Ob prep u Ch. 16

A woman who is breast-feeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breast-feeding and offering suggestions, which statement by the mother indicates the need for additional teaching?

"Some women just can't breast-feed. Maybe I'm one of these women." The statement about some women not being able to breast-feed is incorrect and displays a negative attitude, indicating that the woman is at fault for the current situation. Breast-feeding takes time and practice, and is a learned response. Support and practical suggestions can be helpful. Understanding that some babies need more time helps to reduce any frustration and uncertainty about her ability to breast-feed. A lactation consultant can provide the woman with additional support and teaching to foster empowerment in this situation

Thirty minutes after receiving pain medication, a postpartum woman states that she sill has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the physician immediately.

A patient who delivered twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 to 96/50. Her pulse drops from 80 to 56. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage Some risk factors for developing hemorrhage after delivery include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

Two days after giving birth, a client is to receive RhoGAM. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"RhoGAM suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." RhoGAM is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. RhoGAM is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Seven hours ago, a G5 P4014 woman delivered a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to

Assess and massage the fundus This woman is a multigravida who delivered a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively yearly, it's possible that the client hasn't yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, wouldn't be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse wouldn't want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

A G1 P1001 mother is just home after delivering her first child 5 days ago. Her delivery was complicated by an emergency cesarean delivery resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this patient care issue is

At risk for postpartum depression due to inadequate rest This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.

A client who gave birth by cesarean delivery 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 reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

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 approximately 3 days after birth. 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. (less)

Which of the following is an appropriate nursing intervention for prevention of a urinary tract infection (UTI) in the postpartum woman?

Encouraging the woman to empty her bladder completely every 2 to 4 hours. The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a physician's order and is not necessary as a prevention measure.

You help a postpartum woman out of bed for the first time postpartally and notice that she has a very heavy lochia flow. Which of the following assessment findings would best help you decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which of the following?

atony The uterus in a postpartum patient should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A nurse is instructing a patient who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is best described as which of the following?

creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

Many patients experience a slight fever after delivery especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Many women experience a slight fever (100.4°F [38°C]) during the first 24 hours after delivery. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A patient appears to be resting comfortably 12 hours after delivering her first child. In contrast, she labored for more than 24 hours, the physician had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the patient at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures(eg, forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by

Bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal delivery. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after delivery.

A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after delivery?

Every 15 minutes Postpartum assessment is typically performed every 15 minutes for the first hour. After the second hour, assessment is performed every 30 minutes. The client has to be monitored closely during the first hour after delivery; assessment frequencies of 45 or 60 minutes are too long.

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse does which of the following to prevent prolapse or inversion of the uterus?

Placing a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus.

A patient delivered 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the patient was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the physician and the nurse-midwife to her concern that the patient may be experiencing

Pulmonary embolism These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after childbirth?

Resume intercourse if bright-red bleeding stops The nurse should inform the client that intercourse can be resumed if bright-red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives.

A woman states that she still feels exhausted on her second postpartal day. Your best advice for her would be to do which of the following?

Walk with you the length of her room. Most women report feeling exhausted following childbirth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

A postpartal woman asks you about perineal care. Which of the following recommendations would you give?

Wash her perineum with her daily shower. A suture line should be kept free of lochia to discourage infection. Washing with soap and water at the time of a shower will help to do this.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which of the following?

attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of delivery, because studies show that keeping extra weight longer is a predictor of which of the following?

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

A woman who had a cesarean delivery of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect?

pulmonay emboli One of the postpartum danger signs is calf pain with dorsiflexion of the foot. This would indicate a deep vein thrombosis. With the shortness of breath the patient might have a pulmonary emboli. This scenario would require immediate interventions to prevent the patient's death.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

• Help the mother initiate breastfeeding within 30 minutes of birth. • Encourage breastfeeding of the newborn infant on demand. • Place baby in uninterrupted skin-to-skin contact with the mother.

The nurse who works on a post-partum floor is mentoring a new graduate. She informs the new nurse that a post-partum assessment of the mother includes which of the following? (check all that apply)

• vital signs of mother • pain level • head-to-toe assessment

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth-degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

When doing a health assessment, at which of the following locations would you expect to palpate the fundus in a woman on the second postpartal day and how should it feel?

Fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

A woman yesterday delivered a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at delivery. The nurse's priority is to assist the mother to

Grieve for the loss of the perfect baby Grief is the response to loss. The process of mourning will take precedence over the mother's self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted.

Two days ago, a woman delivered her third infant; she is now preparing for discharge home. After the delivery of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following EXCEPT

Maintain previous household routines to prevent infection The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?

One fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth.

True Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

Venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and wouldn't be the first choice. Transthoracic echocardiography looks at cardiac structures and isn't indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.