Chapter 16 PrepU
During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? generally within 3 to 6 weeks whenever the couple wishes generally after 12 weeks usually within a couple weeks
Correct response: generally within 3 to 6 weeks Explanation: There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.
Rh
If the client is Rh-negative, check the Rh status of the newborn. Verify that the woman is Rh-negative and has not been sensitized, that her indirect Coombs test (antibody screen) is negative, and that the newborn is Rh-positive. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth to prevent a sensitization reaction in the Rh-negative woman who received Rh-positive blood cells during the birthing process.
Which factor puts a client on her first postpartum day at risk for hemorrhage? hemoglobin level of 12 g/dl (120 g/L) uterine atony thrombophlebitis moderate amount of lochia rubra
Correct response: uterine atony Explanation: Loss of uterine tone places a client at higher risk for hemorrhage. Thrombophlebitis does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as: scant. light. moderate. heavy.
Correct response: moderate. Explanation: Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-mL loss; light or small- an approximately 4-inch stain or a 10- to 25-mL loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 mL; and large or heavy-a pad is saturated within 1 hour after changing it.
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "I only eat a low-fiber diet." "I already have some pads with witch hazel at home." "My mom always used dibucaine." "Sitz baths worked the last time."
Correct response: "I only eat a low-fiber diet." Explanation: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
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 above the umbilicus one fingerbreadth below the umbilicus at the level of the umbilicus below the symphysis pubis
Correct response: one fingerbreadth below the umbilicus Explanation: 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.
RhoGAM
Administering RhoGAM prevents initial isoimmunization in Rh-negative mothers by destroying fetal erythrocytes in the maternal system before maternal antibodies can develop and maternal memory cells become sensitized. This is a classic passive immunization technique. The usual protocol for the Rh-negative woman is to receive two doses of Rh immunoglobulin (RhoGAM), one at 28 weeks' gestation and the second dose within 72 hours after childbirth. The standard dose of Rho(D) immune globulin (RhoGAM) is 300 mcg given intramuscularly, which prevents the development of antibodies for an exposure of up to 15 mL of fetal red blood cells
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. Give newborns water and other foods to balance nutritional needs. Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Provide breastfeeding newborns with pacifiers. Place baby in uninterrupted skin-to-skin contact with the mother.
Correct response: 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. Explanation: The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? "It might take up to a week for your bowels return to their normal pattern." "I'll get a laxative prescribed so that you can move your bowels." "That's unusual. Are you making sure to eat enough?" "Let me call your healthcare provider about this problem."
Correct response: "It might take up to a week for your bowels return to their normal pattern." Explanation: Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the healthcare provider is not necessary, and this statement could add to the client's current concern.
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame? 1 week 2 weeks 3 weeks 4 weeks.
Correct response: 2 weeks Explanation: Postpartum blues is a phase of emotional lability characterized by crying episodes, irritability, anxiety, confusion, and sleep disorders. Symptoms usually arise within the first few days after childbirth, reaching a peak at 3 to 5 days and spontaneously disappearing within 10 days. Although postpartum blues is usually benign and self-limited, these mood changes can be frightening to the woman. Women should also be counseled to seek further evaluation if these moods do not resolve within 2 weeks as postpartum depression may be developing.
The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day? 650 calories 500 calories 800 calories 950 calories
Correct response: 650 calories Explanation: Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.
A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time? 3:30 a.m. 5:15 a.m. 7:45 a.m. 9:00 a.m.
Correct response: 9:00 a.m. Explanation: If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Determine the newborn's blood type and rhesus. Determine if this is the client's first baby. Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy.
Correct response: Determine the newborn's blood type and rhesus. Explanation: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
A client is Rh-negative and has given birth to her newborn. What should the nurse do next? Determine the newborn's blood type and rhesus. Determine if this is the client's first baby. Administer Rh immunoglobulins intramuscularly. Ask if the client received rH immunoglobulins during the pregnancy.
Correct response: Determine the newborn's blood type and rhesus. Explanation: The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next? Determine if the client is emptying her bladder. Ask the client when she last urinated. Perform an in and out catheter on the client. Educate the client on how to perform Kegel exercises.
Correct response: Educate the client on how to perform Kegel exercises. Explanation: Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.
A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client? an ice pack applied to the perineum narcotic pain medication a heating pad applied to the perineum a sitz bath
Correct response: an ice pack applied to the perineum Explanation: Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.
A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis bottle feeding excess fatigue and overstimulation by visitors
Correct response: crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors Explanation: The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.
Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? increasing oral fluid intake increasing intravenous fluids screening for bacteriuria in the urine encouraging the woman to empty her bladder completely every 2 to 4 hours
Correct response: encouraging the woman to empty her bladder completely every 2 to 4 hours Explanation: 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 primary care provider's order and is not necessary as a prevention measure.
Thirty minutes after receiving pain medication, a postpartum woman states that she still 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? nothing—it is normal hematoma infection DVT
Correct response: hematoma Explanation: 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 primary care provider immediately.
A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider 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 client at risk for developing? hemorrhage infection depression pulmonary emboli
Correct response: infection Explanation: There are many risk factors for developing a postpartum infection: operative procedures (e.g., 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 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? labor less than 3 hours hemoglobin of 11.5 mg/dl (115 g/L) placenta removed via manual extraction multiparity
Correct response: placenta removed via manual extraction Explanation: Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage.
When palpating for fundal height on a postpartum woman, which technique is preferable? placing one hand at the base of the uterus, one on the fundus placing one hand on the fundus, one on the perineum resting both hands on the fundus palpating the fundus with only fingertip pressure
Correct response: placing one hand at the base of the uterus, one on the fundus Explanation: Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation.
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. between the umbilicus and symphysis pubis. 1 cm below the umbilicus. 2 cm below the umbilicus.
Correct response: the level of the umbilicus. Explanation: 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.