Ob 17

How does the leukocyte level change during the early postpartum period? How would a normal leukocyte level for a postpartum woman be interpreted for a nonpregnant woman?

Leukocytes increase up to 30,000/mm3, with an average of 14,000 to 16,000/mm3. If this high leukocyte level occurred in a woman who was not pregnant or postpartum, infection would be suspected

On a clinic visit 3 days postpartum, the nurse assesses Nita's fundus as firm, midline, and 1 cm below the umbilicus. What kind of lochia should the nurse expect Nita to have at this time?

Lochia flow should be rubra or changing to serosa, scant, and free of foul odor or clots

Describe the changes in lochia and state when these occur

Lochia rubra contains blood, mucus, and bits of decidua, is red or red-brown, and has a duration of approximately 3 days. Lochia serosa contains serous exudate, erythrocytes, leukocytes, and cervical mucus; is pinkish or brown-tinged; its duration is from approximately the third to tenth day. Lochia alba contains leukocytes, decidual cells, epithelial cells, fat, cervical mucus, and bacteria; is white, yellow, or cream-colored; may end by day 14 or last until the end of the third to sixth week

Attachment

Long-term development of affection between the infant and significant other

Describe the influence of oxytocin on lactation

Oxytocin causes milk ejection from the alveoli into the lactiferous ducts

Describe postpartum blues. What is the best response to the blues?

Postpartum blues describes a mild temporary depression that affects 60% to 80% of U.S. women. It begins in the first week and lasts no longer than 2 weeks. The woman has fatigue, insomnia, tearfulness, mood instability, irritability, and anxiety but is able to care for her baby. The primary nursing care is to provide empathy and support and let the woman and her family know that the condition is normal and self-limiting. They should be instructed to call the healthcare provider if depression is severe or prolonged, or the mother is unable to cope with her daily life

What makes any pregnant or postpartum woman at risk for venous thrombosis? What factors increase this risk?

Pregnant and postpartum women have higher fibrinogen levels, which increase their ability to form clots. Factors that lyse clots are not increased, however. Women with varicose veins, history of thrombophlebitis, or prior cesarean birth have additional risks above the baseline risk

Nita plans to breastfeed her twins. She successfully breastfed her other two children. However, she says, "I want to breastfeed, but I really have a lot of cramping when I nurse. I don't remember having that with the other two children." What intervention can help with this problem?

Prescribed analgesics given for postpartum discomfort will not harm the infant if taken for a short time. Lying in a prone position with a small pillow or folded blanket under the abdomen often helps

Describe the influence of progesterone on lactation

Progesterone prepares the breasts for lactation and prevent lactation during pregnancy

Describe the influence of prolactin on lactation

Prolactin initiates milk production in the alveoli after the placenta is expelled

Nita is worried about constipation because she had the same problem after her previous births and has been constipated during the last months of this pregnancy. What interventions and teaching can help Nita avoid constipation?

Teach Nita to increase her ambulation gradually, drink additional fluids (at least eight glasses of water daily), and increase dietary fiber. Prunes are a natural laxative, and she can consult her birth attendant for recommended laxatives if natural remedies do not work

What nursing measures help suppress lactation and manage the discomfort of breast engorgement?

Tell the mother to wear a well-fitting bra or sports bra 24 hours a day. Ice applications and analgesics reduce discomfort. She should avoid actions that stimulate milk production, such as spraying with warm water during showers and pumping or massaging the breasts

Nursing measures to promote bonding and attachment include which of the following? (Select all that apply.) a. Assist the parents in unwrapping the baby to inspect. b. Point out that the infant grasping the mother's or father's finger is a natural reflex. c. Explain the physical changes in the newborn, such as molding, as being normal. d. Encourage the mother to let the infant stay in the nursery as much as possible so the mother can rest. e. Position the infant in a face to face position with the mother.

a. Assist the parents in unwrapping the baby to inspect. e. Position the infant in a face to face position with the mother. Nursing measures to promote bonding and attachment include: Assist the parents in unwrapping the baby to inspect the toes, fingers, and body. Inspection fosters identification and allows the parents to become acquainted with the "real" baby, which must replace the fantasy baby that many parents imagined during the pregnancy. Position the infant in an en face position and discuss the infant's ability to see the parent's face. Face-to-face and eye-to-eye contact is a first step in establishing mutual interaction between the infant and parent.

A newborn is in the crib in his mother's room. The teenage mother is watching TV. When the nurse notes that the baby is awake and quiet, the best nursing action is to: a. Pick the baby up and point out his alert behavior to the mother. b. Tell the mother to pick up her baby and talk to him while he is awake. c. Focus care on the mother, rather than the infant, so that the mother can recuperate. d. Encourage the mother to feed the infant before he begins crying.

a. Pick the baby up and point out his alert behavior to the mother.

A young mother is excited about her first baby. Choose the best teaching to help her obtain adequate rest after discharge. a. Plan to sleep or rest any time the infant sleeps. b. Do all housecleaning while the infant sleeps. c. Cook several meals at once and freeze for later use. d. Tell family and friends not to visit for the first month.

a. Plan to sleep or rest any time the infant sleeps.

Twelve hours after birth, a mother lies in bed resting. Although she has only one more day in the hospital, she does not ask about her baby or provide any care. What is the probable reason for her behavior? a. She is still in the taking-in phase of maternal adaptation. b. She shows behaviors that may lead to postpartum depression. c. She is still affected by medications given during labor. d. She may be dissatisfied with some aspect of the newborn.

a. She is still in the taking-in phase of maternal adaptation.

After a cesarean birth, the woman needs to be assessed routinely. Select all the assessments necessary for this woman. (Select all that apply.) a. Vital signs b. Return of motion and sensation (if regional block was given) c. Abdominal dressing d. Pupil dilation e. Uterine firmness and position f. Urine output g. Deep tendon reflexes h. IV infusion

a. Vital signs b. Return of motion and sensation (if regional block was given) c. Abdominal dressing e. Uterine firmness and position f. Urine output h. IV infusion In addition to the usual postpartum evaluation, following cesarean birth, the mother must be assessed as any other postoperative patient: vital signs including pain, uterine position, dressing, abdomen for distention, lochia, intake (IV and oral) and output (voiding or catheter).

The nurse is assessing the patient's vaginal discharge. It is red and has about a 2-inch stain on the peripad. The nurse will record this finding as a a. light amount of lochia rubra. b. scant amount of lochia alba. c. moderate amount of lochia rubra. d. heavy amount of lochia alba.

a. light amount of lochia rubra. Lochia rubra is red in color and occurs the first 3 or 4 days after birth. A light amount of discharge is classified as a 1- to 4-inch stain on the peripad.

The new mother comments that the newborn "has his father's eyes." The nurse recognizes this as a. part of the bonding process termed claiming. b. the mother trying to find signs of the baby's paternity. c. the mother trying to include the father in the bonding process. d. part of the letting-go phase of maternal adaptation.

a. part of the bonding process termed claiming. Claiming or binding-in begins when the mother begins to identify specific features of the newborn. She then begins to relate features to family members.

A newborn is rooming-in with his teenage mother, who is watching TV. The nurse notes that the baby is awake and quiet. The best nursing action is to a. pick the baby up and point out his alert behaviors to the mother. b. tell the mother to pick up her baby and talk with him while he is awake. c. focus care on the mother, rather than the infant so she can recuperate. d. encourage the mother to feed the infant before he begins crying.

a. pick the baby up and point out his alert behaviors to the mother. Modeling behavior by the nurse is an excellent way to teach infant care. The inexperienced teenage mother can observe the proper skills and then the nurse can encourage her to try those skills.

During the early post-cesarean section phase, it is important for the woman to turn, cough, and deep breathe. The rationale for this is to prevent a. pooling of secretions in the airway. b. thrombus formation in the lower legs. c. gas formation in the intestinal tract. d. urinary retention.

a. pooling of secretions in the airway. The post-cesarean section woman is usually on bed rest for the first 8 to 12 hours. She is at risk for pooling of secretions in the airway. By assisting her to turn, cough, and expand her lungs by breathing deeply at least every 2 hours, the pooling of secretions will be decreased.

When assessing the perineum, episiotomy site, or surgical site, the nurse should assess for specific signs. Select all the signs that are appropriate when assessing a surgical site. (Select all that apply.) a. redness b. edema c. ecchymosis d. discharge e. asymmetry

a. redness b. edema c. ecchymosis d. discharge The acronym REEDA is used as a reminder that the site of an episiotomy or a perineal laceration should be assessed for five signs: redness (R), edema (E), ecchymosis (E), discharge (D), and approximation (A).

The first time a woman ambulates after the birth of the newborn, she has a nursing diagnosis of Risk for injury because of the a. risk for developing orthostatic hypotension. b. development of bradycardia. c. increase in cardiac output. d. increase in circulatory volume.

a. risk for developing orthostatic hypotension. After birth a rapid decrease in intraabdominal pressure results in dilation of the blood vessels supplying the viscera. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in blood pressure when the woman moves from a recumbent to a sitting position. The mother feels dizzy or lightheaded and may faint when she stands. Bradycardia is a normal change during the postpartum period. The cardiac output increases during the postpartum period, but does not produce orthostatic hypotension.

Which stage of maternal role attainment is focused on getting acquainted with the infant's individual personality? a. Anticipatory b. Formal c. Informal d. Personal

b. Formal

Choose the best independent nursing action to aid episiotomy healing in the woman who is 24 hours postpartum. a. Apply antibiotic cream to the area three times each day. b. Squirt warm water over the perineum after voiding or stooling. c. Maintain cold packs to the area at all times for the first 3 days. d. Check the leukocyte level daily and report changes.

b. Squirt warm water over the perineum after voiding or stooling.

A woman who is 18 hours postpartum says she is having "hot flashes" and "sweats all the time." The appropriate nursing response is to: a. Report her signs and symptoms of hypovolemic shock. b. Tell her that her body is getting rid of unneeded fluid. c. Notify her nurse-midwife that she may have an infection. d. Limit her intake of caffeine-containing fluids.

b. Tell her that her body is getting rid of unneeded fluid.

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing women's needs during this stage, should a. foster an active role in the baby's care. b. provide time for the mother to reflect on the events of the childbirth. c. recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. d. promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

b. provide time for the mother to reflect on the events of the childbirth. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition. Once they are met, she is more able to take an active role, not only in her own care but also in the care of the newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions and using written materials to reinforce the content presented are a more effective approach.

The new mother is complaining of pain at the episiotomy site; however, because she is breastfeeding, she does not want any medication. What other alternatives can the nurse offer this mother to help relieve the pain? a. ambulation b. topical anesthetics c. hot fluids to drink d. stool softeners

b. topical anesthetics Topical anesthetics can be applied directly to the site to numb the area. This will not cause systemic effects like pain medications. Sitz baths may also be soothing.

The development of a strong emotional tie of a parent to a newborn is called _____________

bonding

The home care nurse is visiting a new mother who delivered 1 week ago. The mother complains about not being able to sleep and that she is tired and cries easily. The best response by the nurse would be: a. "Having a baby is difficult; it will be a long time before you get a good night's sleep." b. "Maybe your mother can come in and help you out." c. "It is normal for this to happen and should go away in 2 weeks. It must be very difficult for you to feel this way with a new baby." d. "The hospital nurses must not have taught you enough information about the changes you will experience during these first 6 weeks."

c. "It is normal for this to happen and should go away in 2 weeks. It must be very difficult for you to feel this way with a new baby." Postpartum blues begins in the first week and usually last no longer than 2 weeks. The mother needs to be supported during this time and given accurate information about the process. Responses a and b belittle the mother and may make her feel inadequate. Response d places blame on someone else and does not deal with the problem.

A recent immigrant to this country seems reluctant to care for her infant. She keeps the infant in the crib most of the time and asks the nurse to feed the baby. She stays in bed and seems not to want to get up to ambulate. What is a likely interpretation of this behavior? a. This was an unwanted pregnancy and the mother is not bonding with the infant. b. The woman has severe postpartum depression and needs psychiatric care. c. In her culture, new mothers should rest and have others care for the infant. d. The woman comes from an abusive home situation.

c. In her culture, new mothers should rest and have others care for the infant.

When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically a. express a strong need to review events and her behavior during the process of labor and birth. b. exhibit a reduced attention span, limiting readiness to learn. c. attempt to meet the needs of the infant and is eager to learn about infant care. d. have reestablished her role as a spouse and partner.

c. attempt to meet the needs of the infant and is eager to learn about infant care. One week after birth the woman should exhibit behaviors characteristic of the taking-hold phase. This stage lasts for as long as 4 to 5 weeks after birth. Responses a and b are characteristic of the taking-in stage, which lasts for the first few days after birth. Response d reflects the letting-go stage, which indicates that psychosocial recovery is complete.

A mother who is 3 days postpartum calls the clinic and complains of "night sweats." She is afraid that she is going into early menopause. The nurse should base her answer on the fact that a. birth may put some women into early menopause; an appointment is needed to have this checked out. b. night sweats may be an indication of many other problems; an appointment is needed to assess the problem. c. diaphoresis is normal during the postpartum period, and comfort measures can be suggested to the mother. d. diaphoresis is normal only if the mother is breastfeeding.

c. diaphoresis is normal during the postpartum period, and comfort measures can be suggested to the mother. Diaphoresis and diuresis rid the body of excess fluids that accumulated during the pregnancy. Diaphoresis is not clinically significant, but can be unsettling for the mother who is not prepared for it. Explanations of the cause and provision of comfort measures, such as showers and dry clothing, are generally sufficient.

One nursing measure that can help prevent postpartum hemorrhage and urinary tract infections is a. forcing fluids. b. perineal care. c. encouraging voiding every 2 to 3 hours. d. encouraging the use of stool softeners.

c. encouraging voiding every 2 to 3 hours. Urinary retention and overdistention of the bladder may cause urinary tract infection and postpartum hemorrhage. Encouraging the mother to empty her bladder frequently will help prevent retention and overdistention. Forcing fluids and perineal care may assist with preventing urinary tract infections. Stool softeners assist with return of normal bowel elimination.

The day after giving birth, the woman complains that she did not lose all the weight she had gained during the pregnancy. The nurse can best respond to the mother with the knowledge that a. she has lost the most of the weight and the rest will be gone within 1 week. b. she has lost some of the weight and the rest will slowly disappear within 6 weeks. c. it will take about 6 to 12 months for all the weight gained with the pregnancy to disappear. d. most women do not lose all the weight gained with each pregnancy.

c. it will take about 6 to 12 months for all the weight gained with the pregnancy to disappear. Women are very concerned about regaining their normal figure. Nurses must emphasize that weight loss should be gradual and that about 6 to 12 months is usually required to lose most weight gained during pregnancy.

A new father of 1 day expresses concern to the nurse that his wife, who is normally very independent, is asking him to make all the decisions. The nurse can best explain this as a(n) a. normal occurrence because the mother is in pain. b. abnormal occurrence that needs to be assessed further. c. normal occurrence because the mother is in the taking-in phase. d. normal occurrence because the mother is frustrated with the care of the newborn.

c. normal occurrence because the mother is in the taking-in phase. During the taking-in phase, the mother is focused primarily on her own need for fluid, food, and sleep. She may be passive and dependent. This is normal and lasts about 2 days.

A woman was admitted to the ED with her newborn baby. The baby was born 4 days ago at home. The woman had no prenatal care. The nurse is assessing the lab work and sees that the mother has an O-negative blood type, the baby is O-positive, and the Coombs test shows that the mother is not sensitized to the positive blood. The nurse's next action should be a. order Rho(D) immune globulin to be given to the mother. b. order Rho(D) immune globulin to be given to the baby. c. record the findings of the lab work and not plan on any further action at this time.

c. record the findings of the lab work and not plan on any further action at this time. The mother is a candidate for Rho(D) immune globulin; however, it should be given within 72 hours after childbirth to prevent the development of maternal antibodies. Because she gave birth 4 days ago, that time period as passed and she is not sensitized to the positive blood.

During the second postpartum day, a woman asks the nurse, "Why are my afterpains so much worse this time than after the birth of my other child?" The best answer by the nurse would be: a. "Most women forget how strong the afterpains can be." b. "They should not be strong with you because you are breastfeeding." c. "You should not be feeling the pains now; I will notify the physician for you." d. "Afterpains are more severe for women who have already given birth."

d. "Afterpains are more severe for women who have already given birth." Afterpains are more acute for multiparas because repeated stretching of muscle fibers leads to low muscle tone, which results in repeated contraction and relaxation of the uterus. Breastfeeding increases the severity of afterpains. The afterpains are self-limiting and will decrease rapidly after 48 hours.

Choose the sign or symptom that the new mother should be taught to report. a. Occasional uterine cramping when the infant nurses b. Oral temperature that is 37.2° C (99° F) in the morning c. Descent of the fundus one fingerbreadth each day d. Reappearance of red lochia after it changes to serous fluid

d. Reappearance of red lochia after it changes to serous fluid

A birthing center is trying to balance its budget and needs to cut down on certain services they have been providing. One concern of the staff is the follow-up care for new mothers. Which of the following provides follow-up care at the least cost? a. Longer hospital stays for the mother and newborn b. Home visits after discharge c. Return clinic visits d. Telephone counseling services

d. Telephone counseling services Telephone calls are much less expensive than home or clinic visits. They can be used for follow-up calls to discharged patients or for parents to call for help with problems or questions. The major disadvantage is that the nurse cannot perform an in-person assessment of the mother, baby, or home environment.

A new father is reluctant to spoil his newborn by picking her up when she cries. The best nursing response is to: a. Teach him that she will eventually stop crying if he waits. b. Take the baby to the nursery to allow the parents to rest. c. Pick the baby up and rock her until she sleeps again. d. Tell the father that the baby cries to communicate a need.

d. Tell the father that the baby cries to communicate a need.

When teaching the postpartum woman about peripads, the nurse should tell her that: a. She can change to tampons when the initial perineal soreness goes away. b. Pads having cold packs within them usually hold more lochia than regular pads. c. Blood-soaked pads must be returned in a plastic bag to the hospital after discharge. d. The pads should be applied and removed in a front to back direction.

d. The pads should be applied and removed in a front to back direction.

A nurse is asked to do a home visit on a woman who delivered 2 weeks ago. When assessing the woman, the nurse was not able to locate the fundus. The next action would be a. massage the fundus until firm. b. monitor for bleeding. c. arrange transportation for the woman to the nearest hospital. d. document this normal finding.

d. document this normal finding. The uterus descends at the rate of about 1 cm/day. By 10 to 14 days, it is no longer palpable above the symphysis pubis. This is a normal finding.

Immediately after birth, the nurse can anticipate the fundus to be located a. at the umbilicus. b. 2 cm above the umbilicus. c. 1 cm below the umbilicus. d. midway between the symphysis pubis and umbilicus.

d. midway between the symphysis pubis and umbilicus. Immediately after birth the uterus is about the size of a large grapefruit and the fundus can be palpated midway between the symphysis pubis and umbilicus. Within 12 hours the fundus rises to the level of the umbilicus. By the second day, the fundus starts to descend by approximately 1 cm/day.

On the first postpartum day a patient's white blood cell count is 25,000/mm3. The nurse's next action should be to a. notify the physician for an antibiotic order. b. assess the patient's temperature and blood pressure. c. request the count be repeated. d. note the results in the chart.

d. note the results in the chart. Marked leukocytosis occurs during the postpartum period. The WBC count increases to as high as 30,000/mm3. The WBC count should fall to normal values by day 7. Neutrophils, which increase in response to inflammation, pain, and stress to protect against invading organisms, account for the major increase in WBCs. Because this is a normal reading, noting the results in the chart is the appropriate action.

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should a. tell the woman she can rest after she feeds her baby. b. recognize this as a behavior of the taking-hold stage. c. record the behavior as ineffective maternal-newborn attachment. d. take the baby back to the nursery, reassuring the woman that her rest is a priority at this time.

d. take the baby back to the nursery, reassuring the woman that her rest is a priority at this time. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior persists. Mothers need to reestablish their own well-being to care for their baby effectively.

Ice causes vasoconstriction and is most effective if applied soon after the birth to the perineal area to prevent ______________.

edema

The maternal adaptation phase in which the mother relinquishes her previous role as being childless and her old lifestyle is called the _______________ phase

letting-go

Explain how a full bladder shortly after birth can lead to excessive postpartum bleeding

A full bladder moves the uterus out of its normal position. This interferes with the ability of the uterus to contract firmly to occlude open vessels at the placental site, allowing them to bleed excessively

REEDA

Acronym that helps assess wound healing: redness, edema, ecchymosis, drainage, approximation

Describe additional nursing abdomen assessments and care for the woman who has given birth by cesarean

Assess for return of peristalsis by auscultating bowel sounds; observe for abdominal distention and passage of flatus; observe surgical dressing for intactness and drainage; observe incision line after dressing removal for signs of infection (REEDA [redness, ecchymosis, edema, drainage, approximation]); palpate fundus gently

Describe the processes of bonding and attachment

Bonding describes the initial attraction felt by parents toward their newborn infant. It is a one-way process, from parent to infant. Attachment describes a long-term, two-way process that binds parent and infant with mutual affection. Attachment is facilitated by positive feedback from the infant and by mutually satisfying experiences

What is the significance of bradycardia during the early postpartum period?

Bradycardia is normal. Blood volume and cardiac output increase as blood from the uteroplacental unit returns to the central circulation and as excess extracellular fluid enters the vascular compartment for excretion. Because stroke volume increases, pulse decreases

Describe the effect of breastfeeding on uterine involution

Breastfeeding stimulates release of oxytocin from the pituitary gland, which tends to intensify afterpains but also maintains better uterine contraction; this facilitates involution

Homan's sign

Calf pain that occurs when the foot is dorsiflexed

Catabolism

Conversion of living cellular substances to simpler compounds

Subinvolution

Delayed return of the uterus to the nonpregnant state

Bonding

Development of an emotional tie to the infant

Describe possible responses of toddlers to a new baby. How can parents help these toddlers?

During the mother's pregnancy, toddlers may not understand that a new baby is coming. Jealousy may be shown by negative or hostile behaviors. Sleep problems and regression may also occur. Parents need to show their continued love to help the toddler understand that he or she will not be displaced by the new baby. Changes in routines should be postponed until after adjustments are complete

Describe the influence of estrogen on lactation

Estrogen prepares the breasts for lactation and prevent lactation during pregnancy

List signs and symptoms that the postpartum woman should report to her physician or nurse-midwife

Fever; localized area of redness, swelling, or pain in the breasts that is unrelieved by support or analgesics; persistent abdominal tenderness or feelings of pelvic fullness or pelvic pressure; persistent perineal pain; frequency, urgency, or burning when urinating; change in lochia character (increased amount, return to red color, passage of clots, or foul odor); localized tenderness, redness, edema, or warmth of the legs; an abdominal incision with redness, edema, separation of edges, or foul drainage

Describe additional nursing respiratory assessments and care for the woman who has given birth by cesarean

If epidural narcotics were used, check the pulse oximeter or apnea monitor; auscultate breath sounds for retained secretions; assist the mother to turn, cough, and deep-breathe; use an incentive spirometer

What teaching should you provide the postpartum woman to prevent constipation?

Increase activity progressively, drink adequate fluids (at least eight glasses of water daily), and add dietary fiber (found in fruits and vegetables, whole grain cereals, bread, and pasta) to prevent constipation. Prunes are a natural laxative

Why are postpartum women at risk for urinary tract infections?

Increased bladder capacity and decreased bladder tone, along with rapid diuresis, may cause urinary retention. Stasis of urine increases the risk of bacterial growth

Fingertipping

Initial characteristic touch of mother with her newborn

Engrossment

Intense fascination between father and newborn

Describe the effect of breastfeeding on sexual intercourse

Lactation suppresses ovulation and estrogen secretion, causing more vaginal dryness than nonlactating mothers have. This may cause painful sexual intercourse unless lubrication is added

Nita is a multipara who vaginally delivered twin boys 4 hours ago. One weighed 6 lb and the other weighed 5 lb, 6 oz. She is admitted to the mother-baby unit after an uneventful recovery. Your initial assessment reveals the following data: temperature, 37.6° C (97.9° F); pulse, 60 beats per minute (bpm); respirations, 20 breaths per minute; blood pressure, 110/70 mm Hg; fundus slightly soft and located to the right of the umbilicus; lochia moderate; midline episiotomy intact with slight edema. What is your first intervention? Why? What should you do next?

Massage the uterus to cause it to contract firmly and control bleeding. The next intervention should be to assist Nita to empty her bladder or catheterize her (with an order) if she is unable to void. Otherwise, the uterus will relax again

Describe the progression of maternal touch

Maternal touch progression is from fingertipping to palm touch to enfolding the infant and bringing him or her close to the mother's body

Kegel exercises

Method to increase tone of muscles around the vagina and urinary meatus

Describe additional nursing intake and output assessments and care for the woman who has given birth by cesarean

Monitor IV for rate of flow and site condition; observe urine for amount, color, and clarity

Entrainment

Movement of the newborn in rhythm with adult speech

Nita will receive Rho(D) immune globulin (RhoGAM), rubella vaccine, and a diphtheria, tetanus, pertussis (Tdap) vaccine before discharge. What precautions should the nurse teach Nita? Why?

Nita should be cautioned to avoid another pregnancy for at least 4 weeks because a fetus may be harmed by the live virus in rubella vaccine

Nita is a multipara who vaginally delivered twin boys 4 hours ago. One weighed 6 lb and the other weighed 5 lb, 6 oz. She is admitted to the mother-baby unit after an uneventful recovery. Your initial assessment reveals the following data: temperature, 37.6° C (97.9° F); pulse, 60 beats per minute (bpm); respirations, 20 breaths per minute; blood pressure, 110/70 mm Hg; fundus slightly soft and located to the right of the umbilicus; lochia moderate; midline episiotomy intact with slight edema. What is your interpretation of these data?

Nita's fundus is not well contracted and is positioned to the right of the umbilicus, probably because of a full bladder. Her multifetal birth and multiparity increase the risk of postpartum hemorrhage

On a clinic visit 3 days postpartum, the nurse assesses Nita's fundus as firm, midline, and 1 cm below the umbilicus. Are these assessments normal? Why or why not? If they are not normal, is there an explanation?

Nita's fundus is slightly higher than usual, but this is explained by her delivery of twins

Nita's vital signs 8 hours after birth are blood pressure, 112/80 mm Hg, temperature, 37.2° C (99° F), pulse, 52 bpm, and respirations, 18 breaths per minute. Are any nursing interventions needed based on these vital signs? What is the rationale for your judgment?

No interventions are needed. Bradycardia and a slight elevation in temperature are common at this time

Dyspareunia

Painful intercourse

Puerperium

Period from childbirth until the return of the reproductive organs to their nonpregnancy state

En face

Position that facilitates eye-to-eye contact between parent and newborn

Involution

Retrogressive changes that return the reproductive organs to their nonpregnancy state

Nita will receive Rho(D) immune globulin (RhoGAM), rubella vaccine, and a diphtheria, tetanus, pertussis (Tdap) vaccine before discharge. Under what circumstances are these drugs given?

Rho(D) immune globulin is given to the Rh-negative mother if her infant is Rh-positive and if she has not previously built up anti-Rh antibodies. Rubella vaccine is given to the nonimmune postpartum woman to prevent the mother from getting rubella during another pregnancy, which could cause injury to a fetus. The postpartum period is a good time to give the vaccine because it is highly unlikely that she will get pregnant soon, and she is then protected from the disease. Tdap is recommended for all adults who have close contact with infants to prevent their contracting pertussis and giving it to infants

New parents may not recognize signals from the infant that he or she has had enough stimulation and now needs to rest. What signals should the nurse teach parents to recognize?

Signs of overstimulation of the infant include looking away, splaying the fingers, arching the back, and fussiness. These are clues that the infant needs some quiet time

Nita's episiotomy is slightly reddened along the suture line; the edges are closely approximated, and there is no edema, bruising, or drainage. Do these data support the supposition that the episiotomy is healing properly? Why or why not? What nursing actions are appropriate?

Slight reddening is typical of normal healing at this early stage. Close approximation of the edges and lack of drainage confirm that healing seems to be taking place normally. Proper perineal cleansing and pad application should be reinforced. The nurse should also review signs and symptoms of infection to report

Describe postpartum changes in the uterine muscle

Stretched uterine muscle fibers contract and gradually regain their former size and contour

Describe the progression of maternal verbal behaviors

The mother progresses from calling the infant "it" to referring to the infant as "he" or "she" to using the infant's given name

Describe postpartum changes in the uterine muscle cells

The number of uterine muscle cells remains the same, but each cell decreases in size through catabolism

What nursing measures can help the mother of twins attach to her babies?

The nurse provides opportunities for frequent contact with each infant to help parents interact with each twin individually rather than interacting with them as a "package." It is essential to point out unique qualities and characteristics of each infant individually

How should the nurse respond to the parents who are disappointed about the sex of their newborn?

The nurse should help the parents acknowledge and talk about their feelings to help them cope with their disappointment and facilitate their attachment with the child

How can the nurse help the new father adapt to his role?

The nurse should involve the father in infant care teaching and decisions. Fathers may not know what to expect from newborns and benefit from information about growth and development. A review of any prenatal teaching is also helpful

Nita plans to breastfeed her twins. She successfully breastfed her other two children. However, she says, "I want to breastfeed, but I really have a lot of cramping when I nurse. I don't remember having that with the other two children." What is the nurse's best response?

The nurse should reassure Nita that the afterpains are normal, are typically short term, and that analgesics can ease them

Describe postpartum changes in the uterine lining

The outer area of endometrium (decidua) is expelled with the placenta. Remaining decidua separates into two layers: the superficial layer is shed in lochia and the basal layer regenerates new endothelium

Nita plans to breastfeed her twins. She successfully breastfed her other two children. However, she says, "I want to breastfeed, but I really have a lot of cramping when I nurse. I don't remember having that with the other two children." How should the nurse explain why Nita is having more cramping than with her two other births?

Two factors increase afterpains in Nita's case, multiparity and uterine overdistention with two fetuses

When can women expect their menses to resume if they are breastfeeding? If they are not planning to breastfeed?

Women who are breastfeeding may not resume menses for 12 weeks to 18 months, depending on the length and frequency of breastfeeding. Contraception should be used by lactating women by 6 months after giving birth or earlier. Many women who formula-feed will begin menses between 6 and 12 weeks postpartum

Nita is a multipara who vaginally delivered twin boys 4 hours ago. One weighed 6 lb and the other weighed 5 lb, 6 oz. She is admitted to the mother-baby unit after an uneventful recovery. Your initial assessment reveals the following data: temperature, 37.6° C (97.9° F); pulse, 60 beats per minute (bpm); respirations, 20 breaths per minute; blood pressure, 110/70 mm Hg; fundus slightly soft and located to the right of the umbilicus; lochia moderate; midline episiotomy intact with slight edema. What should you immediately teach Nita?

You should immediately teach Nita how to assess her uterus for firmness and the effect of a full bladder, her multiparity, and her multifetal birth on uterine contraction

When reading the postpartum chart the nurse notices that the patient's fundus is recorded as "u+1." The nurse understands that this means the fundus is a. 1 cm above the umbilicus b. 1 cm below the umbilicus c. 1 in above the umbilicus d. 1 in below the umbilicus

a. 1 cm above the umbilicus Descent of the fundus is documented in relation to the umbilicus and is measured in centimeters. Numbers with a plus sign mean that the fundus is above the umbilicus; numbers with a minus sign mean that the fundus is below the umbilicus.

A woman who is 4 hours postpartum ambulates to the bathroom and suddenly has a large gush of lochia rubra. The nurse's first action should be to: a. Determine whether the bleeding slows to normal or remains as a large volume. b. Observe vital signs for signs of hypovolemic shock. c. Check to see what her previous lochia flow has been. d. Identify the type of pain relief that was given when she was in labor.

a. Determine whether the bleeding slows to normal or remains as a large volume.

When checking a woman's fundus 24 hours after the cesarean birth of her first baby, the nurse finds her fundus at the level of her umbilicus, firm, and in the midline. The appropriate nursing action related to this assessment is to: a. Document the normal assessment. b. Determine when she last urinated. c. Limit her intake of oral fluids. d. Massage her fundus vigorously.

a. Document the normal assessment

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be a. Soft, nontender; colostrum is present. b. Leakage of milk at let-down. c. Swollen, warm, and tender on palpation. d. A few blisters and a bruise on each areola.

a. Soft, nontender; colostrum is present. Breasts are essentially unchanged for the first 2 or 3 days after birth. Colostrum is present and may leak from the nipples. On day 3 or 4 lactation begins and engorgement can occur, resulting in the findings of b and c. Response d indicates problems with the breastfeeding techniques used.

To promote bonding during the first hour after birth, the nurse can do which of the following? (Select all that apply.) a. delay procedures if appropriate b. allow the father to hold the newborn c. demonstrate proper bottle feeding techniques d. allow as much contact with the newborn as possible e. use the time to do parent teaching on newborn characteristics

a. delay procedures if appropriate b. allow the father to hold the newborn d. allow as much contact with the newborn as possible Early, unlimited and prolonged contact between parents and infants is of primary importance to facilitate the bonding and attachment process. Procedures should be delayed to allow parents uninterrupted time with the newborn.

Constipation is a common problem during the postpartum period. Select all the reasons for constipation during this period. (Select all that apply.) a. diminished bowel tone b. overhydration during labor c. episiotomy that causes the fear of pain with elimination d. iron supplementation e. some pain medications

a. diminished bowel tone c. episiotomy that causes the fear of pain with elimination d. iron supplementation e. some pain medications Constipation may occur from decreased food and fluid intake during labor, reduced activity, iron intake, decreased muscle and bowel tone, and fear of pain during defecation.

The new parents express concern that their 4-year-old son is jealous of the new baby. They are planning on going home tomorrow and are not sure how the preschooler will react when they bring the baby home. Which one of the following suggestions by the nurse will be most helpful? a. Be aware that the child may regress to an earlier stage. b. Have the mother spend time with the child while the father cares for the baby. c. Have the child stay with a grandparent until the parents adjust to the new baby. d. Tell the child that he is a "big boy" now and doesn't need his crib so the new baby will be using it for a while.

b. Have the mother spend time with the child while the father cares for the baby. The child needs to have the mother's love reaffirmed. By giving the child some private time with the mother, he will get the extra attention and reassurance he needs at this point.

A woman who is 3 hours postpartum has had difficulty in urinating. She finally urinates 100 mL. The initial nursing action is to: a. Insert an indwelling catheter. b. Have her drink additional fluids. c. Assess the height of her fundus. d. Chart the urination amount.

c. Assess the height of her fundus.

To help the postpartum woman avoid constipation, the nurse should teach her to: a. Avoid intake of foods such as milk, cheese, or yogurt. b. Take a laxative for the first 3 postpartum days. c. Drink at least 1600 mL of noncaffeinated fluids daily. d. Limit her walking until the episiotomy is fully healed.

c. Drink at least 1600 mL of noncaffeinated fluids daily.

The nurse can encourage the parents to care for their infant by: a. Staying out of the room for as long as possible. b. Having the grandmother nearby as a backup. c. Giving positive feedback when they provide care. d. Correcting their performance whenever they make a mistake.

c. Giving positive feedback when they provide care.

The nurse places one hand above the symphysis pubis during uterine massage to: a. Make the massage more comfortable for the woman. b. Increase the effectiveness of the procedure. c. Help prevent the uterus from inverting. d. Help determine the firmness of the uterus.

c. Help prevent the uterus from inverting.

While doing patient teaching, the woman tells the nurse, "I don't have to worry about contraception because I am breastfeeding." The nurse should base her answer on the fact that a. breastfeeding can be considered a reliable system of birth control. b. breastfeeding can be used as a contraceptive method if strict guidelines are followed through. c. breastfeeding is not a reliable contraceptive method.

c. breastfeeding is not a reliable contraceptive method. Menses in a breastfeeding mother may resume between 12 weeks and 18 months. Normally the first few cycles of menses are without ovulation; however, ovulation may occur before the first menses. Therefore other contraceptive measures are important considerations for this mother.

When assessing a woman who gave birth 2 hours ago, the nurse notices a constant trickle of lochia. The uterus is well contracted. The next nursing action should be to a. massage the fundus. b. continue to monitor. c. notify the physician. d. assess the blood pressure and pulse for changes.

c. notify the physician. Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. The uterus is well contracted, so further massage is not necessary.

When the father develops a bond with the new infant and has an intense interest in how the infant looks and responds, this is called ________________

engrossment

The placental site heals by a process of _______________

exfoliation