Ch 22; maternity & peds

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."

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breastfeeding.

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.

The nurse reviews the history of a postpartum woman, G3, P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?

deep venous thrombosis

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 psychosis

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth

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?"

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus.

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.

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

Assess for pedal edema. (Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.)

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?

Assess for warmth, erythema, and pedal edema.

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 (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 is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra.

A woman who has just given birth to her infant tells the nurse that she is putting the baby up for adoption. The nurse must serve as an advocate for this mother. What would the nurse do to assist the client in placing the child for adoption?

Keep the client informed of her rights and options and support her decision.

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.

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 bladder is distended.

Which situation should concern the nurse treating a postpartum client within a few days of birth?

The client feels empty since she gave birth to the neonate.1

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

Uterine atony

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

a client who had a nonelective cesarean birth

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply.

inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. (Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.)

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

massaging the fundus firmly

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

uterine atony

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings.