Chapter 21, Nursing Care of the Family During the Postpartum Period

Which nursing information is appropriate for the postpartum client who is taking analgesics for pain relief and is anxious that the medication may pass into her breast milk and adversely affect the infant?

"Take the medication immediately after breastfeeding."

Which condition would the nurse assess in a postpartum client who does not breastfeed her newborn infant?

Breast engorgement

Which caloric intake is appropriate for the lactating client who gave birth to twins 1 month earlier?

More than 2700 kcal/day

Which statement accurately reflects the La cuarentena ritual for a Hispanic client?

This ritual occurs over a period of 40 days.

Which nursing suggestion is appropriate when providing discharge teaching to a nonlactating client with breast engorgement to reduce tissue swelling and suppress milk production?

"Apply fresh cabbage leaves on the breast."

Which nursing instruction is appropriate to give the postpartum client before administering the varicella vaccine on the day of discharge from the hospital? Select all that apply.

"You must return for a second dose in 4 to 8 weeks." "Use contraception for 1 month to avoid pregnancy."

Which nursing explanation is appropriate for a client who is 6 hours postpartum and asks when she will receive a RhoGAM injection?

"The baby's blood type has not come back yet."

Which nursing actions are appropriate for a postpartum client who complains of lightheadedness and nausea, saturates a perineal pad within 15 minutes, and whose skin is cool and clammy? Select all that apply.

Administering lactated Ringer's solution Elevating the client's legs to a 30-degree angle Administering oxygen by nonrebreather face mask

Which nursing intervention would suppress lactation in the client who had a stillbirth?

Advise the client to wear a breast binder for the first 72 hours after giving birth.

Which nursing intervention is appropriate for the postpartum client who has a fourth-degree laceration?

Apply an ice pack to limit edema during the first 12 to 24 hours.

Which nursing action is appropriate for the client who underwent a vaginal delivery 3 hours earlier and is reporting severe perineal pain?

Apply ice packs in the perineum.

Which nursing action is needed when preparing for assessment of the fundus of a postpartum client?

Ask the client to urinate and empty her bladder.

What nursing action is appropriate for the postpartum client with excessive bleeding and a normal blood pressure?

Assess urinary output and level of consciousness.

Which nursing action is appropriate for the postpartum client who is receiving magnesium sulfate therapy for preeclampsia and is found to have leg warmth and tenderness?

Elevate the client's leg.

Which nursing intervention reduces postpartum fatigue (PPF) in the breastfeeding client?

Encourage relatives and friends to bring meals and help with housework.

Which nursing interventions help reduce the risk of postpartum hemorrhage? Select all that apply.

Encouraging voiding Determining uterine tone Providing uterine massage

Which further assessment is appropriate for the postpartum client who does not take pleasure in the infant and also fails to respond appropriately to infant cues?

Evaluating the client for postpartum depression

Which would be the postpartum nurse's priority assessment based on the report at 0900 from Labor and Delivery to transfer a client to the postpartum unit?

Fundus

Which condition is suspected for the postpartum client who 2 hours after giving birth is anxious, complains of intense perineal pain with a strong urge to have a bowel movement, has a firm fundus at the umbilicus and midline, and has moderate lochia rubra with no clots?

Hematoma formation

Which components are included in a cultural assessment? Select all that apply.

Infant care and attachment Primary language spoken Ability to read and write English Religious or cultural beliefs and folk medicine practices

Which medication is appropriate for the postpartum client with fourth-degree perineal lacerations who has been prescribed opioid analgesics but is now experiencing constipation?

Laxatives

Which nursing action is appropriate for the client 1 hour after birth with findings of a fundus that is boggy, midline, and 1 cm below the umbilicus and a lochial flow that is profuse, with two plum-sized clots?

Massage her fundus.

Which nursing action is appropriate for the postpartum Rh-negative client who is prescribed 300 mcg (1 vial) of Rh immune globulin, but whose Kleihauer-Betke test report shows that more than 30 mL of fetal blood is present in the maternal circulation?

Obtain a change of dose prescription.

Which postpartum complication is indicated for the client who has lost 600 mL of blood within 24 hours and has a soft and relaxed uterus?

Postpartum hemorrhage

Which condition is consistent with a postpartum client 12 hours after delivery who presents with soft breasts, uterus at the level of umbilicus, dark red rubra, and deep tendon reflexes of 4+?

Preeclampsia

Which are the priority nursing interventions for the prevention of excessive bleeding after giving birth? Select all that apply.

Preventing bladder distention Maintaining good uterine tone

Which components of a cultural assessment aid in planning effective interventions for a postpartum client? Select all that apply.

Primary language Dietary preferences Folk medicine practices Ability to read and write English

Which nursing information is appropriate to include in the postpartum client's teaching to help her adjust to her role as a mother?

Probable family issues and coping strategies

Which vaccines are appropriate to include when informing a postpartum client? Select all that apply.

Rubella vaccine Varicella vaccine Tetanus-diphtheria-acellular pertussis (Tdap) vaccine

The primary health care provider suggests Kegel exercises to a postpartum client. One week later, the client complains of incontinence from the exercises. What would the nurse conclude from the client's condition?

The client did not perform the exercises correctly.

Which assessment finding would indicate a need to cancel the rubella vaccination for a postpartum client?

The client informs the nurse that her spouse is immunocompromised.

Within which timeframe is it appropriate to initiate breastfeeding for infants after birth?

1 to 2 hours

Which statement by the client with uterine atony and pain in the lower abdomen indicates a risk for fundal relaxation?

"I massage my uterus for 45 minutes every 8 hours."

Which nursing instruction is appropriate to give a postpartum client to prevent infection?

"Wipe from front to back after using the toilet."

Which nursing intervention is appropriate 3 hours after vaginal delivery for a client who has perineal pain that rates 3/10, a perineal ice pack, and a reddened and edematous episiotomy repair?

Administer an Nonsteroidal anti-inflammatory drug (NSAID).

Which intervention is appropriate to administer for the postpartum client with a fourth-degree perineal laceration who is experiencing severe constipation?

Administer a stool softener.

Which psychosocial factors are appropriate to assess when understanding a client's behavior during the postpartum period? Select all that apply.

Family size Cultural beliefs Previous birth experiences

Which food is appropriate to suggest to the postpartum client to increase docosahexaenoic acid (DHA) in breast milk?

Fish

Which is the priority nursing action for the client who gave birth 5 hours ago and is completely saturating a perineal pad within 15 minutes?

Massage the client's fundus.

Which symptom occurs for the postpartum client who has splanchnic engorgement?

Orthostatic hypotension

Which type of medication is used to decrease excessive bleeding and uterine atony in the postpartum client?

Oxytocic

Which finding is concerning during the assessment of a client who is 12 hours postpartum?

Pain in the left calf with dorsiflexion of the left foot

Which postpartum perineal care techniques demonstrate client understanding of proper care? Select all that apply.

Using soap and warm water to wash the vulva and perineum Washing from the symphysis pubis back to the episiotomy Changing her perineal pad every 2 to 3 hours

Which objective data provide understanding about a client's health status in the immediate postpartum period? Select all that apply.

Urinalysis Hematocrit Hemoglobin

Which nurse finding is most concerning for a client who states, "I would like some medication for my headache and cramping" 2 days after cesarean delivery?

Vital signs