Chapter 14: High-Risk Postpartum Nursing Care

A postpartum woman who describes symptoms of hallucinations and suicidal thoughts is most likely experiencing postpartum __________.

ANS: psychosis Postpartum psychosis is a rare but severe form of mental illness that severely affects not only the new mother, but the entire family. Postpartum psychosis may present with symptoms of postpartum depression. However, the distinguishing signs of psychosis are hallucinations, delusions, agitation, confusion, disorientation, sleep disturbances, suicidal and homicidal thoughts, and a loss of touch with reality.

The development of a large hematoma can place the postpartum woman at risk for __________.

ANS: shock Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full." If the hematoma is large, signs of shock may be evident, and the patient may exhibit an absence of lochia and an inability to void.

The perinatal nurse explains to a new mother that the first sign of a postpartum infection will most likely be an increased __________.

ANS: temperature During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F (38.4°C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

Metritis is an infection that usually starts at the placental site. T/F

ANS: True Metritis is an infection of the endometrium that usually starts at the placental site and spreads to encompass the entire endometrium.

Which of the following are primary risk factors for subinvolution of the uterus? (Select all that apply.) a. Fibroids b. Retained placental tissue c. Metritis d. Urinary tract infection

ANS: a, b, c Uterine fibroids can interfere with involution. Retained placental tissue does not allow the uterus to remain contracted. Infection in the uterus is a risk factor for subinvolution. UTI does not interfere with involution of the uterus.

5. The perinatal nurse teaches the postpartum woman about warning signs regarding development of postpartum infection. Signs and symptoms that merit assessment by the health-care provider include the development of a fever and: a. Breast engorgement b. Uterine tenderness c. Diarrhea d. Emotional lability

ANS: b During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101°F, often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia.

8. The nurse is massaging a boggy uterus. The uterus does not respond to the massage. Which medication would the nurse expect would be given first: a. Methergine b. Ergotrate c. Carboprost d. Oxytocin or pitocin

ANS: d If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large bore needle and administers oxytocic drugs in the following order: oxytocin (Pitocin), followed by methylergonovine (Methergine) or ergonovine (Ergotrate), and carboprost (Hemabate).

14. A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra. An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is: a. Massage the fundus of the uterus. b. Assist the woman to the bathroom and reassess the fundus. c. Notify the physician or midwife. d. Start IV oxytocin therapy as per standing orders.

ANS: A a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony. b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline. c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage. d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

1. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following actions should the nurse perform? a. Supervise all infant care. b. Maintain client on strict bed rest. c. Restrict visitation to her partner. d. Carefully monitor toileting

ANS: A a. It is essential that a client diagnosed with postpartum (PP) psychosis not be left alone with her infant. b. There is no need for a client with PP psychosis to be on strict bed rest. c. Visitation is not usually restricted to the woman's partner. d. There is no need to monitor the client's toileting.

13. Which of the following is an indication for the administration of methylergonovine? a. Boggy uterus that does not respond to massage and oxytocin therapy b. Woman with a large hematoma c. Woman with a deep vein thrombosis d. Woman with severe postpartum depression

ANS: A a. Methylergonovine (methergine) is ordered for PPH due to uterine atony or subinvolution. It is used when massage and oxytocin therapy have failed to contract the uterus. b. Hematoma occurs when blood collects within the connective tissues of the vagina or perineal areas related to a vessel that ruptured and continues to bleed. Methylergonovine stimulates contraction of the smooth muscle of the uterus and would not have an effect on the vaginal or perineal areas. c. Heparin is usually prescribed for treatment of thrombosis. d. Methylergonovine is prescribed for treatment of uterine atony.

2. Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery? a. Nipples b. Fundus c. Lungs d. Rectum

ANS: B a. Her nipples should be assessed, but this is not the priority assessment. b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully. c. Her lungs should be assessed bilaterally, but this is not the priority assessment. d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.

15. A woman who is 12 weeks postpartum presents with the following behavior: she reports severe mood swings and hearing voices, believes her infant is going to die, she has to be reminded to shower and put on clean clothes, and she feels she is unable to care for her baby. These behaviors are associated with which of the following? a. Postpartum blues b. Postpartum depression c. Postpartum psychosis d. Maladaptive mother-infant attachment

ANS: C a. Postpartum blues usually occurs within the first few weeks of the postpartum period. Women experiencing postpartum blues will have mild mood swings, and they can take care of themselves as well as their baby. b. Women with PPD are predominately depressed and do not have mood swings. c. Postpartum psychosis is associated with a break from reality reflected in the woman hearing voices. d. The symptoms reported are reflective of a psychiatric disorder beyond maladaptive attachment.

12. A postpartum nurse has received an exchange report on the four following mother-baby couplets. Based on the provided information, which couplet should the nurse first assess? a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant. b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as "it" and that she requested to have her baby stay in the nursery so she could sleep. c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia. d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for postoperative pain management. Her vital signs are B/P 115/75, P 80, R 18 T 98.

ANS: C a. The priority need for this woman is breastfeeding assistance which does not require immediate attention. b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention. c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits. d. Based on data provided, this woman is stable, but should be assessed second.

3. A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother? a. Risk for altered parenting b. Risk for imbalanced nutrition: less than body requirements c. Risk for ineffective individual coping d. Risk for fluid volume deficit

ANS: D a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting. b. This woman's baby is macrosomic—there is no indication that this woman is consuming a diet that is less than body requirements. c. There is no evidence that this mother is high risk for altered coping. d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

A hematoma is the collection of blood beneath the intact skin layer following an injury to a blood vessel. T/F

ANS: True A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. At the time of injury, pressure necrosis and inadequate hemostasis occur.

Abruptio placenta is a risk factor for amniotic fluid embolism. T/F

ANS: True Risk factors for amniotic fluid embolism include induction of labor, maternal age over 35, operative delivery, placenta previa, abruptio placenta, polyhydramnios, eclampsia, and cervical or uterine lacerations

9. Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2 ½ hours of pushing. She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels "full" and is approximately 4 cm in diameter. Juanita describes this area as "very tender." The most likely cause of these signs and symptoms is: a. Hematoma formation b. Sepsis in the episiotomy site c. Inadequate repair of the episiotomy d. Postpartum hemorrhage

ANS: a A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as "full."

6. The perinatal nurse recognizes that a risk factor for postpartum depression is: a. Inadequate social support b. Age >35 years c. Gestational hypertension d. Regular schedule of prenatal care

ANS: a Recognized risk factors for postpartum depression include an undesired or unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness.

Which of the following actions can decrease the risk for a postpartum infection? (Select all that apply.) a. Diet high in protein and vitamin C b. Increased fluid intake c. Ambulating within a few hours after delivery d. Washing nipples with soap prior to each breastfeeding session

ANS: a, b, c Protein and vitamin C assist with tissue healing. Rehydrating a woman after delivery can assist with decreasing risk for infections. Early ambulation decreases risk for infection by promoting uterine drainage. The woman should not wash her breasts with soap because soap can dry the tissue and increase the woman's risk for tissue breakdown

A G2 P1 woman who experienced a prolonged labor and prolonged rupture of membranes is at risk for metritis. Which of the following nursing actions are directed at decreasing this risk? (Select all that apply.) a. Instruct woman to increase her fluid intake b. Instruct woman to change her peri-pads after each voiding c. Instruct woman to ambulate in the halls four times a day d. Instruct woman to apply ice packs to the perineum

ANS: a, b, c a. Maintaining adequate hydration can decrease a person's risk for infection. b. Lochia is a media for bacterial growth, so it is important to frequently change the peri-pads. c. Ambulation can decrease the risk of infection by promoting uterine drainage. d. Ice pack therapy is directed at decreasing edema of the perineum and promoting comfort. It has no effect on metriosis.

Nursing actions focused at reducing a postpartum woman's risk for cystitis include which of the following? (Select all that apply.) a. Voiding within a few hours post-birth b. Oral intake of a minimum of 1000 mL per day c. Changing peri-pads every 3 to 4 hours or more frequently as indicated d. Reminding the woman to void every 3 to 4 hours while awake

ANS: a, c, d Early voiding helps flush bacteria from the urethra. Voiding every 3 to 4 hours will decrease the risk of bacterial growth in the bladder. Soiled peri-pads are a media for bacterial growth. It is recommend that a postpartum woman drink a minimum of 3000 mL/day to help dilute urine and promote frequent voiding.

7. Karen, a G2, P1, experienced a precipitous birth 90 minutes ago. Her infant is 4200 grams and a repair of a second-degree laceration was needed following the birth. As part of the nursing assessment, the nurse discovers that Karen's uterus is boggy. Furthermore, it is noted that Karen's vaginal bleeding has increased. The nurse's most appropriate first action is to: a. Assess vital signs including blood pressure and pulse. b. Massage the uterine fundus with continual lower segment support. c. Measure and document each perineal pad changed in order to assess blood loss. d. Ensure appropriate lighting for a perineal repair if it is needed.

ANS: b As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and initiate immediate actions. The nurse should first locate the uterine fundus and initiate fundal massage. Nursing actions performed after the massage are frequent vital sign measurements with an automatic device, measuring the length of time it takes for blood loss to saturate a pad, and assessing for bladder distention.

4. The perinatal nurse accurately defines postpartum hemorrhage by including a decrease in hematocrit levels from pre- to postbirth by: a. 5% b. 8% c. 10% d. 15%

ANS: c Historically, practitioners have defined postpartum hemorrhage as a blood loss greater than 500 mL following a vaginal birth and 1000 mL or more following a cesarean birth. Hematocrit levels that decrease 10% from pre- to postbirth measurements are also included in the definition.

10. The perinatal nurse notifies the physician of the findings related to Juanita's assessment. The first step in care will most likely be to: a. Prepare Juanita for surgery b. Administer intravenous fluids c. Apply ice to the perineum d. Insert a urinary catheter

ANS: c If the hematoma is less than 3 to 5 centimeters in diameter, the physician usually orders palliative treatments such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 centimeters may require incision and drainage with the possible placement of a drain.

A woman is 3 hours post-early-postpartum hemorrhage of 800 mL at delivery. Select the nursing actions for care of this patient. (Select all that apply.) a. Limit fluid intake to prevent nausea and vomiting. b. Assess fundus every 4 hours during the first 8 hours. c. Explain the importance of preventing an overdistended bladder. d. Provide assistance with ambulation.

ANS: c, d Fluid intake should be increased following a postpartum hemorrhage to decrease the risk of hypovolemia. The fundus should be assessed a minimum of every hour for the first 4 hours following a PPH. The woman needs to know the importance of preventing an overdistended bladder to decrease the risk of further hemorrhage. After postpartum hemorrhage, a woman is at risk for orthostatic hypotension.

11. The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be: a. "What has happened to you?" b. "Do you have help at home?" c. "Is there anything wrong with your son?" d. "Would you tell me about the first few days at home?"

ANS: d The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the mother-baby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: "Tell me how the first few days at home have gone." This statement provides the new mother with an opportunity to share both positive and negative impressions.

The perinatal nurse provides information about postpartum depression to all families members because of the potential danger not only to the mother but also to the __________.

ANS: infant The earlier that postpartum depression is recognized and treatment begun, the better is the prognosis for a full recovery. The nurse should involve the family in helping the patient cope with her feelings and assisting with infant care.

A nurse assesses a G2 P1 woman who gave birth to a 4500 gram baby boy 2 hours ago. The nurse notes that the woman's labor was only 2 hours and that the infant was delivered by the labor nurse. The nurse's assessment findings are: Fundus firm and midline at umbilicus Lochia heavy—saturates pad within 15 minutes and bleeding is a steady stream without clots Perineum intact, slight bruising Ice pack on perineum Vital signs are B/P 105/65, P 98, R 20, T 38° Based on this information, the nurse is concerned that the woman has a __________ of the __________ or __________.

ANS: laceration; cervix; vagina Based on the assessment data, the woman is experiencing an early postpartum hemorrhage (PPH). The hemorrhage is most likely not due to uterine atony because the fundus is firm and midline. Laceration of the cervix or vagina is the second most common cause of early PPH. This woman is displaying typical signs and symptoms of laceration of cervix or vagina—firm, midline fundus with steady stream of blood without clots.

Postpartum woman are at an increased risk of thrombus formation immediately following birth due to an increased __________ level

ANS: plasma fibrinogen Levels of plasma fibrinogen tend to remain elevated during the first few postpartal weeks. Although this alteration exerts a protective effect against hemorrhage, it increases the patient's risk of thrombus formation