Chpt 23: conditions occurring after delivery
After teaching a class of pregnant women on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: "Using passive range-of-motion exercises in bed sounds easy enough." "He has to do the deep breathing exercises with me." "I should drink more so I don't get dehydrated." "At least I don't have to give up smoking for this one."
"At least I don't have to give up smoking for this one." Explanation: Preventing thrombotic conditions is an important aspect of postpartum care and proper nursing management. There are many simple measures that can be utilized: encouraging leg exercises and walking; using intermittent sequential compression devices; stopping smoking to reduce or prevent vascular vasoconstriction; using compression stockings; performing passive range-of-motion exercises while in bed; using postoperative deep breathing exercises to improve venous return; and increasing fluid intake to prevent dehydration.
A postpartum woman who developed deep vein thrombosis is being discharged on anticoagulant therapy. After teaching the woman about this treatment, the nurse determines that additional teaching is needed when the woman makes which statement? "I will use a soft toothbrush to brush my teeth." "I can take ibuprofen if I have any pain." "I need to avoid drinking any alcohol." "I will call my health care provider if my stools are black and tarry."
"I can take ibuprofen if I have any pain." Explanation: Individuals receiving anticoagulant therapy need to avoid use of any over-the-counter products containing aspirin or aspirin-like derivatives such as NSAIDs (ibuprofen) to reduce the risk for bleeding. Using a soft toothbrush and avoiding alcohol are appropriate measures to reduce the risk for bleeding. Black, tarry stools should be reported to the health care provider.
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "It's strange, one minute I'm happy, the next I'm sad." "I just feel so overwhelmed and tired." "I'm feeling so guilty and worthless lately." "I keep hearing voices telling me to take my baby to the river."
"I'm feeling so guilty and worthless lately." Explanation: Indicators for postpartum depression include feelings related to restlessness, worthlessness, guilt, hopeless, and sadness along with loss of enjoyment, low energy level, and loss of libido. The statements about being overwhelmed and fatigued and changing moods suggest postpartum blues. The statement about hearing voices suggests postpartum psychosis.
The nurse is teaching a prenatal class about preparing for their expanding families. What is helpful advice from the nurse? "Expect your other children to react positively to their new brother/sister." "The hormones of pregnancy may cause anxiety or depression postpartum." "Your old coping methods will adequately get you through this period of adjustment." "Caring for your new infant is instinctual and will come naturally to you."
"The hormones of pregnancy may cause anxiety or depression postpartum." Explanation: The "raging hormones" of pregnancy can keep the woman slightly out of touch with her usual methods of coping. Although she may normally interact and communicate in quite mature ways, during a pregnancy she may become depressed, anxious, withdrawn, or angry as she accomplishes her own developmental tasks. Siblings often react to a pregnancy by regression in behavior and attitude because they fear they will be replaced or unloved. In addition to anticipatory guidance concerning the alterations in family structure and functioning, prenatal preparation for first-time parents involves learning the basics of infant care and preparing for infant feeding, particularly for women who plan to breastfeed.
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I am sad because I am not spending as much time with my toddler now that my newborn is here." "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." "The newborn is not really mine emotionally, since I was never pregnant and do not have children."
"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill.
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 250 ml 750 ml 1000 ml 500 ml
1000 ml Explanation: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.
The nurse is assessing clients, all of which have given birth within the past 24 hours. Which assessment leads the nurse to suspect the client is experiencing postpartum blues? 29-year-old client who has lots of family visiting, offering to help the client with meals and cleaning for the next few months 38-year-old client, G1P1, who is constantly holding the newborn and touching the newborn's hands and fingers 18-year-old client who is currently holding their newborn and looking face-to-face at the newborn without saying a word 30-year-old client who is teary-eyed when asked how they and the newborn are doing with breastfeeding
30-year-old client who is teary-eyed when asked how they and the newborn are doing with breastfeeding Explanation: During the postpartum period, many birthing parents experience some feelings of overwhelming sadness or "baby blues." They may burst into tears easily or feel let down and irritable. This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurred with delivery of the placenta. The client who is holding the baby in en face position shows no sign of sadness. The client with a supportive, close family shows no indication they are experiencing postpartum blues. The client is in a normal phase after birth when exploring the newborn's body, a part of the taking-in phase that occurs 1 to 3 days after birth.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 1000 ml 500 ml 750 ml 300 ml
500 ml Explanation: Postpartum hemorrhage is defined as a cumulative blood loss greater than 500 m after a vaginal birth and greater than 1,000 ml after a cesarean birth, with signs and symptoms of hypovolemia within 24 hours of the birth process.
A nurse is caring for a client in the labor and delivery unit. Immediately after fetal birth, a large amount of blood gushes from the client's vagina. The uterus is not palpable in the abdomen. The client's blood pressure drops significantly and the client becomes very pale. Which nursing action is completed next? Discontinue the oxytocin. Administer oxygen by mask. Place the uterus back into the birth canal. Obtain vital signs.
Administer oxygen by mask. Explanation: When uterine inversion occurs, a large amount of blood suddenly gushes from the vagina. The fundus is no longer palpable in the abdomen. The client begins to show signs of blood loss: hypotension, dizziness, paleness, or diaphoresis. The first nursing action is to apply oxygen. Then, the nurse will discontinue the oxytocin, because it makes the uterus more tense and difficult to replace. Next, the uterus will be replaced by the health care provider, typically while the client is under general anesthesia. The nurse should not attempt to replace the uterus. Vital signs will be obtained as often as every 15 minutes.
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation? Normal vital signs Infection Dehydration Shock
Infection Explanation: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of laboratory data Assessment of the lung fields Assessment of bowel function Assessment of the perineal pad
Assessment of the perineal pad Explanation: Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern.
The nurse instructs a client on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective? The client appears disheveled and listless. The client is cleaning the kitchen while the baby naps. The client is chatting on the telephone with a friend. The client complains of fatigue.
Chatting on the phone with friends indicates that the client is not becoming isolated with baby care. This will help prevent the onset of postpartum depression. Fatigue, listlessness, and trying to be perfect with cleaning are observations that could indicate postpartum depression.
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Assess the fundal height. Assess the temperature. Monitor the pain level. Check the lochia.
Check the lochia. Explanation: The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (38° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.
Which factor in a client's history would alert the nurse to an increased risk for postpartum hemorrhage? prematurity, infection, length of labor uterine atony, placenta previa, operative procedures size of placenta, small baby, operative birth multiparity, age of mother, operative birth
Correct response: uterine atony, placenta previa, operative procedures Explanation: Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and uterine overdistention such as from a large infant, twins, or hydramnios.
A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? pain in the lower abdomen uterine protrusion into the vagina foul-smelling lochia uterine bleeding present
Correct response: uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage.
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 Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.3°C], possibly as high as 104°F [40° C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent.
Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma? Impaired tissue integrity Deficient fluid volume Impaired urinary elimination Ineffective tissue perfusion
Impaired urinary elimination Explanation: Due to the nature and location of a postpartum hematoma, impaired urinary elimination would be the best choice. Urination is impaired from swelling. Ineffective tissue perfusion and impaired tissue integrity are nursing diagnoses associated with postpartum lacerations. Deficient fluid volume is a nursing diagnosis associated with postpartum hemorrhage. In addition to Risk for injury and pain, another appropriate nursing diagnosis would be Risk for impaired urinary elimination related to pressure from the hematoma on urinary structures.
A nurse is caring for a client who has had a cesarean birth and has developed a wound infection. What precautions should be taken by the nurse as a primary prevention measure? Keep the incisions clean and dry. Apply ice packs every 12 to 24 hours. Apply ice and heat alternatively. Use a sitz bath once every 24 hours.
Keep the incisions clean and dry.
A nurse is caring for a client at their 6-week postpartum checkup. The client reports they are still having a small amount of vaginal bleeding and recurring minor nosebleeds that take a while to stop. Which intervention would the nurse prioritize for this client? Observe the body for petechiae and purpura. Prepare the client for a platelet transfusion. Recommend over-the-counter aspirin for discomfort. Perform a digital vaginal examination
Observe the body for petechiae and purpura. Explanation: The client is exhibiting symptoms of a bleeding disorder. Assessing the client for petechiae and purpura could differentiate the cause from immune thrombocytopenic purpura or other disorders like von Willebrand Disease. Assessing the severity of the condition would always come before implementing a platelet transfusion. If the client does have a bleeding disorder, recommending aspirin, which thins the blood, could be harmful. Nurses would not perform a vaginal examination when the client is having vaginal bleeding.
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Domperidone Magnesium sulfate Oxytocin Calcium gluconate
Oxytocin Explanation: Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate.
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? Complete emptying of the breast Use of breast pumps Pierced nipple Frequent feeding
Pierced nipple Explanation: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.
A postpartum woman is prescribed oxytocin to stimulate the uterus to contract. Which action would be most important for the nurse to do? Administer the drug as an IV bolus injection. Give as a vaginal or rectal suppository. Withhold the drug if the woman is hypertensive. Piggyback the IV infusion into a primary line.
Piggyback the IV infusion into a primary line. Explanation: When giving oxytocin, it should be diluted in a liter of IV solution and the infusion set up to be piggy-backed into a primary line to ensure that the medication can be discontinued readily if hyperstimulation or adverse effects occur. It should never be given as an IV bolus injection. Oxytocin may be given if the woman is hypertensive. Oxytocin is not available as a vaginal or rectal suppository.
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? Maladjustment Postpartum psychosis Postpartum blues Postpartum depression
Postpartum psychosis Explanation: Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women.
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. The client would like to watch the nurse give the baby her first bath. The client would like the nurse to take her baby to the nursery so she can sleep. The client is nervous about taking the baby home.
The client feels empty since she gave birth to the neonate. Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.
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. loss of confidence bizarre behavior manifestations of mania inability to concentrate decreased interest in life
The nurse should monitor the client for symptoms such as 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.
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Weak and rapid pulse Warm and flushed skin Decreased respiratory rate Elevated blood pressure
Weak and rapid pulse Explanation: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who had an 8-hour labor a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth a client who conceived following fertility treatments
a client who had a nonelective cesarean birth Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection.
A nurse is caring for a postpartum client who is at risk for uterine atony. Which finding in the client's medical history would be a specific risk factor for uterine atony? history of delivery of a small-for-gestational age infant a previous cesarean birth age of the pregnant client is 25 years a diagnosis of polyhydramnios in the pregnancy
a diagnosis of polyhydramnios in the pregnancy Explanation: Uterine atony (failure of the uterus to sufficiently contract) is associated with circumstances that cause greater distention of the uterus, such as polyhydramnios, multiple pregnancies, and macrosomia. History of a cesarean birth, birth of an SGA infant, and age of 25 are not risk factors.
A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract? excessive traction on umbilical cord history of hypertension development of endometritis birth of a large newborn
birth of a large newborn Explanation: The nurse knows that lacerations of the genital tract may occur with the birth of a large infant. Other risk factors for lacerations include forceps or vacuum birth, precipitous second stage, and rapid expulsion. Scarring from prior gynecologic or birth events and vulvar, perineal, or vaginal varicosities increase the incidence of lacerations. When the client experiences excessive traction on the umbilical cord coupled with rapid expulsion of the uterine contents, it leads to uterine inversion and not lacerations of the genital tract. Endometritis is the primary cause of postpartum infections; it is not known to lead to lacerations of the genital tract.
The nurse reviews the history of a postpartum woman G3P3 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? metritis deep venous thrombosis uterine atony postpartum hemorrhage
deep venous thrombosis Explanation: Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity.
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? insomnia feelings of anxiety sadness delusional beliefs
delusional beliefs Explanation: Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, delusional beliefs, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of anxiety, sadness, and insomnia are associated with postpartum depression.
Misoprostol is given to a client experiencing postpartum hemorrhage. The nurse assesses the client for which side effects of this medication? Select all that apply. diarrhea respiratory distress urinary retention nausea high blood pressure
diarrhea nausea Misoprostol is a prostaglandin E1 analogue; common side effects include diarrhea and nausea. Elevated BP is a side effect of methergine. Respiratory distress and urinary retention are not side effects of misoprostol.
A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? prophylactic heparin administration compression stockings early ambulation warm compresses
early ambulation Explanation: Although compression stockings and prophylactic heparin administration may be appropriate, the most cost-effective preventive method is early ambulation. It is also the easiest method. Warm compresses are used to treat superficial venous thrombosis.
A postpartum woman has a history of von Willebrand disease (vWD). The client is being prepared for discharge, and a referral for health care follow-up is made to assess for potential postpartum hemorrhage. The nurse understands that this client is at greatest risk for hemorrhage during which time during the postpartum period? first 3 days first 6 weeks first month first week
first week Explanation: During pregnancy, the von Willebrand factor level increases in most women; thus, labor and birth usually proceed normally. However, all women should be monitored for excessive bleeding, particularly during the first week postpartum.
A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom? no breast milk in the affected breast an ecchymotic area on the affected breast an inverted nipple on the affected breast hardening of an area in the affected breast
hardening of an area in the affected breast Explanation: Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is breast tenderness
Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also reports significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition? uterine atony laceration hematoma bladder distention
hematoma Explanation: The woman most likely has a hematoma based on the findings: firm uterus with bright-red bleeding; localized bluish bulging area just under the skin surface in the perineal area; severe perineal or pelvic pain; and difficulty voiding. A laceration would involve a firm uterus with a steady stream or trickle of unclotted bright-red blood in the perineum. Bladder distention would be palpable along with a soft, boggy uterus that deviates from the midline. Uterine atony would be noted by a uncontracted uterus.
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? fluid volume overload pulmonary emboli hemorrhage infection
hemorrhage Explanation: Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa, abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.
A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced placental abruption (abruptio placentae). Based on this information, what postpartum complication would the nurse expect is happening? pulmonary emboli fluid volume overload infection hemorrhage
hemorrhage Explanation: Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa, abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.
An expectant mother is on heparin for previous blood clots and voicing concerns about how her medications will affect her baby. The nurse would inform the mother that: heparin does not cross the placenta and is safe for her to take. it is recommended to stop taking the heparin while she is pregnant. any medication that an expectant mother takes can cause sequelae for the infant. she should discontinue the heparin and change to another anticoagulant.
heparin does not cross the placenta and is safe for her to take. Explanation: Heparin is a medication that does not cross the placenta and therefore is safe to use during pregnancy. Not all medications cause fetal sequelae. It is not recommended to abruptly discontinue any medication without consulting the mother's health care provider. Heparin is the safest anticoagulant for a pregnant woman to take.
A client in her sixth week postpartum reports general weakness. The client has stopped taking iron supplements that were prescribed to her during pregnancy. The nurse would assess the client for which condition? hypertension hypothyroidism hyperglycemia hypovolemia
hypovolemia Explanation: The nurse should assess the client for hypovolemia as the client must have had hemorrhage during birth and puerperium. Additionally, the client also has discontinued iron supplements. Hyperglycemia can be considered if the client has a history of diabetes. Hypertension and hyperthyroidism are not related to discontinuation of iron supplements.
A nurse teaches a postpartum woman about her risk for thromboembolism. The nurse determines that additional teaching is required when the woman identifies which as a factor that increases her risk? increase in red blood cell production immobility increase in clotting factors vessel damage
increase in red blood cell production Explanation: Clotting factors that increased during pregnancy tend to remain elevated during the early postpartum period. Giving birth stimulates this hypercoagulability state further. As a result, these coagulation factors remain elevated for 2 to 3 weeks postpartum (Silver & Major, 2010). This hypercoagulable state, combined with vessel damage during birth and immobility, places the woman at risk for thromboembolism (blood clots) in the lower extremities and the lungs. Red blood cell production ceases early in the postpartum period, which leads to mean hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly over the next 2 weeks.
A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn? hypovolemia trauma infection hemorrhage
infection Explanation: Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so bacteria can ascend.
A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? inspecting the placenta after delivery for intactness manually removing the placenta at birth applying pressure to the umbilical cord to remove the placenta administering broad-spectrum antibiotics
inspecting the placenta after delivery for intactness Explanation: After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to uterine inversion, which in turn would result in hemorrhage.
While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?
laceration Explanation: Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.
A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? an improperly positioned baby during feedings normal findings in breastfeeding mothers too much milk being retained mastitis
mastitis Explanation: Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.
Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? oxytocin agent nifedipine indomethacin magnesium sulfate
oxytocin agent Explanation: The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion.
A woman who gave birth to a healthy baby 5 days ago is experiencing fatigue and weepiness, lasting for short periods each day. Which condition does the nurse believe is causing this experience? postpartum baby blues postpartum anxiety postpartum reaction postpartum depression
postpartum baby blues Explanation: Postpartum baby blues is common in women after giving birth. It is a mild depression; however, functioning usually is not impaired. Postpartum blues usually peaks at day 4 or 5 after birth. Postpartum anxiety and postpartum depression do not usually start until at least 3 to 4 weeks and up to 1 year following the birth of a baby. Postpartum reaction is a term to include postpartum depression, anxiety, and psychosis.
The nurse is assessing a client at a postpartum visit and notes the client is emotionally sensitive, reports being a failure, and appears extremely sad. The nurse concludes the client is presenting with which potential condition? postpartum depression postpartum anxiety disorder postpartum blues postpartum psychosis
postpartum depression Explanation: The client is showing signs of postpartum depression. Postpartum blues are due to lack of sleep and emotional labilities. Postpartum psychosis is symbolized by confusion, hallucinations, and delusions. Postpartum anxiety disorder involves shortness of breath, chest pain, and tightness.
The nurse receives a report on a client with type 1 diabetes whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware of these complications and knows to monitor the client closely for which of the following? gestational hypertension increased insulin needs postpartum mastitis postpartum hemorrhage
postpartum hemorrhage Explanation: The client is at risk for a postpartum hemorrhage from the overdistention of the uterus because of the extra amniotic fluid and the large neonate. The uterus may not be able to contract as well as it would normally. The client with diabetes usually has decreased insulin needs for the first few days postpartum. Neither polyhydramnios nor macrosomia would increase the client's risk of gestational hypertension or mastitis.
A nurse is preparing a class for a group of new parents on the psychological adaptations that occur after the birth. The nurse should include which signs and symptoms that might suggest postpartum depression? Select all that apply. restlessness hunger sleeping well feelings of worthlessness feeling overwhelmed
restlessness feelings of worthlessness feeling overwhelmed The symptoms of postpartum depression will last longer and are different than the baby blues. Some signs and symptoms of depression include feeling the following: restless, worthless, guilty, hopeless, moody, sad, and overwhelmed.
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? infection hormonal shifting of relaxin and estrogen thromboembolic disorder of the lower extremities normal response to the body converting back to prepregnancy state
thromboembolic disorder of the lower extremities Explanation: Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution uterine prolapse uterine contraction uterine atony
uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.
A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client? cervical laceration disseminated intravascular coagulation uterine atony retained placental fragment
uterine atony Explanation: Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.
Which complication is most likely responsible for a late postpartum hemorrhage? clotting deficiency cervical laceration perineal laceration uterine subinvolution
uterine subinvolution Explanation: Late postpartum bleeding is usually the result of subinvolution of the uterus. Retained products of conception or infection commonly cause subinvolution. Cervical or perineal lacerations can cause an immediate postpartum hemorrhage. A client with a clotting deficiency may have an immediate postpartum hemorrhage if the deficiency is not corrected at the time of birth.
A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first? venous duplex ultrasound of the right leg venogram of the right leg noninvasive arterial studies of the right leg transthoracic echocardiogram
venous duplex ultrasound of the right leg Explanation: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.