OB: Chapter 22: Nursing Management of the Postpartum Woman at Risk

A postpartum patient is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient?

Measure blood pressure.

When treating a postpartum woman for hemorrhage, the nurse will prepare the client for a blood transfusion once the estimates of blood loss reach which level? a)1,000mL b)1,500mL c)1,750mL d)1,250mL

b)1,500mL Explanation: Once estimates of blood loss reach 1,500 mL, transfusion of blood products should be instituted immediately.

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 99.6°F (37.5°C) b) 100.4°F (38°C) c) 102.4°F (39.1°C) d) 104.2°F (40.1°C)

b)100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection.

A postpartal woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breast-feeding. The nurse's best response would be that:

it depends on the type of anticoagulant she is taking

When providing care for a postpartum client at a 6-week check up, which behavior would alert the nurse the client may have postpartum psychosis?

restless and agitated, concerned with self When a woman has postpartum psychosis the signs may vary, but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation.

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:

"At least I don't have to give up smoking for this one."

A new mother is diagnosed with a venous thromboembolism in her left calf. Which risk factor is associated with this problem? Select all that apply.

- cesarean birth -obesity

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.

-decreased interest in life -inability to concentrate -loss of confidence

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 104.2°F (40.1°C) b) 99.6°F (37.5°C) c) 102.4°F (39.1°C) d) 100.4°F (38°C)

100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000mL

What postpartum client should the nurse monitor most closely for signs of a postpartum infection?

A client who had a nonelective cesarean birth

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse? a) Returns her son to the nursery because of fatigue. b) Absent verbalization about the birthing process. c) Cuddles her son close to her while feeding. d) Tells visitors about her son and the labor.

Absent verbalization about the birthing process. Correct Explanation: After delivery the woman would be excited and interested in the delivery and the infant. A woman may be tired and to ask for sleep is also expected, unexpected is the absent verbalization of the activities and birth. Therefore options A, C, and D are incorrect answers.

The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing?

Administering an enema

A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question?

Administration of an enema

The nurse is caring for a client within the first four hours of her cesarean birth. Which nursing intervention would be appropriate to prevent thrombophlebitis?

Ambulate the client as soon as her vital signs are stable. The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) Her perineum is obviously edematous on inspection. b) She tells you she is extremely thirsty. c) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. d) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart.

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Correct Explanation: Postpartal women who void in small amounts may be experiencing bladder overflow from retention.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching

Avoid over-the-counter (OTC) salicylates

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Attachment, lochia color, complete blood cell count b) Blood pressure, pulse, complaints of dizziness c) Height, level of orientation, support systems d) Degree of responsiveness, respiratory rate, fundus location

Blood pressure, pulse, complaints of dizziness Correct Explanation: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time?

Breast-feeding can continue

A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the patient about breast-feeding during this time?

Breast-feeding can continue.

A client develops mastitis 3 weeks after giving birth. What part of client self-care is emphasized as most important?

Breastfeed or otherwise empty her breasts every 1 to 2 hours

The nurse is planning interventions to prevent the onset of urinary retention in a postpartum patient. Why are these interventions needed?

Decreased bladder sensation results from edema because of pressure of birth.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?

Dorsiflex her right foot and ask if she has pain in her calf. A positive Homans' sign (pain in the upper calf upon dorsiflexion) is not a definitive diagnostic sign as it is insensitive and nonspecific and is no longer recommended as an indicator of DVT. That is because calf pain can also be caused by other conditions. Ask the woman if she has pain or tenderness in the lower extremities and assess for reddness and warmth and if she has increased pain when she ambulates or bears weight.

Which clinical manifestation in a woman with DVT should you report immediately? a) Edema b) Homan's sign c) Pyrexia d) Dyspnea

Dyspnea Explanation: Dyspnea in any patient with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A patient who has a DVT would be expected to have a positive Homan's sign, pyrexia, and edema.

The nurse assess the client who is 1 hour postpartum and discovers a heavy, steady gush of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider?

Laceration

The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?

Pad count

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Pad count b) Urine volume excreted c) Complete blood count d) Vital signs

Pad count Correct Explanation: The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?

She should continue to breast-feed; mastitis will not infect the neonate

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client is nervous about taking the baby home b) The client would like the nurse to take her baby to the nursery so she can sleep c) The client feels empty since she delivered the neonate d) The client would like to watch the nurse give the baby her first bath

The client feels empty since she delivered 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 wouldn't 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

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

Uterine atony. Correct Explanation: When a uterus does not contract well, the denuded placental surface can bleed excessively. Therefore options A, C, and D are incorrect.

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Weak and rapid pulse b) Decreased respiratory rate c) Elevated blood pressure d) Warm and flushed skin

Weak and rapid pulse Correct Explanation: The sign of weak and rapid pulse is the body in compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible. The other options are incorrect.

Which instruction would the nurse include in the teaching plan for a postpartal client with a history of thromboembolism to reduce the risk of a recurrence?

Wear support hose or antiembolic stockings. When caring for a postpartal client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.

Which of the following is the most frequent reason for postpartum hemorrhage? a) Endometritis. b) Uterine atony. c) Perineal lacerations. d) Disseminated intravascular coagulation.

b)Uterine atony. Explanation: When a uterus does not contract well, the denuded placental surface can bleed excessively. Therefore options A, C, and D are incorrect.

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

get a pad count; monitor the client's vital signs; and assess the client's uterine tone

A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation?

massage the fundus

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony

The nurse notes that a client's uterus, which was firm after the fundal massage, has become "boggy." Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Mastitis b) Endometritis c) Episiotomy infection d) Subinvolution

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 [38.4°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.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her hematocrit level is over 45%. d) Her urine output is over 50 mL/h.

Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Staphylococcus aureus b) Streptococcus pyogenes c) Group beta-hemolytic streptococci (GBS) d) Escherichia coli

Staphylococcus aureus Correct Explanation: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis isn't harmful to the neonate. E. coli, GBS, and S. pyogenes aren't associated with mastitis. GBS infection is associated with neonatal sepsis and death.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus (S. aureus)

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?

Symptoms include fever, chills, malaise, and localized breast tenderness

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

Upon examination of a postpartal client's perineum, the nurse notes a large hematoma. The client does not report any pain, and lochia is dark red and moderate in amount. Which factor would most likely contribute to the nurse not discovering the perineal hematoma prior to the examination?

The client has a history of epidural anesthesia.

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? a) Uterine bleeding present b) Foul smelling lochia c) Pain in the lower abdomen d) Uterine protrusion into the vagina

a)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.

What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?

activated partial thromboplastin time The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

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?

birth of a large newborn

Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth

You are caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would you need to assess before the woman ambulates? a) Height, level of orientation, support systems b) Attachment, lochia color, complete blood cell count c) Blood pressure, pulse, complaints of dizziness d) Degree of responsiveness, respiratory rate, fundus location

c)Blood pressure, pulse, complaints of dizziness Explanation: Continue to monitor the woman's vital signs for changes. If she reports dizziness or light-headedness when getting up, obtain her blood pressure while lying, sitting, and standing, noting any change of 10 mm Hg or more.

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: T 101.2°F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Shock b) Normal vital signs c) Infection d) Dehydration

c)Infection Explanation: Temperatures elevated above 100.4°F 24 hours after delivery are indicative of possible infection.

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time

c)Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect.

The nurse recognizes that any client may develop postpartum hemorrhage and frequent assessments are conducted to ensure this is not happening. Which of the following is the most common cause of postpartum hemorrhage? a)Distended bladder b)Uterine lacerations c)Uterine Atony d)Placenta Previa

c)Uterine atony Explanation: The most common cause of postpartum hemorrhage is uterine atony, or failure of the uterus to contract and retract after birth. Any factor that causes the uterus to relax after birth will cause bleeding, even a full bladder that displaces the uterus. Placenta previa and uterine lacerations are potential contributors to hemorrhaging but not the main cause.

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: T 101.2° F; (38.4° C) HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection.

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor

An Rh positive client vaginally gives birth to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection?

length of labor A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal birth, and Rh status of the client do not place the mother at increased risk

A nurse is caring for a client with a postpartum laceration. Which of the following nursing diagnoses would be most appropriate? Select all that apply. a) Ineffective tissue perfusion b) Risk for disuse syndrome c) Risk for injury d) Impaired tissue integrity e) Ineffective thermoregulation

d)• Impaired tissue integrity c)• Risk for injury a)• Ineffective tissue perfusion Explanation: The nursing diagnoses associated with postpartum laceration include ineffective tissue perfusion, risk for injury, and impaired tissue integrity. Ineffective thermoregulation is a nursing diagnosis associated with an infection such as urinary tract infections. Risk for disuse syndrome is a nursing diagnosis associated with thromboembolic disorders.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor less than 12 hours long. b) A nonelective cesarean birth. c) A planned cesarean birth. d) Labor more than 12 hours long.

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 nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Staphylococcus aureus The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings. The client's affect is consistent with postpartum blues, a transient source of sadness experienced during the first week after birth. The nurse should offer support to the client and encourage her to discuss her concerns and feelings. The client's emotional state is normal and contacting the care provider is not indicated. Discussing the client's feelings with family members is a violation of confidentiality and is not an appropriate action. Documenting the interaction is indicated but should take place after the encounter is completed.

The nurse notes that a client's uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?

Check for bladder distention, while encouraging the client to void

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?

Patient is chatting on the telephone with a friend.

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) Symptoms include fever, chills, malaise, and localized breast tenderness b) The most common pathogen is group A beta-hemolytic streptococci c) Mastitis usually develops in both breasts of a breast-feeding client d) A breast abscess is a common complication of mastitis

a)Symptoms include fever, chills, malaise, and localized breast tenderness Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?

increased vaginal acidity leading to growth of bacteria Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?

At 8 hours postdelivery she has voided a total of 100 mL in four small voidings

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?

Avoid over-the-counter (OTC) salicylates. Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron will not affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Refrain from performing any leg exercises b) Avoid products containing aspirin c) Avoid prolonged straining during defecation d) Sit with legs crossed over each other

Avoid products containing aspirin Correct Explanation: The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises when caring for a client with cystocele and rectocele

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which information would be important to collect first?

coagulation studies Coagulation studies should be prescribed immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?

consistency, shape, and location Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 250 ml. b) 750 ml. c) 500 ml. d) 1000 ml.

d)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 determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a)250mL b)300mL c)100mL d)500mL

d)500mL Explanation: Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

Which clinical manifestation in a woman with deep vein thombosis (DVT) should the nurse report immediately?

dyspnea Dyspnea in any client with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A client who has a DVT would be expected to have calf pain, pyrexia, and edema.

A woman is two 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 The woman with endometritis typically looks ill and commonly develops a fever of 100.4° F (38° C) or higher (more commonly 101° F [38.4° 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

When assessing a postpartum patient who was diagnosed with a cervical laceration which has been repaired, what sign should the nurse report as a possible development of hypovolemic shock? a) Decreased respiratory rate b) Warm and flushed skin c) Elevated blood pressure d) Weak and rapid pulse

b)Weak and rapid pulse Explanation: The sign of weak and rapid pulse is the body in compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible. The other options are incorrect.

A client who gave birth vaginally 16 hours ago states she doesn't need to void at this time. The nurse reviews the documentation and finds that the client hasn't voided for 7 hours. Which response by the nurse is indicated? a) "I'll contact your physician." b) "If you don't attempt to void, I'll need to catheterize you." c) "It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." d) "I'll check on you in a few hours."

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness." Correct Explanation: After a vaginal delivery, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It's premature to catheterize the client without allowing her to attempt to void first. There's no need to contact the physician at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

A client has had a cesarean birth. Which of the following amounts of blood loss would the nurse document as a postpartum hemorrhage in this client? a) 500 ml. b) 250 ml. c) 750 ml. d) 1000 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.

In which time period would the nurse expect a client who has given birth to twins to experience late postpartum hemorrhage?

24 hours to 12 weeks after birth Delayed or late postpartum hemorrhages occur more than 24 hours but less than 12 weeks postpartum. Immediate, early, or primary postpartum hemorrhages occur within 24 hours of birth.

The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? a) 300 mL b) 250 mL c) 500 mL d) 100 mL

500 mL Explanation: Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? a) Roll a bath blanket or towel and place it firmly behind the knees b) Limit oral intake of fluids for the first 24 hours to prevent nausea c) Assist client in performing leg exercises every two hours d) Ambulate the client as soon as her vital signs are stable

Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Client's temperature remains below 100.4° F or 38° C orally b) Fundus remains firm and midline with progressive descent c) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour d) Client maintains a urinary output greater than 30 mL per hour

Client's temperature remains below 100.4° F or 38° C orally Explanation: As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

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

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. a) True b) False

False

Over 75% of women who give birth experience postpartum depression. a) True b) False

False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? a) Uterine laceration b) Late postpartum hemorrhage c) Early postpartum hemorrhage d) Pelvic hematoma

Pelvic hematoma Explanation: A hematoma also can form deep in the pelvis where it is much more difficult to identify. The primary symptom is deep pain unrelieved by comfort measures or medication and accompanied by vital sign instability.

Eight days after birth the woman notices a return to red lochia. What condition does the nurse anticipate this patient is experiencing?

Retained placental fragments

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question?

Take an oral contraceptive daily. When caring for a client with DVT, the nurse should instruct the client to avoid using oral contraceptives. Cigarette smoking, use of oral contraceptives, sedentary lifestyle, and obesity increase the risk for developing DVT. The nurse should encourage the client with DVT to wear compression stockings. The nurse should instruct the client to avoid using products containing aspirin when caring for clients with bleeding, but not for clients with DVT. Prolonged rest periods should be avoided. Prolonged rest involves staying motionless; this could lead to venous stasis, which needs to be avoided in cases of DVT.

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. 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 postpartum client is recovering from the birth and emergent repair of a cervical laceration. Whch sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

Weak and rapid pulse

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Avoid massaging the breast area b) Apply cold compresses to the breast c) Avoid frequent breastfeeding d) Perform handwashing before breastfeeding

d)Perform handwashing before breastfeeding Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

Your patient is showing signs and symptoms of a pulmonary embolism. What should you do? a) Lay the patient flat and start oxygen. b) Sit the patient up 90 degrees and call the RN. c) Start oxygen at 2 to 3 liters per minute via nasal cannula. d) Raise the head of the bed to at least 45 degrees.

d)Raise the head of the bed to at least 45 degrees. Explanation: Immediate action is crucial for the woman who develops a pulmonary embolism. Immediately raise the head of the bed to at least 45 degrees to facilitate breathing. Begin oxygen therapy at 8 to 10 liters per minute via facemask and notify the physician.

When planning care for a postpartum patient, the nurse is aware the most common site for postpartum infection is which of the following? a) Urinary b) Breast c) Integumentary d) Reproductive

d)Reproductive Explanation: The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of the patients.

About 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?

femoral thrombophlebitis A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard, inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which possible effect?

interference with the maternal-newborn attachment process The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breastfeeding, delayed development of the newborn, or altered maternal hormonal function.

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 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.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?

laceration of the cervix There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. 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.

The nurse assesses the client who is one hour postpartum and observes a heavy steady gush of bright red blood from the vagina in the presence of a firm fundus. What is the most likely cause of this finding?

lacerations A gush of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

oxytoxic agent

Manual manipulation was used to reposition the uterus of a client who experienced uterine inversion. Which medication would the nurse administer as prescribed after repositioning?

oxytoxic agent 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 postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to:

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

A postpartum woman is diagnosed as having endometritis. Which position would the nurse expect to place her in based on this diagnosis?

semi-Fowler's A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would be contraindicated.

A Hispanic 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?

uterine atony 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?

uterine subinvolution

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 5T's tool will recognize which of the following as being a potential cause of postpartum hemorrhage? (Select all that apply.) a)Technique of delivery b)Time c)Thrombin d)Tone e)Tissue

c)Thrombin d)Tone e)Tissue Explanation: A helpful way to remember the causes of postpartum hemorrhage is by using the 5 T's: tone; tissue; trauma; thrombin; and traction.

You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her urine output is over 50 mL/h. d) Her hematocrit level is over 45%.

b)Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is administering a postpartal woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?

"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a) "Postpartum psychosis usually appears soon after the woman comes home." b) "Postpartum depression develops gradually, appearing within the first 6 weeks." c) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization." d) "Postpartum blues usually resolves by the 4th or 5th postpartum day."

"Postpartum depression develops gradually, appearing within the first 6 weeks." Correct Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

Anticoagulants Correct Explanation: Anticoagulant therapy is used as the primary treatment option for DVT. This makes options A, C, and D incorrect.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

Applying ice

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Restricting fluids b) Applying ice c) Applying warm compresses d) Administering bromocriptine (Parlodel)

Applying ice Correct Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply.

Assess the client's uterine tone. Monitor the client's vital signs. Get a pad count. A nurse should evaluate the efficacy of IV oxytocin therapy by assessing the uterine tone, monitoring vital signs, and getting a pad count. Assessing the skin turgor and assessing deep tendon reflexes are not interventions applicable to administration of oxytocin.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus

A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

Assess the woman's fundus.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Begin an IV infusion of Ringer's lactate solution. b) Assess the woman's vital signs. c) Assess the woman's fundus. d) Call the woman's health care provider.

Assess the woman's fundus. Correct Explanation: To have a suggested idea of the location of the bleeding, the nurse would need to assess the fundus of the patient first.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery

Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery Correct Explanation: Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly bright red blood gushes from the vagina. The nurse recognizes that which of the following is the most likely cause of this postpartum hemorrhage? a) Cervical laceration b) Retained placental fragment c) Disseminated intravascular coagulation d) Uterine atony

Cervical laceration Explanation: Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance. 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. 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, but there is no evidence for this in the scenario.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Check for bladder distention, while encouraging the client to void c) Use semi-Fowler's position to encourage uterine drainage d) Perform vigorous fundal massage for the client

Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

It is discovered that a new mother has developed a puerperal infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4° F or 38° C orally

It is discovered that a new mother has developed a puerperal infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition?

Client's temperature remains below 100.4° F or 38° C orally. As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

A client presents to the clinic with her 3-week-old infant complaining of general flu-like symptoms and a painful right breast. Assessment reveals temperature 101o8F (38.8oC) and the right breast nipple with a hard area that is red and warm. Which instruction should the nurse prioritize for this client?

Complete the 10-day antibiotic prescription even if she begins to feel better. ***Explanation---Mastitis is an infection of the breast tissue with common complaints of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is hard, warm, and tender on palpation. Nursing care focuses on supporting continued breast feeding, preventing milk stasis and administering antibiotics for a full 10 days. The woman should empty her breast every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Bend her knee and palpate her calf for pain. b) Ask her to raise her foot and draw a circle. c) Blanch a toe and count the seconds it takes to color again. d) Dorsiflex her right foot and ask if she has pain in her calf.

Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe

A woman who gave birth to an infant 3 days ago has developed a uterine infection. She will be on antibiotics for 2 weeks. What is the priority education for this client?

Encourage an oral intake of 2 to 3 liters per day.

The client has a nursing diagnosis of deficient fluid volume related to blood loss. Which nursing actions would the nurse include in this client's plan of care?

Encourage intake of oral fluids

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

The nurse is assisting a new mother who is several hours postpartum. Which reaction by the new mother should the nurse prioritize?

Ignores the newborn crying

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis? a) Plugged milk duct b) Breast yeast c) Mastitis d) Engorgement

Mastitis Correct Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

A client who underwent a cesarean delivery suddenly complains of shortness of breath and pain approximately 2 hours after delivery. Which action should the nurse prioritize?

Ensure the head of the bed is at 45 degrees

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal?

Escherichia coli E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of metritis, but some species of Klebsiella may cause urinary tract infections.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal? a) Klebsiella pneumoniae b) Gardenerella vaginalis c) Escherichia coli d) Staphylococcus aureus

Escherichia coli Explanation: E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of metritis, but some species of Klebsiella may cause urinary tract infections.

A nurse is caring for a 38-year-old overweight client 24-hours post cesarean birth. The client is reporting calf tenderness. Which should the nurse do first?

Have the client rest with the extremity elevated. The client is probably experiencing a deep vein thrombosis (DVT). The nurse would maintain bed rest with the effected extremity elevated until the diagnosis could be confirmed. Once the diagnosis is confirmed, and anticoagulant may be prescribed. It is not priority to determine the severity of the pain or a respiratory rate.

The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?

Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

Which assessment on the third postpartal day would make the nurse evaluate a woman as having uterine subinvolution?

Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) She experiences "pulling" pain while breastfeeding. c) Her uterus is at the level of the umbilicus. d) Her uterus is 2 cm above the symphysis pubis.

Her uterus is at the level of the umbilicus. Explanation: A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus

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?

Infection

A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: Temp 101.2F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Normal vital signs b) Dehydration c) Infection d) Shock

Infection Explanation: Temperatures elevated above 100.4F 24 hours after delivery are indicative of possible infection. All but the temperature for this patient are within normal limits, so they are not indicative of shock or dehydration

The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? a) Perform the examination as quickly as possible b) Instruct the client to empty her bladder before the examination c) Wear sterile gloves when assessing the pad and perineum d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus

Instruct the client to empty her bladder before the examination Explanation: An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves aren't necessary. The postpartum examination shouldn't be done quickly. The nurse can take this time to teach the client about the changes in her body after delivery.

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 of the following would the nurse suspect? a) Laceration b) Hematoma c) Uterine atony d) Uterine inversion

Laceration Correct 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.

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Length of labor b) Size of the neonate c) Method of delivery d) Maternal Rh status

Length of labor Correct Explanation: A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal delivery, and Rh status of the client don't place the mother at increased risk

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Performing bimanual compressions b) Massaging the fundus firmly c) Notifying the primary health care provider d) Administering ergonovine (Ergotrate)

Massaging the fundus firmly Correct Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin (Pitocin). Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Administer amoxicillin, as prescribed b) Obtain a clean-catch urine specimen c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic

Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

Palpate her fundus. Correct Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

The nurse instructs a patient on actions to prevent postpartum depression. During a home visit, which observation indicates that instruction has been effective?

Patient is chatting on the telephone with a friend

Which of the following instructions should the nurse offer a client as primary preventive measures to prevent mastitis? a) Perform handwashing before breastfeeding b) Avoid massaging the breast area c) Avoid frequent breastfeeding d) Apply cold compresses to the breast

Perform handwashing before breastfeeding Correct Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold, not warm, moist heat to the breast. Gently massaging the affected area of the breast also helps.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Maladjustment b) Postpartum psychosis c) Postpartum blues d) Postpartum depression

Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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. Maladjustment is a distracter for this question

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum depression b) Postpartum blues c) Postpartum panic disorder d) Postpartum psychosis

Postpartum psychosis Explanation: The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily--often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time

Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect...

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include nipple piercing. b) Risk factors include complete emptying of the breast c) Risk factors include breast pumps. d) Risk factors include frequent feeding.

Risk factors include nipple piercing. Correct 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; use of plastic-backed breast pads.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?

Risk for fatigue related to chronic bleeding due to subinvolution Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma? a) Risk for impaired urinary elimination b) Deficient fluid volume c) Ineffective tissue perfusion d) Impaired tissue integrity

Risk for impaired urinary elimination Explanation: 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. Ineffective tissue perfusion and impaired tissue integrity are nursing diagnoses associated with postpartum lacerations. Deficient fluid volume is a nursing diagnoses associated with postpartum hemorrhage.

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should stop breast-feeding until completing the antibiotic b) She should continue to breast-feed; mastitis won't infect the neonate c) She should supplement feeding with formula until the infection resolves d) She shouldn't use analgesics because they aren't compatible with breastfeeding

She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed

The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? a) A breast abscess is a common complication of mastitis b) The most common pathogen is group A beta-hemolytic streptococci c) Symptoms include fever, chills, malaise, and localized breast tenderness d) Mastitis usually develops in both breasts of a breast-feeding client

Symptoms include fever, chills, malaise, and localized breast tenderness Correct Explanation: Mastitis is an infection of the breast characterized by flulike symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine subinvolution b) Uterine contraction c) Uterine prolapse d) 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.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Hemoglobin level of 12 g/dl b) Moderate amount of lochia rubra c) Thrombophlebitis d) Uterine atony

Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

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? a) Uterine bleeding present b) Pain in the lower abdomen c) Foul smelling lochia d) Uterine protrusion into the vagina

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

When caring for a client with postpartum blues, which intervention would be most appropriate? a) Validate the client's emotions, allowing her to express them freely b) Administer antidepressants as prescribed to lessen postpartum blues c) Recommend the client to a support group or to a mental health professional d) Avoid allowing contact between the newborn and the client

Validate the client's emotions, allowing her to express them freely Explanation: When caring for a client with postpartum blues, the nurse should validate the client's emotions and allow the client to express them freely. The nurse should not administer antidepressants to the client since these drugs are administered only during depression, postpartum or otherwise. Recommending the client to a support group or a mental health professional is not an appropriate intervention when caring for a client with postpartum blues. The nurse need not avoid contact between the mother who is experiencing postpartum blues and her infant

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Wound care and hand washing b) Use of warm compresses and sitz baths c) Proper perineal care d) Strict adherence to antibiotic therapy

Wound care and hand washing Correct Explanation: The use of systemic corticosteroids prior to delivery has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand-washing.

Which woman should you suspect of having endometritis? a) A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. b) A woman with a history of infection and smoking who develops a temperature of 101 degrees on the fourth postpartum day. She reports severe perineal pain. The edges of the episiotomy have separated. c) An obese woman who has a temperature of 100.4 degrees at 12 hours after delivery. Her lochia is moderate; vaginal cultures are negative. d) A woman with PROM before delivery complains of severe burning with urination, malaise and severe temperature spikes on the seventh postpartum day. WBC is 21,850cells/mm3; temperature is 101 degrees; and her skin is pale and clammy.

a)A woman with diabetes who has delivered vaginally and develops tachycardia and a fever of 101.7 degrees on the third postpartum day. The next day, she appears ill; fever is 102.9 degrees; WBC is 31,500 cells/mm3; blood cultures are negative. Explanation: Endometritis is an infection of the endometrium of the uterus. The woman has an very elevated temp greater than 24 hours after delivery and high WBC. She would be treated for infection and monitored. Therefore options B, C, and D are incorrect.

Which of the following would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? a) Activated partial thromboplastin time b) Prothrombin time c) Platelet level d) Fibrinogen level

a)Activated partial thromboplastin time Explanation: The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a) Assess the woman's fundus. b) Begin an IV infusion of Ringer's lactate solution. c) Call the woman's health care provider. d) Assess the woman's vital signs.

a)Assess the woman's fundus. Explanation: In order to have a suggested idea of the location of the bleeding the nurse would need to assess the funds of the patient first. Although all actions may be appropriate, they would not have the priority of fundal assessment.

You are conducting discharge teaching with a postpartum woman. What would be an important instruction for this patient? a) Call her caregiver if lochia moves from serosa to rubra. b) Call her caregiver if lochia moves from rubra to serosa. c) Call her caregiver if lochia moves from serosa to alba. d) Call her caregiver if amount of lochia decreases.

a)Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, patient education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary-care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

It is discovered that a new mother has developed a puerperal infection. Which of the following is the most likely expected outcome that the nurse will identify for this patient related to this condition? a) Client's temperature remains below 100.4° F or 38° C orally b) Fundus remains firm and midline with progressive descent c) Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour d) Client maintains a urinary output greater than 30 mL per hour

a)Client's temperature remains below 100.4° F or 38° C orally Explanation: As fever would accompany a puerperal infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to puerperal infection as does the reduced temperature.

A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Endometritis b) Episiotomy infection c) Mastitis d) Subinvolution

a)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 [38.4°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.

The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse most likely expect the culture to reveal? a) Escherichia coli b) Staphylococcus aureus c) Gardenerella vaginalis d) Klebsiella pneumoniae

a)Escherichia coli Explanation: E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of metritis, but some species of Klebsiella may cause urinary tract infections.

A 35-year-old G2, P2 client presents to her postpartum appointment with vague complaints. The nurse suspects postpartum depression after the client expresses all except which of the following? a)Feels like eating all the time b)Change in sleep c)Appears detached from infant d)Lack of energy and motivation

a)Feels like eating all the time Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which of the following medications would be contraindicated in her case? a)Hemabate b)Cytotec c)Methergine d)Pitocin

a)Hemabate Explanation: Hemabate is contraindicated with asthma due to the risk of bronchial spasms. Pitocin should be given undiluted as a bolus injection, Cytotec should not be given to women with active CVD, pulmonary or hepatic disease, and Methergine should not be given to a woman who is hypertensive.

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman is complaining of a painful area on one breast with a red area. The nurse notes a local area on one breast, red and warm to touch. Which of the following should the nurse suspect is the potential diagnosis? a) Mastitis b) Engorgement c) Plugged milk duct d) Breast yeast

a)Mastitis Explanation: Mastitis usually occurs 2-3 weeks after delivery and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy. The scenario described is not indicative of a plugged milk duct or engorgement. Breast yeast is a distracter for this question.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Obtain a clean-catch urine specimen b) Administer amoxicillin, as prescribed c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic

a)Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which of the following is the most likely nursing diagnosis for this patient? a) Risk for fatigue related to chronic bleeding due to subinvolution b) Risk for infection related to microorganism invasion of episiotomy c) Risk for impaired breastfeeding related to development of mastitis d) Ineffective peripheral tissue perfusion related to interference with circulation secondary to development of thrombophlebitis

a)Risk for fatigue related to chronic bleeding due to subinvolution Explanation: Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which of the following primary conditions? (Select all that apply.) a)Septicemia b)Abruptio placenta c)Isoimmunization d)Ectopic pregnancy e)Severe preeclampsia

a)Septicemia b)Abruptio placenta e)Severe preeclampsia Explanation: DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should continue to breast-feed; mastitis won't infect the neonate b) She should supplement feeding with formula until the infection resolves c) She should stop breast-feeding until completing the antibiotic d) She shouldn't use analgesics because they aren't compatible with breastfeeding

a)She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine atony b) Uterine contraction c) Uterine prolapse d) Uterine subinvolution

a)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.

Disseminated intravascular coagulation is a life-threatening condition that the nurse recognizes can occur as a complication secondary to which primary conditions? Select all that apply.

abruptio placenta severe preeclampsia septicemia DIC is always a secondary diagnosis that occurs as a complication of abruptio placenta, amniotic fluid embolism, intrauterine fetal death with prolonged retention of the fetus, severe preeclampsia, HELLP syndrome, septicemia, and hemorrhage.

Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) Her uterus is at the level of the umbilicus. c) Her uterus is 2 cm above the symphysis pubis. d) She experiences "pulling" pain while breastfeeding.

b)Her uterus is at the level of the umbilicus. Explanation: A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus.

Which of the following assessments would lead you to believe a postpartal woman is developing a urinary complication? a) Her perineum is obviously edematous on inspection. b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. c) She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. d) She tells you she is extremely thirsty.

b) At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartal women who void in small amounts may be experiencing bladder overflow from retention

Retention of placental fragments commonly leads to hypertension. a) False b) True

b) True

After teaching a class on ways to decrease the postpartum complication of thrombotic conditions, the nurse recognizes more teaching is needed when one of the participants states: a)"Using passive range-of-motion exercises in bed sounds easy enough." b)"At least, I don't have to give up smoking for this one." c)"He has to do the deep breathing exercises with me." d)"I can drink more, so I don't get dehydrated."

b)"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, to include 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.

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a) "Postpartum blues usually resolves by the 4th or 5th postpartum day." b) "Postpartum depression develops gradually, appearing within the first 6 weeks." c) "Postpartum psychosis usually appears soon after the woman comes home." d) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

b)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy

Which of the following behaviors exhibited by a 4-hour postpartum woman requires further interventions by the nurse? a) Returns her son to the nursery because of fatigue. b) Absent verbalization about the birthing process. c) Cuddles her son close to her while feeding. d) Tells visitors about her son and the labor.

b)Absent verbalization about the birthing process. Explanation: After delivery the woman would be excited and interested in the delivery and the infant. A woman may be tired and to ask for sleep is also expected, unexpected is the absent verbalization of the activities and birth. Therefore options A, C, and D are incorrect answers.

When diagnosed with a deep vein thrombosis, the nurse knows the patient will be treated with which medication? a) Non-steroidal inflammatory b) Anticoagulants c) Narcotic analgesics d) Beta blockers

b)Anticoagulants Explanation: Anticoagulant therapy is used as the primary treatment option for DVT. This makes options A, C, and D incorrect.

A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Ask her to raise her foot and draw a circle. b) Dorsiflex her right foot and ask if she has pain in her calf. c) Bend her knee and palpate her calf for pain. d) Blanch a toe and count the seconds it takes to color again.

b)Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe.

Over 75% of women who give birth experience postpartum depression. a) True b) False

b)False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%.

The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. a) True b) False

b)False Explanation: The majority of women who experience postpartal psychosis had symptoms of mental illness before pregnancy.

The nurse is assisting a client in completing the Postpartum Depression Screening Scale tool to assess for postpartum depression. Which of the following is least likely to be screened with this tool? a)Emotional liability b)Family and social support system c)Guilt d)Cognitive impairment

b)Family and social support system Explanation: The Postpartum Depression Screening Scale is divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance/ emotional liability; loss of self-esteem; guilt/shame/ cognitive impairment; and suicidal thoughts.

About 10 days following birth, a new mother visits her physician with localized symptoms of redness, swelling, warmth, and a hard inflamed vessel in one leg. The nurse should suspect which of the following conditions? a) Subinvolution b) Femoral thrombophlebitis c) Mastitis d) Uterine atony

b)Femoral thrombophlebitis Explanation: A woman experiencing a femoral thrombophlebitis will usually have unilateral localized symptoms such as redness, swelling, warmth, and a hard inflamed vessel in the affected leg. Symptoms for thrombophlebitis usually present about 10 days after birth. Symptoms of uterine atony are a soft fundus and hemorrhage from the vagina. Symptoms of mastitis, infection of the breast, include a painful, swollen, reddened breast; fever; and scant breast milk. Symptoms of subinvolution include an enlarged, soft uterus and lochial discharge.

In preparing for a class in teaching women and their partners, which of the following would be the most important to emphasize as helping to prevent postpartum complications? a)Adequate follow-up with their health care provider b)Handwashing c)Ensure proper hydration d)Limiting contact with outsiders for the first week

b)Handwashing Explanation: Stressing proper handwashing, especially after perineal care and before and after breast-feeding will help to decrease the chances of infection and complications accompanying it.

The nurse is teaching a group of students about factors that place a pregnant woman at risk for infection in the postpartum period. Which of the following would the nurse be least likely to include? a) Loss of protection with premature rupture of membranes b) Increased vaginal acidity leading to growth of bacteria c) Prolonged labor with multiple vaginal examinations to evaluate progress d) Retained placental fragments

b)Increased vaginal acidity leading to growth of bacteria Explanation: Vaginal acidity is decreased due to the presence of amniotic fluid, blood, and lochia, all of which are alkaline. An alkaline environment encourages the growth of bacteria. With rupture of membranes, the barrier is removed, allowing bacteria to ascend through the internal genital structures. A prolonged labor with multiple vaginal examinations provides opportunities for exposure to organisms, with time for the bacteria to multiply. Retained placental fragments provide an excellent medium for bacterial growth.

When teaching a postpartum woman about possible complications during this time, the nurse would include information about which of the following as a possible effect? a) Ineffectiveness of breast-feeding b) Interference with the maternal-newborn attachment process c) Delayed development of the newborn d) Alteration in normal maternal hormonal function

b)Interference with the maternal-newborn attachment process Explanation: The nurse would include information that maternal postpartum complications affect not only the health status of the woman, but also that of the newborn by potentially interfering with the maternal-newborn attachment process. Furthermore, they can disrupt the dynamics of the entire family, with health-related, fiscal, and emotional effects and costs. Maternal postpartum complications are not known to result in ineffective breast-feeding, delayed development of the newborn, or altered maternal hormonal function.

An Rh-positive client vaginally delivers a 6-lb, 10-oz neonate after 17 hours of labor. Which condition puts this client at risk for infection? a) Method of delivery b) Length of labor c) Size of the neonate d) Maternal Rh status

b)Length of labor Explanation: A prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, vaginal delivery, and Rh status of the client don't place the mother at increased risk

When monitoring a postpartum client 2 hours after delivery, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a) Administering ergonovine (Ergotrate) b) Massaging the fundus firmly c) Notifying the primary health care provider d) Performing bimanual compressions

b)Massaging the fundus firmly Explanation: Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin (Pitocin). Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding doesn't respond to massage and oxytocin. The primary health care provider should be notified if the client doesn't respond to fundal massage, but other measures can be taken in the meantime.

A postpartal woman calls you into her room because she is having a very heavy lochia flow containing large clots. Your first action would be to a) Assess her blood pressure. b) Palpate her fundus. c) Have her turn to her left side. d) Assess her perineum.

b)Palpate her fundus. Explanation: Palpating the fundus will cause it to contract and reduce bleeding. This makes options A, C, and D incorrect.

Samantha delivered her fourth child after protracted and difficult labor during which oxytocin was used to augment her contractions. The next day, her vaginal bleeding continues to be moderately heavy with numerous large clots. Palpating her fundus, you find that it is in the midline but boggy and above the level of the umbilicus. Fundal massage is indicated; what should you do first? a) Ensure that her bladder is empty. b) Place one hand over the symphysis pubis. c) Insert uterine packing to control the hemorrhage. d) Seek an order to obtain and administer an oxytocic.

b)Place one hand over the symphysis pubis. Explanation: A boggy fundus with active bleedings and clots the day after delivery is indicative of uterus atony. The nurse should prepare to initiate fundal massage.The first step in this procedure is to place one had over the symphysis pubis. The first step in fundal massage is not to ensure that the patient's bladder is empty, seek an order for an oxytocic, nor insert uterine packing.

Methylergonovine is ordered for a woman experiencing postpartum hemorrhage. The nurse monitors the woman closely for which of the following adverse effects? a) Headache b) Seizures c) Uterine hyperstimulation d) Flushing

b)Seizures Explanation: Seizures, hypertension, uterine cramping, nausea, vomiting, and palpitations are adverse effects of methylergonovine. Uterine hyperstimulation is an adverse effect of oxytocin. Flushing and headache are adverse effects of carboprost.

Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client would like to watch the nurse give the baby her first bath b) The client feels empty since she delivered the neonate c) The client would like the nurse to take her baby to the nursery so she can sleep d) The client is nervous about taking the baby home

b)The client feels empty since she delivered 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 wouldn't 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.

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Moderate amount of lochia rubra b) Uterine atony c) Thrombophlebitis d) Hemoglobin level of 12 g/dl

b)Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.

A Hispanic woman 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 of the following causes of the hemorrhage is most likely in this client? a) Cervical laceration b) Uterine atony c) Retained placental fragment d) Disseminated intravascular coagulation

b)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? a) Cervical laceration b) Uterine subinvolution c) Perineal laceration d) Clotting deficiency

b)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 isn't corrected at the time of delivery.

Jerry, who is hypertensive and who received corticosteroids during pregnancy, delivered by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care to teach her? a) Proper perineal care b) Wound care and hand washing c) Use of warm compresses and sitz baths d) Strict adherence to antibiotic therapy

b)Wound care and hand washing Explanation: The use of systemic corticosteroids prior to delivery has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand-washing.

Which of the following would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply. a) Hematuria b) Leukocytosis c) Foul-smelling lochia d) Pain on both sides of the abdomen e) Flank pain

b)• Leukocytosis c)• Foul-smelling lochia d)• Pain on both sides of the abdomen Explanation: Signs and symptoms of metritis include lower abdominal tenderness or pain on one or both sides, foul-smelling lochia, and leukocytosis. Hematuria and flank pain would be associated with a urinary tract infection.

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage?

by frequently assessing uterine involution The nurse should closely assess the woman for hemorrhage after giving birth by frequently assessing uterine involution. Assessing skin turgor and blood pressure and monitoring hCG titers will not help to determine hemorrhage.

After teaching a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? a)"Postpartum psychosis usually appears soon after the woman comes home." b)"Postpartum psychosis usually involves psychotropic drugs but not hospitalization." c)"Postpartum depression develops gradually, appearing within the first 6 weeks." d)"Postpartum blues usually resolves by the fourth or fifth postpartum day."

c)"Postpartum depression develops gradually, appearing within the first 6 weeks." Explanation: Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the fourth to fifth postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

Which of the following instructions would the nurse include in the teaching plan for a postpartum woman with mastitis? a)"Limit the amount of fluid you drink so your breasts don't get much fuller." b)"Stop breast-feeding until the pain and swelling subside." c)"Try applying warm compresses to your breasts to encourage the milk to be released." d)"You'll need to take this medication to stop the milk from being produced."

c)"Try applying warm compresses to your breasts to encourage the milk to be released." Explanation: Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breast-feeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.

In which time period would the nurse most likely expect a client who has delivered twins to experience late postpartum hemorrhage? a) 24 to 48 hours after delivery b) 6 weeks to 3 months after delivery c) 24 hours to 6 weeks after delivery d) 6 weeks to 6 months after delivery

c)24 hours to 6 weeks after delivery Explanation: Late or secondary postpartum hemorrhages occur more than 24 hours but less than 6 weeks postpartum. Early or primary postpartum hemorrhages occur within 24 hours of delivery.

Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor more than 12 hours long. b) Labor less than 12 hours long. c) A nonelective cesarean birth. d) A planned cesarean birth.

c)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 nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? a) Roll a bath blanket or towel and place it firmly behind the knees b) Assist client in performing leg exercises every two hours c) Ambulate the client as soon as her vital signs are stable d) Limit oral intake of fluids for the first 24 hours to prevent nausea

c)Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching? a) Shortness of breath is a common adverse effect of the medication b) Wear knee-high stockings when possible c) Avoid over-the-counter (OTC) salicylates d) Avoid iron replacement therapy

c)Avoid over-the-counter (OTC) salicylates Explanation: Discharge teaching should include informing the client to avoid OTC salicylates, which may potentiate the effects of anticoagulant therapy. Iron won't affect anticoagulation therapy. Restrictive clothing should be avoided to prevent the recurrence of thrombophlebitis. Shortness of breath should be reported immediately because it may be a symptom of pulmonary embolism.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which of the following instructions should the nurse offer the client as a caution when the client receives anticoagulation therapy? a) Sit with legs crossed over each other b) Refrain from performing any leg exercises c) Avoid products containing aspirin d) Avoid prolonged straining during defecation

c)Avoid products containing aspirin Explanation: The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises when caring for a client with cystocele and rectocele.

The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Perform vigorous fundal massage for the client c) Check for bladder distention, while encouraging the client to void d) Use semi-Fowler's position to encourage uterine drainage

c)Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. Which of the following is believed to be the cause of postpartum affective disorders? a)Medications used during labor and delivery b)Lack of social support from family or friends c)Drop in estrogen and progesterone levels after birth d)Preexisting conditions in the client

c)Drop in estrogen and progesterone levels after birth Explanation: Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them? a) Disruption in fetal clotting mechanisms b) Laceration of the placenta c) Laceration of the cervix d) Disruption of placental clotting mechanisms

c)Laceration of the cervix Explanation: There are four major causes of postpartum hemorrhage: uterine atony, inability of the uterus to contract effectively; lacerations to the uterus, cervix, vagina, or perineum; retained placenta; and disruption in maternal clotting mechanisms. 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.

When working in a free clinic for children, the nurse observes a mother with her 2 week infant. Which of the following behaviors should the nurse bring to the attention of the health care provider? a) Talking to the infant and rocking the infant b) Breastfeeding the infant in public c) Non-responsive to the infant crying d) Discussing her birth with another new mom

c)Non-responsive to the infant crying Explanation: When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up. Options A, C, and D are normal activities for a new mother who is two weeks post partum.

Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect? a) Early postpartum hemorrhage b) Late postpartum hemorrhage c) Pelvic hematoma d) Uterine laceration

c)Pelvic hematoma Explanation: A hematoma also can form deep in the pelvis where it is much more difficult to identify. The primary symptom is deep pain unrelieved by comfort measures or medication and accompanied by vital sign instability.

Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Postpartum blues b) Maladjustment c) Postpartum psychosis d) Postpartum depression

c)Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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. Maladjustment is a distracter for this question.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which of the following complications? a)Postpartum Hemorrhage b)Uterine Atony c)Deep venous thrombosis d)Metritis

c)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 35), and multiparity.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum panic disorder b) Postpartum depression c) Postpartum psychosis d) Postpartum blues

c)Postpartum psychosis Explanation: The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily--often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

You are the nurse giving an educational presentation to the local Le Leche league chapter. One woman asks you about mastitis. What would be your best response? a) Risk factors include frequent feeding. b) Risk factors include complete emptying of the breast c) Risk factors include nipple piercing. d) Risk factors include breast pumps.

c)Risk factors include nipple piercing. 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; use of plastic-backed breast pads.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, the nurse recognizes which of the following would not be used as an indicator of possible hemorrhage? a)Estimated amount of blood loss b)Uterine tone c)Signs of shock d)Vital signs

c)Signs of shock Explanation: Signs of shock do not appear until the hemorrhage is far advanced due to the increased fluid and blood volume of pregnancy. Vital signs would show an increased pulse rate and decreased level of consciousness. The amount of lochia would be much greater than usual and urinary output would be diminished, with signs of acute renal failure. The uterus may also appear soft and spongy, instead of firm.

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism? a) Group beta-hemolytic streptococci (GBS) b) Streptococcus pyogenes c) Staphylococcus aureus d) Escherichia coli

c)Staphylococcus aureus Explanation: The most common cause of mastitis is S. aureus, transmitted from the neonate's mouth. Mastitis isn't harmful to the neonate. E. coli, GBS, and S. pyogenes aren't associated with mastitis. GBS infection is associated with neonatal sepsis and death.

Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? a) Applying warm compresses b) Administering bromocriptine (Parlodel) c) Restricting fluids d) Applying ice

d)Applying ice Explanation: Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids doesn't reduce engorgement and shouldn't be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.

Which measurement best describes delayed postpartum hemorrhage? a) Blood loss in excess of 1,000 ml, occurring 24 hours to 6 weeks after delivery b) Blood loss in excess of 300 ml, occurring 24 hours to 6 weeks after delivery c) Blood loss in excess of 800 ml, occurring 24 hours to 6 weeks after delivery d) Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery

d)Blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after delivery Explanation: Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which of the following conditions would the nurse identify as necessitating the cautious administration of this drug? a) Respiratory problems b) Low blood pressure c) Mild fever d) Cardiovascular disease

d)Cardiovascular disease Explanation: The nurse should know that the client with cardiovascular disease must understand that the drug has to be administered cautiously. Nurses must administer methylergonovine maleate with caution in women who have elevated blood pressure or cardiovascular disease because it causes a sudden increase in blood pressure and could initiate a cerebrovascular accident in women at risk with pre-existing conditions. Low blood pressure, respiratory problems, or mild fever is not known to enforce cautious use of methylergonovine maleate in clients with early postpartum hemorrhage.

A 17-year-old nulliparous client presents in active labor. It is discovered that she received no prenatal care. Which of the following would be important to collect first? a)Urinalysis b)HIV status c)STI status d)Coagulation studies

d)Coagulation studies Explanation: Coagulation studies should be ordered immediately to determine her coagulation status to help eliminate potential bleeding problems. Her STI and HIV status, although important, are not necessary emergently.

One of the primary assessments you, as a postpartum nurse, make every day is for postpartum hemorrhage. What do you assess the fundus for? a) Consistency, location, and place b) Content, lochia, place c) Location, shape, and content d) Consistency, shape, and location

d)Consistency, shape, and location Explanation: Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm. each postpartum day.

Within 24 hours of delivery, Diane begins to complain of pain in the pelvic region. Comfort measures and medication fail to eliminate the pain, her pulse is rapid, and her blood pressure, hematocrit, and hemoglobin are low. Her fundus is firm, however, and her lochia is dark red and flowing in only moderate amounts; no pooling is evident. You suspect a) Deep-vein thrombosis b) Retained placental fragments c) Lacerations in the uterus d) Deep pelvic hematoma

d)Deep pelvic hematoma Explanation: The assessment data indicate a blood loss in the body, and the lack of active bleeding leads one to believe it may be a hematoma. Retained placental fragments are characterized by late postpartum bleeding. Along with an abrupt onset of bleeding, the woman's uterus is not well-contracted. The woman with DVT may have no symptoms. If she does exhibit signs, these typically include swelling and calf pain or tenderness in the affected leg. The area may be warm, tender, and red. Homans' sign (pain on dorsiflexion of the foot) may be positive. Lacerations can occur as small tears or cuts in the perineal tissue, vaginal sidewall, or cervix.

A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain? a) Urge her to walk to relieve muscle spasm. b) Apply ice to her leg above the knee. c) Massage the calf of her leg. d) Keep covers off the leg.

d)Keep covers off the leg. Explanation: Pressure or cold on the leg can interfere with blood circulation. Massaging the leg or urging her to walk could cause a clot to move and become a pulmonary embolus.

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 of the following would the nurse suspect? a) Uterine inversion b) Uterine atony c) Hematoma d) Laceration

d)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.

When assessing the patient for postpartum hemorrhage the nurse monitors which of the following every hour? a) Vital signs b) Complete blood count c) Urine volume excreted d) Pad count

d)Pad count Explanation: The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A postpartum woman is diagnosed as having endometritis. Which position would you expect to place her in based on this diagnosis? a) Trendelenburg. b) On her left side. c) Flat in bed. d) Semi-Fowler's.

d)Semi-Fowler's. Explanation: A semi-Fowler's position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side or in the Trendelenburg position would be contraindicated.

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which of the following should alert the nurse to a potential infection in the client? a)Temperature of 37.5% C or higher after the first 12 hours after childbirth b)Temperature of 39% C or higher after the first 48 hours after childbirth c)Temperature of 38.5% C or higher after the first 36 hours after childbirth d)Temperature of 38% C or higher after the first 24 hours after childbirth

d)Temperature of 38% C or higher after the first 24 hours after childbirth Explanation: Postpartum infection is defined as a fever of 38% C or 100.4% F or higher after the first 24 hours after childbirth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A 27-year-old G1, P1 woman arrives in the emergency department accompanied by her husband and new infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when? a)Within 2 months of giving birth b)Within 5 months of giving birth c)Within 4 months of giving birth d)Within 3 months of giving birth

d)Within 3 months of giving birth Explanation: Postpartum psychosis general surfaces within 3 months of giving birth.

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Perform fundal massage b) Administer methotrexate c) Estimate the size of the hematoma and report it d) Apply an ice pack to the site e) Administer an antibiotic f) Administer a mild analgesic as prescribed

f)• Administer a mild analgesic as prescribed d)• Apply an ice pack to the site c)• Estimate the size of the hematoma and report it Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.

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.

inability to concentrate loss of confidence 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

The nurse is conducting a review class for a group of perinatal nurses about factors that place a pregnant woman at risk for infection in the postpartum period. The nurse determines that additional teaching is needed when the group identifies which factor?

increased vaginal acidity leading to growth of bacteria

Which complication is most likely responsible for a late postpartum hemorrhage?

uterine subinvolution 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 client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?

within 3 months of giving birth Postpartum psychosis generally surfaces within 3 months of giving birth

A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Administer methotrexate b) Apply an ice pack to the site c) Administer a mild analgesic as prescribed d) Administer an antibiotic e) Estimate the size of the hematoma and report it f) Perform fundal massage

• Estimate the size of the hematoma and report it • Administer a mild analgesic as prescribed • Apply an ice pack to the site Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.

In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status?

"How much blood was on the two pads?"

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums."

A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?

"I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.

The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective?

"If the drainage changes from clear to bright red, I am to call the doctor."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after delivery for you to have a full bladder even though you can't sense the fullness."

On the third day postpartum, which temperature is internationally defined as a postpartal infection?

100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?

1000 mL 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 determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?

500 mL Postpartum hemorrhage is defined as a blood loss of greater than 500 mL after a vaginal birth or more than 1,000 mL after a cesarean birth.

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts?

Apply ice

A client who had an emergency cesarean birth for fetal distress 3 days ago is preparing for discharge. When reviewing the home care instructions with the nurse, the client reveals she is saddened about her cesarean and feels let down that she was not able to have a vaginal birth. When questioned further, the client states she feels "weepy about everything" and cannot stop crying. What nursing action is indicated first?

Ask the client to elaborate on her feelings.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema.

A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?

Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth that resulted in lacerations 4 hours ago. What should the nurse do next?

Assess for uterine contractions. The nurse needs to identify whether the bleeding is from lacerations or uterine atony. This can be done by looking for a well contracted uterus with bright-red vaginal bleeding. Lacerations commonly occur during forceps birth. In subinvolution of the uterus, there is inadequate contraction, resulting in bleeding. A boggy uterus with vaginal bleeding is seen in uterine atony. Once the nurse knows the cause of the bleeding, the condition can be treated.

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

Assess for warmth, erythema, and pedal edema.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

Assess the woman's fundus.

A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?

Avoid products containing aspirin. The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises.

A nurse is a caring for a postpartum client. What instruction should the nurse provide to the client as a precautionary measure to prevent thromboembolic complications?

Avoid sitting in one position for long periods of time.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?

Call her caregiver if lochia moves from serosa to rubra. Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4° F (38° C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client?

Check the lochia. 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 (30.0° 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.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

DVT

Why are postpartal women prone to urinary retention?

Decreased bladder sensation results from edema because of pressure of birth

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?

Encourage to continue breast-feeding

A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?

Encourage to continue breast-feeding.

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

Inability to concentrate; decreased interest in life; and loss of confidence

A postpartum client saturates a peripad in 30 minutes. What is the nurse's first action in this situation?

Massage the fundus

A postpartum patient is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient?

Measure blood pressure

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

Oxytocin

Which findings would lead the nurse to suspect that a postpartum woman has developed metritis? Select all that apply

Pain on both sides of the abdomen; leukocytosis; and foul-smelling lochia

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

Palpate her fundus.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis?

Perform handwashing before breast-feeding.

The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider?

Restless and agitated, concerned with self and not the infant

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?

Risk factors include nipple piercing. 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.

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate?

She should continue to breast-feed; mastitis will not infect the neonate.

Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?

She should continue to breastfeed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.

A postpartal woman is prescribed an antibiotic because of endometritis. Her breast-fed infant should be observed particularly for which of the following?

Signs of thrush and easy bruising

The nurse is caring for a woman who delivered via a cesarean delivery approximately 16 hours earlier. Which assessment finding should the nurse prioritize?

Steadily decreasing volume of urine

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

Teach that adequate hydration helps clear the infection quicker

The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

Teach that adequate hydration helps clear the infection quicker.

On postpartum day 4, a client has a temperature of 101.4°F (38.6°C). Which findings would be consistent with a diagnosis of endometritis? Select all that apply.

Tender uterus and foul-smelling lochia

The nurse palpates a postpartal woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The clien's bladder is distended and is causing the uterus to deviate to the right.

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 nurse palpates a postpartal woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding?

The client's bladder is distended and is causing the uterus to deviate to the right.

The nurse is concerned that a postpartum patient with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this patient?

Weak and rapid pulse

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage?

A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding?

White plaques in the mouth

A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?

a nonelective cesarean birth 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.

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first?

administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.

The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?

bladder distention

Which measurement best describes delayed postpartum hemorrhage?

blood loss in excess of 500 ml, occurring 24 hours to 6 weeks after birth Postpartum hemorrhage involves blood loss in excess of 500 ml. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case?

carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive.

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication?

deep venous thrombosis 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 35), and multiparity.

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders

drop in estrogen and progesterone levels after birth

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders?

drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.

Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?

impaired urinary elimination

A nurse is assessing vital signs for a postpartum client 48 hours after birth. The vital signs are: temp 101.2° F (38.4° C); HR 82 beats/min.; RR 18 breaths/min.; BP 125/78 mm Hg. How will the nurse interpret the vital signs?

infection 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.

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure

A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding?

lack of pleasure Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed, cry a lot, exhibit a lack of energy and motivation, experience a lack of pleasure, changes in appetite, sleep, or weight, withdraw from friends and family, feel negatively toward her baby, or shows lack of interest in her baby

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially?

massaging the fundus firmly Initial management of excessive postpartum bleeding is firm massage of the fundus and administration of oxytocin. Bimanual compression is performed by a primary health care provider. Ergotrate should be used only if the bleeding does not respond to massage and oxytocin. The primary health care provider should be notified if the client does not respond to fundal massage, but other measures can be taken in the meantime.

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

mastitis

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?

oxytocin

When assessing a client for postpartum hemorrhage, the nurse monitors what every hour?

pad count The way to monitor for bleeding every hour is to assess pads and percent of pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

A postpartal woman calls the nurse into her room because she is having a very heavy lochia flow containing large clots. The nurse's first action would be to

palpate her fundus. Palpating the fundus will cause it to contract and reduce bleeding.

A nurse is caring for a client who gave birth vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth?

postpartal hemorrhage

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis

Two weeks after their baby is born, a father calls to report that his wife is behaving strangely. She is extremely talkative and energetic, and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when the father asks her about the child, "As if," the father says, "she's forgotten that we even have a baby!" The nurse tells him to bring the mother in right away because the nurse suspects the mother is suffering from what condition?

postpartum psychosis Postpartum psychosis can present with a client in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign 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.

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

postpartum psychosis The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily—often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.

Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of least help in identifying the possibility of hemorrhage?

signs of shock

Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client?

temperature of 38° C or higher after the first 24 hours after birth Postpartum infection is defined as a fever of 38° C or 100.4° F or higher after the first 24 hours after birth, occurring on at least two of the first 10 days after birth, exclusive of the first 24 hours.

A client develops mastitis 3 weeks after giving birth. What part of self-care does the nurse tell her is most important?

to breastfeed or otherwise empty her breasts every 1 to 2 hours Mastitis treatment involves complete removal of the milk from the breast as often as possible but no longer than a 3 hour time span and antibiotic therapy. It is most important to have the women keep the breast empty to prevent further stasis of milk ducts and worsening mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care.

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

uterine atony

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

uterine atony 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.

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse

When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?

weak and rapid pulse The sign of weak and rapid pulse in the body is a compensatory mechanism attempting to increase the blood circulation. This finding needs to be reported to the health care provider and RN as soon as possible.

A client who is hypertensive and who received corticosteroids during pregnancy gave birth by cesarean and subsequently developed endometritis. Her incision is red, warm, and very sensitive to touch, and she remains febrile despite antibiotic therapy. What is the most important aspect of post hospital care the nurse should teach her?

wound care and hand washing The use of systemic corticosteroids prior to birth has increased her risk for development of an infection. She has been treated for endometritis and is now at greater risk for infection. Hand washing is the best defense again transmission of any infection. While adherence to antibiotic therapy, proper perineal care, and use of warm compresses and sitz baths may be indicated, they would not be a higher priority than wound care and hand washing.