Maternity- the Postpartum Period and Associated Complications

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 1. vital signs 2. fundal height 3. presence of calf pain 4. LOC

1 Rationale: pulmonary embolism is a complication of thrombophlebitis. changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. calf pain is an indicator of thrombophlebitis. LOC may change as the condition worsens; worsening would indicate hypoxia

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure dropped 20 points, the diastolic blood pressure dropped 10 points, and her pulse is 120 bpm. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? 1. reassuring the client 2. applying perineal pressure 3. monitoring the fundal height 4. preparing the client for surgery

4 Rationale: the information provided in the question indicates that the client is experiencing blood loss. surgery would be indicated for this complication to stop the bleeding.

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1. i dont need birth control because i will be breastfeeding 2. i need to increase my caloric intake by 500 calories 3. i shouldnt use soap to wash my breast because i will be breastfeeding 4. i need to be sure that i increase my fluid intake and take my prenatal vitamins while breastfeeding

1 Rationale: amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating. the use of soap on the breasts is to be avoided becuase it tends to remove natural oils, which can lead to cracked nipples. the caloric intake should be increase by 200 to 500 calories per day.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 1. monitor the vital signs 2. elevate the HOB 3. increase the IV flow rate 4. administer oxygen by face mask, as prescribed

4 Rationale: because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. options 1 and 2 may be components of the plan of care, but they are not the most important actions. the nurse would not increase the IV flow rate without a prescription from the HCP to do so

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. maintaining strict bed rest 2. monitoring the vital signs every 2 hours 3. performing firm fundal massage every 2 hrs 4. keeping the client and her family members informed of her progress

4 Rationale: keeping the client and her family informed about her condition will help minimize fear and apprehension.

The nurse is assigned to care for the client after a c section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. ambulate frequently 2. wear support stockings 3. apply warm, moist packs to the legs 4. remain on bet rest, with the legs elevated

1 Rationale: stasis is believed to be a major predisposing factor for the development of thrombophlebitis. because c section delivery poses as a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis

The nurse notes that the 4 hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the RN and then performs which action? 1. checks the vital signs 2. begins fundal massage 3. encourages ambulation 4. encourages the client to drink fluids

1 Rationale: symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and reslessness, and thirst. the nurse would check the vital signs. the nurse would not ambulate the client or encourage fluids until specific prescriptions are given.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1. red 2. pink 3. white 4. serosanguineous

1 Rationale: the color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. the color of the lochia then changes to a pinkish brown and occurs from day 4 to day 10 postpartum. finally, the lochia changes to a creamy white color that occurs from day 10 to day 14

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. to the right of the abdomen 2. at the level of the umbilicus 3. about 4 cm above the level of the umbilicus 4. one fingerbreadth above the symphysis pubis

2 Rationale: after delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. if the fundus is 4cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. if the fundus is noted to the right of the abdomen, it may indicate a full bladder. by about 10 days postpartum, the uterus will be in the symphysis pubis area

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1. this is a normal expectation after episiotomy 2. the mother should be allowed bathroom privileges only 3. the bright red bleeding is abnormal and should be reported 4. the perineal assessment should be performed more frequently

3 Rationale: lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. this bright red bleeding is abnormal and needs to be reported.

The nurse is caring for a postpartum client. At 4 hours postpartum, the clients temp is 102 degress. Which is the appropriate nursing action? 1. apply cool packs to the abdomen 2. continue to monitor the temo 3. remove the blanket from the clients bed 4. notify the RN, who will then contact the HCP

4 Rationale: during the first 24 hours postpartum, the mothers temp may be elevated as a result of dehydration. however, if the temp is more than 2 degress above normal, this may indicate infection, and the HCP will need to be notified. applying cool packs to the abdomen is an inappropriate action, and this action requires a prescription.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1. check the vital signs every 4 housr 2. measure the fundal height every 4 hours 3. prepare a heart pack for application to the area 4. prepare an ice pack for application to the area

4 Rationale: the application of ice will reduce the swelling cause by hematoma formation in the vulvar area

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1. the inverted uterus returning to normal 2. the gradual reversal of the uterine muscle into the abdominal cavity 3. the descent of the uterus into the pelvic cavity, which occurs at a rate of 2cm/day 4. the progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approx 1cm/day

4 Rationale: involution is the progressive descent of the uterus into the pelvic cavity. after birth, descent occurs at a rate of approx 1cm/day

The nurse is preparing a list of self care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on this list? SATA 1. rest during the acute phase 2. wear a supportive, nonunderwire bra 3. maintain a fluid intake of at least 3000ml 4. continue to breastfeed if the breasts are not too sore 5. take the prescribed antibiotics until the soreness subsides 6. avoid decompression of the breasts by breastfeeding or breast pump

1, 2, 3, 4 Rationale: mastitis is an infection of the lactating breast. client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000ml per day, and taking analgesics to relieve discomfort. antibiotics may be prescribed and are taken until the complete prescribed course is finished. they are not stopped when the soreness subsides. additional supportive measures include the use of moist heat or ice packs and the wearing of a supportive bra. continued decompression of the breast by breastfeeding or breast pump is important to empty the breast and prevent the formation of an abscess

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1. breastfeed only during the daytime hours 2. apply cold compresses to the breast before feeding 3. avoid the use of a bra while the breasts are engorged 4. massage the breasts before feeding to stimulate let down

4 Rationale: comfort measures for breast engorgement include massing the breasts before feeding to stimulate let down, wearing a supportive and well fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding