OB postpartum exam
What findings should the nurse report to the health care provider for a postpartum client who delivered 12 hours ago? Select all that apply. White blood cell count of 28,000/mm3 Temperature of 101.8°F (38.8°C) Lochia rubra Fundal height level of one fingerbreadth above the umbilicus Episiotomy appears edematous
Fundal height level of one fingerbreadth above the umbilicus Temperature of 101.8°F (38.8°C) Explanation: The uterine fundus should be one fingerbreadth below, not above, the umbilicus. Maternal temperature does increase slightly after delivery but 38.8°C (101.8°F) is too high and the doctor needs to be made aware of it. All other findings are normal.
A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Increase IV oxytocin or breastfeed the newborn. 2Determine the site of bleeding. 3Massage the fundus if boggy. 4Assess blood pressure. 5Notify the primary care provider. 6Palpate the fundus.
Determine the site of bleeding. Palpate the fundus. Massage the fundus if boggy. Increase IV oxytocin or breastfeed the newborn. Assess blood pressure. Notify the primary care provider. Explanation: Determining the site of bleeding is the first assessment. Palpate the fundus. If the fundus is boggy, take steps to stimulate contractions by massaging. Stimulate contractions by oxytocin or breastfeeding. Assess blood pressure, and assess for safety to ambulate. Notify the health care provider and continue to monitor the client.
An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. What was the birth weight of the infant? Has the mother had any previous pregnancies? Has the mother ever been sensitized to Rh-positive blood? Has the mother experienced any miscarriages or abortions? Has she delivered by cesarean section or vaginally?
Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? Has the mother experienced any miscarriages or abortions? Explanation: An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, abortion or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.
A new mother delivered 1 week ago and is tearful, anxious, sad, and has no appetite. She is diagnosed with postpartum blues. What factors contribute to this problem? Select all that apply. Hormonal changes Discomfort Disrupted sleep patterns Fatigue Lack of activity
Hormonal changes Fatigue Discomfort Disrupted sleep patterns Explanation: Postpartum blues occur in 40% to 80% of postpartum women. The exact cause is unknown but there are certain factors that do contribute to this occurring. These include hormonal changes, disrupted sleeping patterns from getting up with the newborn, discomfort from delivery, and fatigue. Too much activity causes postpartum blues, not lack of activity.
During the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply. Telling the nurse about her delivery experience. Desiring to hold her infant Asking the nurse to take the newborn away so she can rest. Needing assistance with changing her peripad Changing her newborn's diaper with guidance from the nurse.
Needing assistance with changing her peripad Telling the nurse about her delivery experience. Asking the nurse to take the newborn away so she can rest. Explanation: In the early postpartum period, the new mother is focused upon herself and concerned about her needs. She is very dependent, having difficulty making decisions and requesting help with self-care. She relives the delivery experience and wants to share it with others. This period may last several hours or several days.
A urinalysis is done on a postpartum mother 24 hours after delivery. Which findings would be considered normal for this client? Select all that apply. trace WBCs gross proteinuria moderate glycosuria Occasional RBCs mild ketonuria
moderate glycosuria mild ketonuria Occasional RBCs trace WBCs Explanation: Urine in a client in the early postpartum period may display ketonuria secondary to dehydration or prolonged labor, glycosuria from the inability of the kidneys to filter properly immediately following delivery, and RBC's from lochia contamination. Gross proteinuria is an abnormal finding for a urinalysis of this client.
A nurse is reviewing the medical record of a postpartum woman in preparation for assessment. Which factor would the nurse identify as increasing the woman's risk for infection? Select all that apply. episiotomy denuded endometrial arteries urinary stasis white blood cell count 25,000/mm³ hemoglobin 11.0 g/100 mL
urinary stasis denuded endometrial arteries episiotomy Explanation: The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity, such as an episiotomy. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation. A hemoglobin finding lower than 10.5 g/100 ml suggests anemia.
A nurse visiting a postpartum client at home is reviewing the need for the woman to meet her own nutritional needs. The woman is breastfeeding her newborn. The nurse determines that the client understands her nutritional needs based on which statements? Select all that apply. "I need to drink about 2 to 3 quarts of fluid each day." "I will have at least 4 to 5 servings of milk each day." "I need to eat about 7 servings of vegetables daily." "I should have about 4 servings of fruits each day." "I need to cut way back on any fats and oils daily.
"I need to drink about 2 to 3 quarts of fluid each day." "I should have about 4 servings of fruits each day." "I will have at least 4 to 5 servings of milk each day." Explanation: Daily nutritional recommendations for the lactating woman include: 2 to 3 quarts of fluids, 4 servings each of fruits and vegetables, 4 to 5 servings of milk, 7 servings of meat, poultry, fish and eggs, and 5 servings of fats, oils and sweets.
Eight hours after delivery, the client is found to have a perineal hematoma. The health care provider prescribes insertion of a Foley catheter. The client does not understand why she needs a catheter, because she has voided twice since giving birth. Which responses by the nurse explain the need for a Foley catheter? Select all that apply. "If you are bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for you to void." "The Foley catheter is necessary to keep the blood out of your bladder and from contaminating your urine." "A Foley catheter will decrease the risk of developing a urinary infection while we are monitoring the condition of the perineum." "As the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later." "The hematoma can get larger and place pressure on your kidneys and decrease the amount of urine produced."
"If you are bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for you to void." "As the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later." Explanation: With the presence of a perineal hematoma, there are two reasons for inserting a Foley catheter: (1) if there is continued bleeding into the tissue, the hematoma may put pressure on the urethra, making it impossible for the patient to void; and (2) as the hematoma gets larger or if it extends into the vagina, it will be much harder to place the catheter later. The hematoma is not in proximity to the kidneys. The bleeding is in the tissue surrounding the urethra, not into the bladder. The placement of a Foley catheter actually increases the risk of a urinary tract infection
Rho(D) immune globulin is administered to which clients? Select all that apply. A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood A newborn with type O-negative blood and a negative Coombs test An Rh-negative woman following an ectopic pregnancy A client who is Rh-positive and gave birth to a 7-pound baby An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday
An Rh-negative woman who had a spontaneous abortion (miscarriage) yesterday An Rh-negative woman following an ectopic pregnancy A Rh negative woman who gives birth at 32 weeks gestation to a baby with A+ blood Explanation: Rho(D) immune globulin is never given to an individual with Rh positive blood, and it is never given to the neonate following birth. Rho(D) immune globulin is given to women with Rh negative blood following an ectopic pregnancy, a spontaneous abortion (miscarriage), and the birth of an Rh positive neonate.
A postpartum woman is developing thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply. Ask if her pain that is relieved with walking. Assess for a low-grade fever. Assess for edema in the affected leg. Assess for redness and warmth in the affected leg.
Assess for redness and warmth in the affected leg. Assess for edema in the affected leg. Assess for a low-grade fever. Explanation: The nurse should ask the woman if she has pain or tenderness in the lower extremities when ambulating and if that pain is relieved by rest and elevation. Also assess for redness, warmth, and edema as well as a low-grade fever.
Six hours after birth, a client's first void is 70 ml. What is the nurse's next action? Assess for dehydration. Assess for perineal hematoma. Assess for a urinary tract infection. Assess for residual urine.
Assess for residual urine. Explanation: Given the small volume voided, the nurse would assess for residual urine. Clients experience diuresis after birth; therefore, a large volume of urine is expected. A urinary tract infection is characterized by burning, frequency, and dysuria. A perineal hematoma, if large, may obstruct the urethra and cause an inability to void, but it will not impact the quantity voided.
A nurse is to care for a client during the postpartum period. The client reports pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? Select all that apply. Breasts are hard. Nipples are fissured. Breasts are soft. Nipples are cracked. Breasts are tender.
Breasts are hard. Breasts are tender. Explanation: Engorged breasts are hard and tender, and the nurse should assess for these signs. Improper positioning of the infant on the breast, not engorged breasts, results in cracked, blistered, fissured, bruised, or bleeding nipples in the breastfeeding woman.
The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply. Breasts are non-painful One reddened area on the left breast 3 cm in size. Nipples have several cracks on both breasts. Breasts feel slightly firm. Flattened nipple on the right breast
Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful Explanation: Normal findings for a breast exam in a Day 2 postpartum mother should include non-painful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.
A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply. If infant refuses to feed, pump the breast to maintain flow. Continue breastfeeding on the left side, if the infant is willing to latch on. Use a bottle to feed the infant until the pain and tenderness subside. Take prescribed antibiotics until all prescribed doses are completed. Until antibiotics are completed, pump the left breast and dispose of the milk.
Continue breastfeeding on the left side, if the infant is willing to latch on. Take prescribed antibiotics until all prescribed doses are completed. If infant refuses to feed, pump the breast to maintain flow. Explanation: An infection of the breast during lactation is termed mastitis. Mastitis can interfere with lactation, and sometimes an infant will refuse to nurse on the affected side. The women's medical provider must be notified to initiate antibiotic treatment. Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of maternal mastitis.
A client is experiencing postpartum hemorrhage shortly after the birth of the infant. Which nursing intervention(s) would be appropriate for this client? Select all that apply. Encourage the client to breastfeed the infant, if she is breastfeeding. Turn the client on the side and inspect the area under the buttocks for blood. Begin uterine massage with both hands on the fundus of the uterus. Encourage increased fluid intake. Monitor vital signs every 15 minutes.
Encourage the client to breastfeed the infant, if she is breastfeeding. Begin uterine massage with both hands on the fundus of the uterus. Turn the client on the side and inspect the area under the buttocks for blood. Encourage increased fluid intake. Monitor vital signs every 15 minutes. Explanation: If a client is experiencing a postpartum hemorrhage, the nurse needs begin uterine massage and increase her fluid intake. If eating and drinking are not advisable due to the client's status, IV fluids are started. Breastfeeding releases oxytocin, which aids in uterine contractions. The nurse should always turn the client over to check for pooled blood under the buttocks to get a more accurate assessment of blood loss. Since hemorrhaging can result in tachycardia and hypotension from hypovolemia, frequent monitoring of the client's vital signs is imperative.
A nurse is making a home visit to a black woman who gave birth to a healthy newborn 4 days ago. When developing the plan of care for this woman, which considerations would the nurse need to integrate into the plan of care? Select all that apply. The woman may stay at home for the first 40 days. Extended family members may be involved with caring for the infant. Oils may be used on the newborn's skin and hair. Bathing the newborn may be postponed for the first week. The woman may avoid eye contact with the nurse who is making the visit.
Extended family members may be involved with caring for the infant. Bathing the newborn may be postponed for the first week. Oils may be used on the newborn's skin and hair. Explanation: In the black culture, the mother may share care of the infant with extended family members, avoid bathing the newborn for the first week, and apply oils to the newborn's skin and hair to prevent dryness and cradle cap. Avoiding eye contact with health care providers would be more commonly associated with the Filipino American culture. Staying home for the first 40 days after birth would be more commonly associated with Islamic culture.
A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that apply. Third stage of labor of 10 minutes Hemoglobin 8.0 g/dL (80.0 g/L) Labor induction with oxytocin Labor of 1 1/2 hours Forceps birth
Labor of 1 1/2 hours Labor induction with oxytocin Forceps birth Explanation: Factors that increase a postpartum woman's risk for postpartum hemorrhage include: precipitous labor of less than 3 hours, labor induction, use of operative procedures such as forceps, and prolonged third stage of labor (greater than 30 minutes). A hemoglobin level less than 10.5 g/dL (105.0 g/L) increases the woman's risk for postpartum infection.
A postpartum mother calls the nurse in and tells her that her right calf hurts whenever she walks around the room or in the hall. What other data needs to be collected in assessing this client for a DVT? Select all that apply. Note capillary refill of the toes. Note any reddened areas on the right calf. Feel the right calf for increased warmth. Measure the diameter of both calves. Have the mother actively flex both legs for equal movement.
Feel the right calf for increased warmth. Note any reddened areas on the right calf. Measure the diameter of both calves. Explanation: A deep vein thrombus (DVT) is suspected in a client who is complaining of pain in her calves and, upon inspection, there is redness of the calf, increased size, and increased warmth. It is not advised to have the client actively flexing her legs due to the risk of dislodging the clot. Checking capillary refill will provide no more information related to a DVT.
A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. Hypotonic bowel sounds Urination of 100 ml every 4 hours Fundus one finger-breadth below the umbilicus Inverted nipples following breastfeeding Moderate saturation of peripad every 3 hours
Fundus one finger-breadth below the umbilicus Moderate saturation of peripad every 3 hours Explanation: A fundus should be one finger-breadth below the umbilicus at 24-hours postpartum, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and urination of 100 ml every 4 hours is inadequate given the occurrence of diuresis.
A breastfeeding client presents with a temperature of 102.4°F (39°C) and a pulse of 110 bpm. She reports general fatigue and achy joints, and her left breast is engorged, red, and tender. Which instructions would the nurse anticipate being given to this client? Select all that apply. × Until antibiotics are completed, pump the left breast and dispose of the milk.× × × × If infant refuses to feed, pump the breast to maintain flow.× × × × Take prescribed antibiotics until all prescribed doses are completed.× × Continue breastfeeding on the left side, if the infant is willing to latch on.× Use a bottle to feed the infant until the pain and tenderness subside.×
If infant refuses to feed, pump the breast to maintain flow.× Take prescribed antibiotics until all prescribed doses are completed.× Continue breastfeeding on the left side, if the infant is willing to latch on.× Correct response: Continue breastfeeding on the left side, if the infant is willing to latch on.× Take prescribed antibiotics until all prescribed doses are completed.× If infant refuses to feed, pump the breast to maintain flow.× Explanation: An infection of the breast during lactation is termed mastitis. Mastitis can interfere with lactation, and sometimes an infant will refuse to nurse on the affected side. The women's medical provider must be notified to initiate antibiotic treatment. Mothers should be instructed to continue breastfeeding if the infant will breastfeed from the affected side. If the infant refuses, instruct the mother to pump her breasts to maintain flow (and to avoid clogged ducts) and then offer the affected breast after 12 to 24 hours. Unless specifically directed otherwise, infants are safe to continue to breastfeed while a mother is being treated for mastitis; there is no reason to provide alternative feeding methods or to wean because of maternal mastitis.
The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. Place the patient in Trendelenburg position for inspection. Gently palpate for any hematomas. Palpate the episiotomy for pain. Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids.
Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas. Explanation: The client is placed in the Sims position, not Trendelenburg position, for inspection. The nurse will then use a light to look at the perineum, noting any hemorrhoids, inspecting the episiotomy (if present) and palpating for any hematomas. The episiotomy is not palpated due to the pain associated with it, and the nurse can visually inspect it.
A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply. Hemorrhoidal discomfort Iron supplements Perineal pain Intake of too many fluids Poor diet after delivery
Perineal pain Hemorrhoidal discomfort Iron supplements Explanation: After delivery, many women experience a great deal of perineal pain, as well as hemorrhoidal pain, which leads to constipation because the woman is reluctant to defecate, fearing pain. Additionally, iron supplements contribute to constipation also.
When teaching an unlicensed assistant personnel (UAP) how to provide perineal care on a postpartum woman, the nurse would include which steps? Select all that apply. Place a protective pad under the client's buttocks. Separate labia and clean discharge using spray bottle. Wash hands and put on a pair of sterile gloves. Place the client in high-Fowler position. Remove perineal pad in the direction of front to back.
Place a protective pad under the client's buttocks. Remove perineal pad in the direction of front to back. Explanation: Before beginning perineal care, the nurse should be certain to wash the hands well and don clean, not sterile, gloves. The nurse should then place a plastic-covered pad under the woman's buttocks to protect the bed from lochia or water. With the woman lying supine, the nurse should remove the perineal pad from front to back. A common method of cleaning is to spray the perineum with clear tap water from a spray bottle. When doing this, the nurse should direct the spray toward the front of the perineum and allow it to flow from front to back, from the vaginal to the rectal area, to reduce cross-bacterial transmission into the vagina. The labia have a tendency to close and cover the vaginal opening, and the nurse should not separate the labia.
Which intervention(s) will the nurse recommend for a breastfeeding mother diagnosed with mastitis? Select all that apply. Encourage client to breastfeed the infant every 3 to 4 hours Take antibiotics as prescribed Apply warm compresses to the affected breast PRN Take acetaminophen as needed for pain Rub expressed breast milk on the nipples after each feeding session Do not breastfeed from the affected breast
Take antibiotics as prescribed Apply warm compresses to the affected breast PRN Rub expressed breast milk on the nipples after each feeding session Take acetaminophen as needed for pain Explanation: A woman with mastitis is encouraged to continue breastfeeding her infant, and it is recommended to breastfeed about every 2 hours, while the infant is awake. Application of warm compresses helps reduce the discomfort of the infection and encourage healing. The primary health care provider will prescribe antibiotics and the client should complete the regimen. Mastitis can result when bacteria enters through cracks in the nipples. Rubbing breastmilk on the nipples after feeding helps reduce cracks, therefore decreasing the chance of the client experiencing mastitis again. Acetaminophen is safe to take while breastfeeding. The client can still breastfeed from the affected breast. However, if it is too painful, the client must express milk from the breast manually or with a pump to prevent engorgement (also a cause of mastitis) and promote continued milk production.
Which interventions would the nurse take to reduce the incidence of infection in a postpartum woman? Select all that apply. Wash her hands before and after caring for the client. Encourage intake of fluids following delivery and after discharge. Recommend that the mother change her peripads every 12 hours. Teach proper positioning of the infant for breastfeeding. Have the mother maintain a low activity level to allow the perineum to heal.
Teach proper positioning of the infant for breastfeeding. Encourage intake of fluids following delivery and after discharge. Wash her hands before and after caring for the client. Explanation: To reduce the incidence of postpartum infection, the nurse would always wash her hands before and after caring for the client or her infant. The nurse should also recommend adequate fluid intake to encourage urination and prevent urinary retention, which can lead to a UTI. By teaching proper positioning of the infant for breastfeeding, the frequency of cracked nipples is reduced and cracked nipples can cause mastitis. Peripads are changed more frequently than every 12 hours and perineal care is provided. Early ambulation, rather than little activity, is recommended to strengthen the mother's immune system.
Which client should the postpartum nurse assess first after receiving shift report? The 3-day postpartum client who has a pulse of 50 bpm. The 1-day postpartum client who has a respiratory rate of 20 breaths/minute. The 2-day postpartum client who has a blood pressure of 138/90 mm Hg. The 12-hour postpartum client who has a temperature of 100.4° F (38° C).
The 2-day postpartum client who has a blood pressure of 138/90 mm Hg. Explanation: The postpartum client with a blood pressure of 138/90 mm Hg is showing signs of hypertension and should be seen first to assess for preeclampsia. Preeclampsia can occur during the postpartum period. A pulse rate of 50 bpm and a respiratory rate of 20 breaths/minute are within the normal range. A fever of 100.4° F (38° C) or less during the first 24 hours postpartum is common.
The nurse inspects the client's perineum and finds it is red, swollen, and tender. The nurse explains to the client that she needs to be monitored for blood loss, especially because of bleeding into the tissue of the perineum because of the third degree laceration sustained while giving birth. What parameters will the nurse assess to detect signs of additional blood loss? Select all that apply. Blood pressure Urine output Pulse rate Amount of lochia Uterine fundus
Urine output Blood pressure Pulse rate Explanation: Assessment findings consistent with blood loss are increased pulse rate, decreased blood pressure, and decreased urine output. Bleeding into the perineal tissue may not be visible, therefore monitoring these parameters is important. Because bleeding is related to the laceration, uterine involution is not impacted and the assessment of the fundus is not going to provide useful data. Similarly, the amount of lochia will not provide useful data about bleeding into the perineal tissue.
A nurse is reviewing the labor and birth record of a postpartum woman. The nurse determines the need for frequent monitoring for infection based on which factors in the woman's history? Select all that apply. Use of fetal scalp electrode for internal fetal monitoring Rupture of membranes of 10 hours duration Use of regional anesthesia for birth Forceps-assisted vaginal birth History of gestational diabetes
Use of regional anesthesia for birth Use of fetal scalp electrode for internal fetal monitoring Forceps-assisted vaginal birth History of gestational diabetes Explanation: Factors that increase a woman's risk for postpartum infection include: prolonged rupture of membranes (greater than 18 to 24 hours); regional anesthesia that decreases perception of need to void; insertion of fetal scalp electrode or intrauterine pressure catheters for internal fetal monitoring during labor (provides entry into uterine cavity); instrument-assisted childbirth, such as forceps or vacuum extraction (increases risk of trauma to genitalia); and gestational diabetes (decreases body's healing ability and provides higher glucose levels on skin and in urine, which encourages bacterial growth).
A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. Maintain correct posture. Use good body mechanics. Use of witch hazel pads. Use of anesthetic sprays. Use of warm sitz baths.
Use of warm sitz baths. Use of anesthetic sprays. Use of witch hazel pads. Explanation: The nurse should tell the client to use warm sitz baths, witch hazel pads, and anesthetic sprays to provide local comfort. Using good body mechanics and maintaining a correct position are important to prevent lower back pain and injury to the joints.
A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings should be reported to the assigned nurse? Select all that apply. Fundal height is one fingerbreadth below the umbilicus. The client's abdomen is mildly distended and bowel sounds are hypoactive. The client reports breakthrough pain level of 7-8. Bleeding is noted on the abdominal dressing 2 x 5 cm in size. Uterus feels boggy.
Uterus feels boggy. The client reports breakthrough pain level of 7-8. Explanation: Following a cesarean section delivery, the client may experience numerous discomforts and problems. In this incidence, the fundal height is normal, the amount of bleeding is not abnormal, and mild abdominal distention with hypoactive bowel sound is expected. The concerning findings that need to be reported to the RN are the boggy uterus and the increased pain level. A boggy uterus can lead to hemorrhage and the pain level of 7-8 needs to be addressed with ordered narcotics.
A nurse is assisting a postpartum client out of bed to the bathroom for the first time. Which interventions would be most appropriate? Select all that apply. Sit her in a chair after getting out of bed before going to the bathroom. Frequently ask the client how her head feels. Elevate the head of the bed for several minutes before getting her up. Check her blood pressure after she stands up. Walk alongside the client to the bathroom.
Walk alongside the client to the bathroom. Elevate the head of the bed for several minutes before getting her up. Frequently ask the client how her head feels. Explanation: One of the safety concerns during the postpartum period is orthostatic hypotension. When the woman rapidly moves from a lying or sitting position to a standing one, her blood pressure can suddenly drop, causing her pulse rate to increase. She may become dizzy and faint. Appropriate interventions include: checking blood pressure first before ambulating the client; elevating the head of the bed for a few minutes before ambulating the client; having the client sit on the side of the bed for a few moments before getting up; helping the client to stand up, and staying with her; ambulating alongside the client and providing support if needed; and frequently asking the client how her head feels. Having her sit in the chair after getting out of bed would be inappropriate because the client's blood pressure may already have dropped.
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. hypotension obesity precipitous birth cesarean birth maternal age greater than 30
cesarean birth obesity Explanation: If a new mother experiences a postpartum venous thromboembolism, she may have medical as well as obstetrical risk factors. These factors include a maternal age greater than 35 years, obesity, cesarean birth, and a prolonged labor. Hypertension, not hypotension, is a risk factor.
preparing for a birth education class for a group of pregnant women and their partners, the nurse will be describing the uterine involution changes that occur after the pregnancy. Which information will be included in the class? Select all that apply. contraction of muscular fibers return to its prepregnancy size approximately 1 week after birth the importance of Kegel exercises to prevent involution regeneration of the uterine epithelium catabolism of the individual myometrial cells
contraction of muscular fibers catabolism of the individual myometrial cells regeneration of the uterine epithelium Explanation: Involution involves three retrogressive processes: contraction of the muscle fibers; catabolism of the individual myometrial cells; and regeneration of the uterine epithelium from the lower layer of the decidua after the upper layers have been sloughed off. At approximately 1 week after birth, the uterus shrinks in size by 50%; at the end of 6 weeks it should reach approximately the size as its prepregnancy weight.
A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. frequent trips to the bathroom due to diuresis crying baby inability to get adequate pain relief excess fatigue and overstimulation by visitors bottle feeding
crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors Explanation: The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.
The nurse is caring for a client who had been administered an anesthetic block during labor. For which risks should the nurse watch in the client? Select all that apply. urinary retention ambulation difficulty incomplete emptying of bladder bladder distention perineal laceration
incomplete emptying of bladder bladder distention urinary retention Explanation: Many women have difficulty with feeling the sensation to void after giving birth if they have received an anesthetic block during labor, which inhibits neural functioning of the bladder. This client will be at risk for incomplete emptying, bladder distention, difficulty voiding, and urinary retention. Ambulation difficulty and perineal lacerations are due to episiotomy.
The nurse explains to a client who recently gave birth that she will undergo both retrogressive and progressive changes in the postpartal period. Which changes are retrogressive? Select all that apply. beginning of a parental role formation of breast milk involution of the uterus return of blood volume to prepregnancy level decrease of pregnancy hormones contraction of the cervix
involution of the uterus contraction of the cervix decrease of pregnancy hormones return of blood volume to prepregnancy level Explanation: Retrogressive changes represent a return to prepregnancy conditions and include involution of the uterus, contraction of the cervix, decrease of pregnancy hormones, and return of the blood volume to prepregnancy level. Progressive changes involve changes to new processes or roles, such as the formation of breast milk (lactation) and the beginning of a parental role.
Which findings would lead the nurse to suspect that a postpartum woman has developed endometritis? Select all that apply. leukocytosis foul-smelling lochia hematuria flank pain pain on both sides of the abdomen
pain on both sides of the abdomen foul-smelling lochia leukocytosis Explanation: Signs and symptoms of endometritis 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 woman presents to her first postpartum visit reporting she does not feel well. Which findings would lead the nurse to suspect that she has developed endometritis? Select all that apply. flank pain hematuria odorless lochia pain on both sides of the abdomen leukocytosis
pain on both sides of the abdomen leukocytosis Explanation: Signs and symptoms of endometritis 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.