CH 19 Postpartum Woman at Risk

The nurse is assisting in developing a care plan for a client who had an episiotomy. Which interventions would be included for the nursing diagnosis: Acute pain related to perineal sutures as manifested by client stating pain of 8 out of 10? Select all that apply.

Administer sitz baths three to four times per day Encourage Kegel exercises with each voiding

Which of the following would lead the nurse to suspect that a postpartum client is experiencing hypovolemic shock?

Cyanosis and oliguria

A woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F (38.3°C). She reports abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?

Endometritis

A client with postpartum hematoma is admitted to a local health care facility. Which of the following would the nurse assess as a characteristic of this condition?

Rectal pressure

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response

Risk factors include nipple piercing.

A woman arrives at the office for her 4-week postpartal 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 fatigue related to chronic bleeding due to subinvolution

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?

delirium

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?

delusional beliefs