OB Chapter 25
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? Wear knee-high stockings when possible. Avoid iron replacement therapy. Shortness of breath is a common adverse effect of the medication. Avoid over-the-counter (OTC) salicylates.
Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.
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. Perform the examination as quickly as possible. Place the client in a supine position with her arms overhead for the examination of her breasts and fundus. Wear sterile gloves when assessing the pad and perineum.
Instruct the client to empty her bladder before the examination. An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.
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 can continue breastfeeding my infant, but it may be somewhat uncomfortable." "I am able to pump my breast milk for my baby and throw away the milk." "I will stop breastfeeding until I finish my antibiotics." "When breastfeeding, it is recommended to begin nursing on the infected breast first."
"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." 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.
The nurse receives a report on a client who delivered a healthy neonate 1 hour ago. What data should she monitor during the immediate postpartum period (first 2 hours) of this client? blood glucose level height of fundus stool test for occult blood electrocardiogram (ECG)
height of fundus A complete physical examination should be performed every 15 minutes for the first 1 to 2 hours postpartum, including determination of the fundus, lochia, perineum, blood pressure, pulse, and bladder function. A blood glucose level must be obtained only if the client has risk factors for an unstable blood glucose level or if she has symptoms of an altered blood glucose level. An ECG would be necessary only if the client is at risk for cardiac difficulty. A stool test for occult blood generally wouldn't be valid during the immediate postpartum period because it's difficult to sort out lochial bleeding from rectal bleeding.
On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition? sadness feelings of anxiety delusional beliefs insomnia
delusional beliefs Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.
A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client? Change her perineal pads frequently. Keep the environment quiet to encourage rest. Take analgesics for uterine pain. Encourage an oral intake of 2 to 3 liters per day.
Encourage an oral intake of 2 to 3 liters per day. Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 ml/hr. The other three actions are important but not the highest priority for this client.
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?" "What time did you last change your pad?" "When did you last void?" "Are you in any pain with your bleeding?"
"How much blood was on the two pads?" 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.
Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? "I will make handprints and footprints of the baby for you to keep." "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" "Have you named your baby yet? I would like to know your baby's name." "I know you are hurting, but you can have another baby in the future."
"I know you are hurting, but you can have another baby in the future." Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 1000 mL 300 mL 750 mL 500 mL
500 mL Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 mL after a vaginal birth and greater than 1,000 mL after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.
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? Escherichia coli Streptococcus pyogenes (group A strep) Staphylococcus aureus group B streptococcus (GBS)
Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.
Which measurement best describes delayed postpartum hemorrhage? blood loss in excess of 3000 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth blood loss in excess of 1,000 ml, occurring within 24 hours after birth blood loss in excess of 300 ml, occurring within the first 24 hours after birth
blood loss in excess of 500 ml, occurring at least 24 hours and up to 12 weeks after birth Late postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum, but can occur any time between 24 hours and 12 weeks after birth The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.
A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? applying pressure to the umbilical cord to remove the placenta manually removing the placenta at birth administering broad-spectrum antibiotics inspecting the placenta after delivery for intactness
inspecting the placenta after delivery for intactness After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
A postpartum woman is being discharged with anticoagulant therapy for treatment of deep vein thrombosis. After teaching the woman about this therapy, the nurse determines that the teaching was successful based on which statement? "I should avoid taking acetaminophen if I have a headache." "I need to apply pressure to any cut for 5 to 10 minutes." "The medicine will make my stools turn black." "It's okay for me to use a regular razor to shave my legs."
"I need to apply pressure to any cut for 5 to 10 minutes." Anticoagulant therapy increases the woman's risk for bleeding. The statement about applying pressure to a cut would be correct. The woman should use an electric razor for shaving and avoid aspirin-containing products while on anticoagulant therapy. Black stools are not expected but indicate bleeding and should be reported.
A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately? dyspnea, bradycardia, hypertension, and confusion weakness, anorexia, change in level of consciousness, and coma dyspnea, diaphoresis, hypotension, and chest pain pallor, tachycardia, seizures, and jaundice
dyspnea, diaphoresis, hypotension, and chest pain Sudden unexplained shortness of breath and reports of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.
A nurse is making a home visit to a postpartum client. Which finding would lead the nurse to suspect that a woman is experiencing postpartum psychosis? insomnia delirium feelings of guilt sadness
delirium Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of guilt, sadness, and insomnia are associated with postpartum depression.
A new mother is diagnosed with a venous thromboembolism in her left calf. Which risk factor is associated with this problem? Select all that apply. precipitous birth maternal age greater than 30 obesity cesarean birth hypotension
obesity cesarean birth If a new mother experiences a postpartum venous thromboembolism, she may have medical as well as obstetrical risk factors. These factors include a maternal age greater than 35 years, obesity, cesarean birth, and a prolonged labor. Hypertension, not hypotension, is a risk factor.
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? "I'll contact your health care provider." "If you don't attempt to void, I'll need to catheterize you." "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."
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.
After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? "Postpartum depression develops gradually, appearing within the first 6 weeks." "Postpartum blues usually resolves by the 4th or 5th postpartum day." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization." "Postpartum psychosis usually appears soon after the woman comes home."
"Postpartum depression develops gradually, appearing within the first 6 weeks." Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.
The nurse is providing education to a postpartum woman who has developed a uterine infection. Which statement by the woman indicates that further instruction is needed? "I will change my perineal pad regularly to remove the infected drainage." "When I am sleeping or lying in bed, I should lie flat on my back." "If my abdomen becomes firm, or if I don't urinate as much, I need to call the doctor." "I will take frequent walks around my home to promote drainage."
"When I am sleeping or lying in bed, I should lie flat on my back." With a uterine infection, the client needs to be in a semi-Fowler position to facilitate drainage and prevent the infection from spreading. Changing the perineal pads regularly; walking to promote drainage; and contacting the doctor if her uterus becomes rigid (or if she notes a decrease in urinary output) are all correct actions.
The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next? Use semi-Fowler position to encourage uterine drainage. Perform vigorous fundal massage for the client. Check for bladder distention, while encouraging the client to void. Offer analgesics prescribed by health care provider.
Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Apply ice to the perineum to decrease pain of a perineal infection. Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Drink plenty of fluids to decrease a bladder infection. Finish all antibiotics to decrease a genital tract infection.
Finish all antibiotics to decrease a genital tract infection. A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid massaging the breast area. Avoid frequent breastfeeding. Perform handwashing before breastfeeding. Apply cold compresses to the breast.
Perform handwashing before breastfeeding. 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.
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? Decreased respiratory rate Warm and flushed skin Elevated blood pressure Weak and rapid pulse
Weak and rapid pulse 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.
A client is 10 days postpartum. Which of the following would the nurse expect to assess if the client develops a genital tract infection? lochia rubra and excessive clots hypovolemic shock cyanosis and oliguria hypotension and chills
hypotension and chills Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis, and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and limit the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.
A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? calf pain with dorsiflexion of the foot leg pain on ambulation with mild ankle edema perineal pain with swelling along the episiotomy sharp, stabbing chest pain with shortness of breath
sharp, stabbing chest pain with shortness of breath Sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary embolism is the most urgent.
On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which findings would be consistent with a diagnosis of endometritis? Select all that apply. swollen, warm breast tender uterus fluctuant, perineal mass strong afterpains foul-smelling lochia
tender uterus strong afterpains foul-smelling lochia Endometritis is an infection of the uterine lining. Assessment findings include a tender uterus, foul-smelling lochia, and strong afterbirth pains. A fluctuant perineal mass would be consistent with a hematoma. A swollen, warm breast at day 4 would be consistent with breast engorgement.
A health care provider is discussing the results of a recent sonogram with the client. A new diagnosis of uterine displacement is made. Which statement indicates a need for further teaching? "Kegel exercises may help strengthen my perineal muscles and decrease stress incontinence." "To eliminate the source of the problem, my uterus will have to be removed." "My bladder can enter into my vagina if the muscles of the vagina are weak." "You thought that I had a problem when doing my pelvic examination."
"To eliminate the source of the problem, my uterus will have to be removed." When caring for a client experiencing a uterine displacement, the nurse should assess for urinary incontinence, dysmenorrhea, low back pain, infertility, recurrent vaginal infections, dyspareunia, varicose veins, and aching legs. When the client states that surgery is required to remove the uterus, this is not accurate. Only if there is extensive weakening with a cystocele (bladder) or rectocele would surgical intervention be needed. Removing the uterus is not the first option for treatment. Kegel exercises are often encouraged. A pelvic examination can identify uterine displacement.
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." "You can breastfeed your newborn while taking any anticoagulation medication." "It is appropriate for you to sit with your legs crossed over each other." "It is expected for you to have minimal blood in your urine during therapy."
"You need to avoid medications which contain acetylsalicylic acid." The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy.
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother? Roll a bath blanket or towel and place it firmly behind the knees. Assist client in performing leg exercises every 2 hours. Limit oral intake of fluids for the first 24 hours to prevent nausea. Ambulate the client as soon as her vital signs are stable.
Ambulate the client as soon as her vital signs are stable. The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of the perineal pad Assessment of the lung fields Assessment of laboratory data Assessment of bowel function
Assessment of the perineal pad 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.
It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client maintains a urinary output greater than 30 ml per hour. Fundus remains firm and midline with progressive descent. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour. Client's temperature remains below 100.4°F (38.8°C) orally.
Client's temperature remains below 100.4°F (38.8°C) orally. As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature.
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? Gardnerella vaginalis Escherichia coli Staphylococcus aureus Klebsiella pneumoniae
Escherichia coli 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 recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? Suggest that she take an oral analgesic. Obtain a clean-catch urine specimen. Encourage her to drink large amounts of fluid. Administer amoxicillin, as prescribed.
Obtain a clean-catch urine specimen. The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.
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? Frequent feeding Use of breast pumps Pierced nipple Complete emptying of the breast
Pierced nipple Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.
A 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 Risk for infection related to microorganism invasion of episiotomy Risk for fatigue related to chronic bleeding due to subinvolution Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis
Risk for fatigue related to chronic bleeding due to subinvolution 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.
Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? She should stop breastfeeding until completing the antibiotic. She should continue to breastfeed; mastitis will not infect the neonate. She should not use analgesics because they are not compatible with breastfeeding. She should supplement feeding with formula until the infection resolves.
She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? Teach that adequate hydration helps clear the infection quicker. Instruct to use a sitz bath while voiding. Ask primary care provider to prescribe an analgesic. Advise her to take acetaminophen to ease symptoms.
Teach that adequate hydration helps clear the infection quicker. Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 ml of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth. The other choices are also options but address the symptoms and not the root cause. The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection.
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. There is an infection inside the uterus. The uterine placement is normal. The bladder is distended.
The bladder is distended. If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.
A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug? mild fever cardiovascular disease low blood pressure respiratory problems
cardiovascular disease Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident (stroke) in women at risk with preexisting conditions. Low blood pressure, respiratory problems, or mild fever are not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage.
A client who had a cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client complains of discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be: having the client stand facing the water in a warm shower. using a breast pump to facilitate removal of stagnant breast milk. informing the physician that the client is showing early signs of breast infection. encouraging the client to wear a supportive bra.
encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs about three days after birth. The client's vital signs are stable and don't indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.
An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection? length of labor maternal Rh status size of the neonate method of birth
length of labor The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk.
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum blues postpartum psychosis postpartum depression postpartum panic disorder
postpartum psychosis The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.
The client reports to the health care providers office stating that her lochia has changed from lochia alba to lochia rubra. Which does the nurse suspect? uterine atony uterine inversion retained placental fragments cervical or vaginal lacerations
retained placental fragments The nurse suspects a late postpartum hemorrhage since the lochia has progressed to lochia alba and then it returned to lochia rubria. Late postpartum hemorrhage is typically due to subinvolution secondary to retained placental fragments, distended bladder, uterine fibroid (uterine myoma), and infection. Uterine atony, lacerations, and uterine inversion would most likely lead to early postpartum hemorrhage.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 1000 mL 750 mL 300 mL 500 mL
1000 ml Postpartum hemorrhage (PPH) is defined as a cumulative blood loss greater than 1,000 ml with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery. Morbidity from PPH can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization. Hemorrhage is the most common reason postpartum women are admitted to intensive care units and it is the most preventable cause of maternal death.
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. A breast abscess is a common complication of mastitis. The most common pathogen is group A streptococcus (GAS). Mastitis usually develops in both breasts of a breastfeeding client.
Symptoms include fever, chills, malaise, and localized breast tenderness. Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? hardening of an area in the affected breast no breast milk in the affected breast an ecchymotic area on the affected breast an inverted nipple on the affected breast
hardening of an area in the affected breast Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness.
Which assessment finding would be suggestive of adequate tissue perfusion in a client who has experienced a postpartum hemorrhage? oxygen saturation of 94% urinary output of 60 cc's over the last hour capillary refill of 4 seconds cool, clammy skin
urinary output of 60 cc's over the last hour A client who is well perfused will have a urinary output of at least 30 ml/hr. If a client is not well perfused and experiencing a fluid deficit, the skin will be cool and clammy, not warm and dry. The capillary refill of a well-perfused client is 3 seconds or less and the oxygen saturation should be at least 95%.
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 Height, level of orientation, support systems Degree of responsiveness, respiratory rate, fundus location Attachment, lochia color, complete blood cell count
Blood pressure, pulse, reports of dizziness 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.
The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client? administrating a selective serotonin reuptake inhibitor telling the client that she has no need to be depressed talking to the client and reassuring her that she will feel better soon scheduling electroconvulsive therapy
administrating a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.
On completing fundal palpation, the nurse notes that the fundus is situated in the client's left abdomen. Which action is appropriate? Call the client's primary health care provider for direction. Straight-catheterize the client for half of her urine volume. Straight-catheterize the client immediately. Ask the client to empty her bladder.
Ask the client to empty her bladder. A full bladder may displace the uterine fundus to the left or right side of the abdomen. A straight catheterization is unnecessarily invasive if the client can urinate on her own. Nursing interventions should be completed before notifying the primary health care provider in a nonemergency situation.
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? Ask the client to raise the foot and draw a circle. Assess for warmth, erythema, and pedal edema. Blanch a toe, and count the seconds it takes to color again. Bend the knee and palpate the calf for pain.
Assess for warmth, erythema, and pedal edema. This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).
The nurse would be alert for which of the following complications when caring for a 38-year-old postpartum client with a history of obesity and diabetes? thromboembolic complications septic pelvic thrombophlebitis postpartum infections uterine prolapse
thromboembolic complications The nurse should monitor the client for thromboembolic complications. The risk for thromboembolic complications increase when the client is older than 35, is obese, and has a history of diabetes or a pre-existing cardiovascular disease. Uterine prolapse occurs more commonly in perimenopausal clients. A client diagnosed with a puerperal infection is at increased risk for septic pelvic thrombophlebitis. Endometritis is the primary cause of postpartum infections.
Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition? uterine subinvolution hypertension retained placental fragments thrombophlebitis
thrombophlebitis The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine atony uterine contraction uterine prolapse uterine subinvolution
uterine atony 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.
The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage? A cervical laceration Disseminated intravascular coagulation Retained placental fragments Uterine atony
A cervical laceration Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance. Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, but there is no evidence for this in the scenario.
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 101.8°F (38.8°C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client? Complete the full course of antibiotic prescribed, even if you begin to feel better. Use NSAIDs, warm showers, and warm compresses to relieve discomfort. Breastfeed or otherwise empty your breasts at least every 3 hours. Increase your fluid intake to ensure that you will continue to produce adequate milk.
Complete the full course of antibiotic prescribed, even if you begin to feel better. Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis, and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and limit the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.
Which postpartum clients would require the nurse to intervene? Select all that apply. Postpartum client requesting newborn stay in nursery so that she can nap. First day postpartum client with blood pressure 84/48, pulse 128, respiratory rate 16. Primipara with vital signs including temperature 100.2°F (37.9°C), blood pressure 140/86, pulse 124, respiratory rate 12. Multipara with vital signs including temperature 99°F (37.2°C), blood pressure 136/84, pulse 96, respiratory rate 32. Primipara with vital signs including temperature 100.2°F (37.9°C), respiratory rate 28, oxygen saturation 94%. Postpartum client with urine output of 30 ml/hour for 2 hours.
First day postpartum client with blood pressure 84/48, pulse 128, respiratory rate 16. Primipara with vital signs including temperature 100.2°F (37.9°C), blood pressure 140/86, pulse 124, respiratory rate 12. Multipara with vital signs including temperature 99°F (37.2°C), blood pressure 136/84, pulse 96, respiratory rate 32. Primipara with vital signs including temperature 100.2°F (37.9°C), respiratory rate 28, oxygen saturation 94%. Postpartum client with urine output of 30 ml/hour for 2 hours. Maternal Early Warning Signs IMMEDIATE ACTION REQUIRED: Systolic BP < 90 or >160 Diastolic BP >100 Heart rate <50 or >120 Respiratory rate <10 or >30 Oxygen saturation <95% Oliguria ml/hr X 2hr <35 Maternal agitation, confusion, unresponsiveness Client with hypertension reporting a non-remitting headache or shortness of breath The first client has an elevated pulse of 124 and needs intervention, heart rate should be > 50 and < 120. A temperature of 100.2°F is an expected finding, due to the inflammatory response after labor. The second client has an elevated respiratory rate of 34, should be >10 or <30, therefore requiring the nurse to intervene. The third client needs intervention as the urine output of 30 ml/hour is too low, should not be below 35 ml/hour. The fourth client requires intervention due to blood pressure 84/48 and pulse 128; systolic blood pressure should be over 90 and heart rate should be under 120. The primipara with an oxygen saturation of 94% is too low and requires nursing intervention. The mother requesting her newborn be kept in the nursery so that she can nap is not demonstrating a concerning situation, unless there are other signs that demonstrate a lack of bonding.
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 Maladjustment Postpartum depression Postpartum psychosis
Postpartum psychosis 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.
A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client? disseminated intravascular coagulation cervical laceration retained placental fragment uterine atony
uterine atony Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.
