartum depression can be severe with negative implications for maternal and neonatal well-being.
A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which condition?
postpartum depression The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorders involve shortness of breath, chest pain, and tightness.
Which factor might result in a decreased supply of breast milk in a postpartum client?
supplemental feedings with formula Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production.
The nurse is assigned to a client on postpartum day 1. Prior to assessing her uterus, where should the nurse anticipate she will locate the fundus?
1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.
A nurse is caring for a postpartum client who has a temperature. Which temperature protocols would the nurse use to indicate a possible infection?
100.5º F (38.1º C) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4º F (38º C) on 2 postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority?
Have the client void, and then massage the fundus until it is firm. The fundus in a postpartum client should decrease 1 cm below the umbilicus each day. The fundus should also be firm to decrease the risk of postpartum hemorrhage. All of the listed interventions are appropriate, but a firm fundus is the priority.
After teaching a group of pregnant women about the skin changes that will occur after the birth of their newborn, the nurse understands there is a need for additional teaching when one of the women makes which statement?
"I can't wait for these stretch marks to disappear after I give birth." Stretch marks gradually fade to silvery lines but do not disappear completely. As estrogen and progesterone levels decrease, the darkened pigmentation on the abdomen, face, and nipples gradually fades.
A breastfeeding client informs the nurse that she is unable to maintain her milk supply. What instruction should the nurse give to the client to improve milk supply?
Empty the breasts frequently. The nurse should tell the client to frequently empty the breasts to improve milk supply. Encouraging cold baths and applying ice on the breasts are recommended to relieve engorgement in nonbreastfeeding clients. Kegel exercises are encouraged to promote pelvic floor tone.
A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone?
Kegel exercises The nurse should recommend that the client practice Kegel exercises to improve pelvic floor tone, strengthen the perineal muscles, and promote healing. Sitz baths are useful in promoting local comfort in a client who had an episiotomy during the birth. Abdominal crunches would not be advised during the initial postpartum period and would not help tone the pelvic floor as much as Kegal exercises.
Healthy bonding behaviors are important to note when the nurse is assessing the new family. What would the nurse consider a warning sign that the mother and infant were not attaching as they should?
Mother states she wanted a boy this time, not another girl. It is important to differentiate between a new parent who is nervous and anxious about her new role and one who is rejecting her parenting role. Warning signals of poor attachment include turning away from the newborn, refusing or neglecting to provide care, and disengagement from the newborn.
While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase?
Showing increased confidence when caring for the newborn Independence with self-care is an important aspect of the taking-hold phase. During the letting-go phase, the woman assumes responsibility and care for the newborn with increased confidence. Recounting her labor experience is usually part of the taking-in phase. Identifying specific features of the newborn is typical of the taking-in phase. Feelings of grief, guilt, and anxiety are part of the letting-go phase where the mother accepts the infant as it is and lets go of any fantasies.
A nurse is caring for the client who gave birth a week ago. The client informs the nurse that she experiences painful uterine contractions when breastfeeding the baby. Which should the nurse do next?
Tell the client to take an NSAID orally. The nurse should explain to the client that the afterpains are due to oxytocin released by the sucking reflex, which strengthens uterine contractions. An NSAID such as ibuprofen will decrease the discomfort from the afterpains. The client should not discontinue breastfeeding as this could decrease her milk supply. A warm shower may help relax the client; however, the NSAID would be more appropriate at this time.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?
uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
A client gave birth vaginally 2 days prior and wishes to prevent getting pregnant again. She asks the nurse when she will need to begin birth control measures. How should the nurse respond?
"Ovulation may return as soon as 3 weeks after birth." Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy. Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than six months after birth.
The nurse, assessing the lochia of a client, attempts to separate a clot and identifies the presence of tissue. Which observation would indicate the presence of tissue?
difficult to separate clots If tissue is identified in the lochia, it is difficult to separate clots. Yellowish-white lochia indicates increased leukocytes and decreased fluid content. Easily separable lochia indicates the presence of clots only. Foul-smelling lochia indicates endometritis.
A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?
"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." Postpartum diuresis is due to the buildup and retention of extra fluids during pregnancy. Bruising and swelling of the perineum, swelling of tissues surrounding the urinary meatus, and decreased bladder tone due to anesthesia cause urinary retention.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in postpartum week does not cause major weight loss.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
When assessing the uterus of a 2-day postpartum client, which finding would the nurse evaluate as normal?
a moderate amount of lochia rubra The client should have lochia rubra for 3 to 4 days postpartum. The client would then progress to lochia serosa being expelled from day 3 to 10. Last the client would have lochia alba from day 10 to 14 until 3 to 6 weeks.
Bonding between a mother and her infant can be defined how?
a process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a year-long process, and the family growing closer together after the birth of a new baby is not bonding.
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have:
acutely decreased. Despite the decrease in blood volume, the hematocrit remains relatively stable and may even increase, reflecting the predominant loss of plasma. An acute decrease in hematocrit is not an expected finding and may indicate hemorrhage.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts?
applying ice 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 client has just given birth to her second child and will breastfeed. Although she wants "lots of kids," she does not want to become pregnant again until her second child is at least 2 years old. The nurse would counsel her to start using birth control at what point?
as soon as she resumes sexual activity She can ovulate even though she is not having a normal menstrual cycle. She needs to take precautions. Beginning to use birth control within 6 weeks, or within 18 months, or as soon as she stops breastfeeding is not affording her protection from getting pregnant. She should use mechanical means of birth control as soon as she resumes sexual activity.
On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?
bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A woman has just given birth to a baby. Her prelabor vital signs were temperature: 98.8° F (37.1° C); blood pressure: 120/70 mm Hg; pulse; 80 beats/min. and respirations: 20 breaths/min. Which combination of findings during the early postpartum period are the most concerning?
blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min. The decrease in BP with an increase in HR and RR indicate a potential significant complication and are out of the range of normals from birth and need to be reported immediately. Shaking chills with a temperature of 100.3º F (37.9º C) can occur due to stress on the body and is considered a normal finding. A fever of 100.4º F (38º C) should be reported. The other options are considered to be within normal limits after giving birth to a baby.
A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.
breastfeeding early ambulation Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
When caring for postpartum clients, the nurse would expect the birth attendant to prescribe what laboratory study the morning after the birth of the baby?
hemoglobin and hematocrit H&H Monitor the H&H and note the H&H before birth. Most practitioners prescribe a postpartum H&H on the morning after birth. If the values drop significantly, the woman may have experienced postpartum hemorrhage. Note the blood type and Rh. If the woman is Rh-, she will need a Rho(D) immune globulin workup. Determine the woman's rubella status. If she is nonimmune, she will need a rubella immunization before she is discharged home.
Which lochia pattern should be reported immediately?
moderate lochia serosa on day 4 postpartum, increasing in volume and changing to rubra on day 5 Lochia by day 4 should be decreasing in amount, and the color should be changing to pink tinge. Red rubra on day 4 may indicate bleeding, and the healthcare provider should be notified. A moderate flow of lochia rubra on day 3 postpartum, changing to serosa on day 5, is a normal finding; as is lochia progressing from rubra to serosa to alba within 10 days of delivery; and so is moderate lochia rubra on day 3, mixed serosa and rubra on day 4, and light serosa on day 5.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience?
postpartum baby blues Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.
The nurse is caring for a client of Asian descent 1 day after she has given birth. Which foods will the client most likely refuse to eat when her meal tray is delivered? Select all that apply.
raw carrots and celery ice cream orange slices Many people of Latin American, African, and Asian descent believe that good health involves a balance of heat and cold. The blood loss during birth is considered loss of warmth, leaving the woman in a cold state. Therefore, cold foods are avoided during this time. Hot soup and mashed potatoes with gravy would provide the warm foods that are desired.
A nurse is providing care to a postpartum woman during the immediate postpartum period. The nurse recognizes that the mother will need assistance with meeting her basic needs based on the understanding that the mother is most likely in which phase?
taking-in phase During the first 24 to 48 hours after giving birth, mothers often assume a very passive and dependent role in meeting their own basic needs, and allow others to take care of them. This is referred to as the taking-in phase. The taking-hold phase occurs when the client begins to assume control over her bodily functions. She is also showing strong interest in caring for the infant by herself. The letting-go phase occurs when the woman has assumed the responsibility for caring for herself and her infant.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is:
taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
Which instruction should the nurse provide to a breastfeeding woman experiencing breast engorgement?
"Take a warm shower just before feeding your infant." Standing in a warm shower or applying warm compresses immediately before feedings will help soften the breasts and nipples to allow the newborn to latch on more easily and will enhance the let-down reflex. Wearing a tight supportive bra all day is appropriate for the woman who is not breastfeeding. Frequent emptying of the breasts helps to resolve engorgement, so the mother should be encouraged to feed the newborn, which would involve touching her breasts and nipples. The breastfeeding woman should apply cold compresses but not ice to her breasts between feedings to reduce swelling.
A client who recently gave birth to her third child expresses a desire to have her older two come to the hospital for a visit. What should the nurse say in response to this request?
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?
vessel damage during birth A woman's risk for thromboembolism increases due to her hypercoagulable state, vessel damage during birth, and immobility. The increase in white blood cell count is unrelated to her risk for thromboembolism. Coagulation factors remain elevated for 2 to 3 weeks postpartum. An episiotomy is not a risk factor for thromboembolism.
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.
A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?
"Be sure to change your pajamas to prevent you from chilling." The nurse should encourage the client to change her pajamas to prevent chilling and reassure the client that it is normal to have postpartal diaphoresis. Drinking cold fluids at night will not prevent postpartum diaphoresis.
When assessing a new father's adaptation to his new role, which statement would indicate that he is in the reality stage?
"I didn't realize all that went into being a dad. I wasn't prepared for this." The statement about not feeling prepared reflects the realization that the man's expectations were not realistic. Many wish to be more involved but do not feel prepared to do so, and this is characteristic of the second stage, reality. The statement that it will be fun to have a baby around but life will not change too much indicates a preconceived idea about what home life will be like with a newborn; this is characteristic of the first stage, expectations. The statement about things not changing reflects the first stage of expectations, where the partner is unaware of the changes that may occur after the birth of the newborn. The statement about learning new skills and enjoying being involved indicate a conscious decision to be at the center of the newborn's life; this is characteristic of the third stage, transition to mastery.
After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment?
"I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months. Breastfeeding is not a totally reliable method of contraception unless the mother exclusively breastfeeds, has had no menstrual period since giving birth, and whose infant is younger than 6 months old; however, ovulation may occur before menstruation.
A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase?
"It sounded like you had quite a time getting here. Would you like to continue your story?" The mother is going through the taking-in phase of relating events during her pregnancy and birth. The nurse can facilitate this phase by allowing the mother to express herself. Diverting the conversation, admonishing the mother, or warning of potential problems does not accomplish this facilitation.
A nurse is making an initial call on a new mother who gave birth to her third baby five days ago. The woman says,"I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother?
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate?
"You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?
6 to 8 weeks after pregnancy During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.
For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation?
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have. The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time.
A client reports she has not had a bowel moment since her infant was born 2 days ago. She asks the nurse what she can do to help her have a bowel movement. What intervention is appropriate to encourage having a bowel movement?
Encourage the client to eat more fiber rich foods. Encouraging fiber rich foods will help with prevention of constipation. The client needs plenty of water, to ambulate, and take stool softeners if ordered by the provider. Offering a stimulant laxative is not appropriate. Adding dairy products to the diet may be a good thing, but will not generally produce a bowel movement. Holding the feces until there is a strong urge to defecate will only increase the risk of constipation as well as possible resultant complications.
Which nursing diagnosis has the highest priority for a postpartum client?
Risk for injury: postpartum hemorrhage related to uterine atony The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.
Which maternal reaction is the most concerning?
She neglects to engage with or provide care for the baby and shows little interest in it. A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with "postpartum blues".
Which client would the nurse be most concerned about on postpartum day 1?
Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth. The elevated BP is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. This makes the other options incorrect.
While educating a class of postpartum clients before discharge home after birth, one woman asks when "will I stop bleeding?" How should the nurse respond?
The bleeding may slowly decrease over the next 1 to 3 weeks, changing color to a white discharge, which may continue for up to 6 weeks. The lochia changes color in the first few weeks postpartum; the active bleeding stops in the first week, but a white discharge may continue for up to 6 weeks after birth. Bleeding does not occur "off and on"; the bleeding stops during the first week but a discharge continues to occur. The discharge may continue for up to six weeks, not just bleeding.
The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply
incomplete emptying of bladder bladder distention urinary retention Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy.
When planning the care for a client during the first 24 hours postpartum, the nurse expects to monitor the client's pulse and blood pressure frequently based on the understanding that the client is at risk for which condition?
hemorrhage The nurse should monitor the pulse and blood pressure frequently in the first 24 hours postpartum because the client is at greatest risk of hemorrhage. Hemorrhoids cause discomfort and contribute to constipation; this does not call for monitoring of pulse and blood pressure frequently. Increased coagulability causes increased risk of thromboembolism in the puerperium. Precipitous labor or instrument-assisted births pose an increased risk for cervical laceration. None of these conditions require monitoring of pulse and blood pressure.
Which factors should a nurse identify as some of the common etiologies of physical and psychological changes during the fourth stage of labor and postpartum? Select all that apply.
hormonal changes genetic predisposition sleep loss The nurse should identify hormonal changes, genetic predisposition, and sleep loss as some of the common etiologies of physical and psychological changes during the fourth stage of labor and postpartum. Nausea and psychological imbalance are not etiologies of physical and psychological changes during the fourth stage of labor and postpartum.
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition?
hypovolemia The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?
inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply.
incomplete emptying of bladder bladder distention urinary retention Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy.
When assessing a postpartum woman, which finding would be most significant in identifying possible postpartum hemorrhage?
increased heart rate Tachycardia in the postpartum woman warrants further investigation. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Red blood cell production ceases early in the puerperium, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage.
The process by which the reproductive organs return to the nonpregnant size and function is termed what?
involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia?
lochia rubra Lochia rubra is red; it lasts for the first few days of the postpartal period.
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains?
oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.
The nurse is used to working on the postpartum floor taking care of women who have had normal vaginal births. Today, however, the nurse has been assigned to help care for women who are less than 24 hours post cesarean birth. The nurse realizes that some areas will not be assessed. What would the nurse leave out of the client assessments?
perineum Usually a woman who experiences cesarean birth does not have an episiotomy, although rarely this may be the case.
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breast-feeding, the nurse would identify which hormone that is responsible for milk production?
prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.
The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest?
promoting skin-to-skin contact on the chest Nurses play a crucial role in assisting the attachment process by promoting early parent-newborn interactions. In addition, nurses can facilitate skin-to-skin contact (kangaroo care) by placing the infant onto the bare chests of mothers and fathers to enhance parent-newborn attachment. This activity will enable them to get close to their newborn and experience an intense feeling of connectedness and evoke feelings of being nurturing parents. Encouraging breast-feeding is another way to foster attachment between mothers and their newborns. Finally, nurses can encourage nurturing activities and contact such as touching, talking, singing, comforting, changing diapers, feeding—in short, participating in routine newborn care.
What is the primary function of uterine contractions after birth of the infant and placenta?
seals off the blood vessels at the site of the placenta The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, the other options are secondary to the constriction of blood vessels at the placental site.
A nurse is caring for a client in the postpartum period. The nurse observes that distention of the abdominal muscles during pregnancy has resulted in separation of the rectus muscles. What intervention should the nurse perform to assist in healing the distended abdominal muscles?
suggesting proper exercise The nurse should suggest proper exercise to the client to heal the distended abdominal muscles. Application of warm compresses, application of moist heat, and massaging the muscles gently are not suggested for distended abdominal muscles
While caring for a client following a lengthy labor and birth, the nurse notes that the client repeatedly reviews her labor and birth and is very dependent on her family for care. The nurse is correct in identifying the client to be in which phase of maternal role adjustment?
taking-in The taking-in phase occurs during the first 24 to 48 hours following the birth of the newborn and is characterized by the mother taking on a very passive role in caring for herself, as well as recounting her labor experience. The second maternal adjustment phase is the taking-hold phase and usually lasts several weeks after the birth. This phase is characterized by both dependent and independent behavior, with increasing autonomy. During the letting-go phase the mother reestablishes relationships with others and accepts her new role as a parent. Acquaintance/attachment phase is a newer term that refers to the first 2 to 6 weeks following birth when the mother is learning to care for her baby and is physically recuperating from the pregnancy and birth.
A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the puerperium is this client in?
taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the puerperium.
During the second day postpartum, a nurse notices that a client is initiating breastfeeding with her infant and changing her infant's diapers with some assistance from her partner. Which phase does the nurse recognize that the woman is experiencing?
the taking-hold phase The taking-in phase is characterized by the woman's dependency on and passivity with others. Maternal needs are dominant, and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is characterized by the woman becoming more independent and interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together. The binding-in phase is a distractor for this question.
A nurse provides care to pregnant women and their families from a wide range of cultural backgrounds and considers their culture and traditions when providing care. As the nurse communicates with the families, the nurse integrates understanding of communication as being more than just speaking and listening. Which aspect must the nurse also consider?
touching Nurses caring for families should consider all aspects of culture, including communication. Communication is more than just an understanding of the person's language but also the meaning of touch and gestures. Nurses must be sensitive to how people respond when being touched and should refrain from it if the client's response indicates that it is unwelcomed.
During an assessment, the nurse notes that the client has been unable to urinate properly since she gave birth and is still bleeding more than expected. The nurse suspects which condition?
uterine atony Urinary retention is a major cause of uterine atony, which allows excessive bleeding. Urinary retention and bladder distention can cause displacement of the uterus from the midline to the right and can inhibit the uterus from contracting properly, which increases the risk of postpartum hemorrhage. The client will have increased diaphoresis as the body works to decrease the blood volume that was necessary during the pregnancy.