Postpartum & Postpartum Complications

The home-care nurse is caring for a postpartal client and suspects the development of postpartum psychosis. Which client findings support the nurse's judgment? SELECT ALL THAT APPLY 1. Has a history of a bipolar (manic-depressive) disorder 2. Reports voices telling her the baby is evil and must die 3. Can't remember details of delivery or when the infant fed last 4. Is tearful without an identifiable reason 5. Is calm and remains seated during the home visit

1, 2, 3. Postpartum psychosis usually becomes evident within three months of delivery. Delusions and hallucinations are common. The risk for suicide or infanticide is increased by the psychotic woman's distorted thoughts about herself or the baby. The psychotic woman would typically display agitation, hyperactivity, and confusion. Adjustment reaction with depressed mood, commonly known as maternal or baby blues occurs in 50-70% of women and is characterized by feelings of fatigue, anxiety, or being overwhelmed by the new maternal role. A key feature is episodic tearfulness without reason that typically occurs within a few days of birth and resolves spontaneously about the 10th postpartal day.

The nurse would assess for which common causative factor in a client who shows signs of retarded uterine involution? SELECT ALL THAT APPLY 1. The use of general anesthesia 2. Overdistended urinary bladder 3. Mother is a primigravida 4. Uterine infection 5. Prolonged labor

1, 2, 4, 5. Among the factors contributing to uterine subinvolution are prolonged labor (frequent contractions), general anesthesia (muscle relaxant), over distended urinary bladder and uterine infection, among others. Being a primigravida is not necessarily associated with subinvolution.

Which intervention should be included when caring for a client with a midline episiotomy with a third-degree laceration? SELECT ALL THAT APPLY 1. Increase fiber in diet. 2. Administer bisacodyl (Dulcolax) suppository. 3. Increase fluid intake. 4. Administer an oral stool softener. 5. Administer an enema.

1, 3, 4. A third- or fourth-degree perineal laceration involves the rectal sphincter, therefore suppositories, enemas, and rectal exams are contraindicated until the rectum heals. Increased fiber and fluids or use of stool softeners are appropriate to promote bowel elimination in all postpartum clients.

The nurse should monitor which postpartum clients who are at high risk for thrombophlebitis? SELECT ALL THAT APPLY 1. A client who had a cesarean delivery 2. A client of normal pre-pregnant weight 3. A client who has five children 4. A client who smokes cigarettes 5. A client who kept active during pregnancy

1, 3, 4. The postpartal woman is prone to develop superficial thrombophlebitis from increased clotting factors, increased number and adhesiveness of platelets during the postpartal period. Numerous factors place clients at risk. Among the most common are cesarean deliveries, lack of mobility, obesity, cigarette smoking, previous history, trauma such as leg stirrups during birth, varicosities, diabetic mothers, multiparas, and anemia.

Which laboratory finding should the nurse assess further on a client 24 hours after delivery? 1. Hemoglobin 7.2 g/dL 2. WBC count 20,000/mm^3 3. Trace to 1+ proteinuria 4. Hematocrit 35%

1. A client with a hemoglobin of 7.2 g/dL would most likely have significant signs and symptoms of anemia, and this could be life-threatening. It would be important to determine if the client had a large estimated blood loss during delivery or if she is currently bleeding excessively. The hematocrit is within normal limits, and mild proteinuria or leukocytosis up to 30,000/mm^3 are common in early postpartum.

Which assessment should alert the nurse to withhold the scheduled dose of methylergonovine maleate (Methergine) for a postpartum client and notify the health care provider? 1. Blood Pressure 142/86 2. Apical Pulse 56 3. Blood type O positive 4. Mother is planning to breastfeed

1. A potential side effect of Methergine is hypertension. If a client's blood pressure is elevated, the nurse should withhold the scheduled dose and notify the physician. An apical heart rate of 56 is within normal limits postpartum. Blood type and Rh factor are not related to the use of Methergine. The chosen method of feeding is not impacted by the use of Methergine.

A new mother complains of "afterpains." The nurse's first action should be to do which of the following? 1. Administer an analgesic. 2. Advise her to stop breastfeeding until the pain stops. 3. Encourage her to empty her bladder. 4. Assess her vital signs.

1. Afterpains are anticipated in the postpartum client and are effectively treated with analgesics. It is unnecessary to stop breastfeeding, empty the bladder, or assess vital signs.

A client delivered 90 minutes ago. She is alert and physically active in bed. She states that she needs to go to the bathroom. What is the nurse's most appropriate response? 1. "I'll walk you to the bathroom and stay with you." 2. "I'll get a bedpan for you." 3. "It's important that you wipe yourself from front to back after urinating." 4. "Wipe the stitches back and forth to increase circulation."

1. Clients are at risk for orthostatic hypotension, especially right after delivery. The nurse should stay with the client the first time she ambulates after delivery to promote safety. Early ambulation prevents circulatory stasis in the lower extremities and should be encouraged. The perineum should be patted (not wiped) dry from front to back to avoid trauma, discomfort, and contamination with bacteria from the anal region. It is unnecessary to use a bedpan.

This is the first postoperative day for a client who had a cesarean delivery. The client asks the nurse why she has to get up and walk when it hurts her incision so much. What would the nurse include in a response? 1. Walking decreases the risk of blood clots after surgery. 2. Walking encourages deep breaths to blow off the anesthetic from surgery. 3. Early ambulation is important to stimulate milk production. 4. Walking will decrease the occurrence of afterpains.

1. Clients who have had a cesarean delivery are at risk for complications of surgery, including thrombophlebitis. Early ambulation can significantly decrease the risk of blood clots and other postoperative complications.

The nurse interprets that which factor in a client's history places the woman at greatest risk for postpartum endometritis? 1. Cesarean delivery after 24 hours of labor and failure to progress 2. Use of external fetal monitoring during labor 3. Ruptured membranes for four hours prior to delivery 4. Spontaneous vaginal delivery after eight hours of labor

1. Factors contributing to postpartum endometritis include the introduction of pathogens with invasive procedures, prolonged labor, and prolonged rupture of membranes. The risk of endometritis is greater after a cesarean delivery, especially after a long labor and prolonged rupture of membranes. The other options are neither invasive nor do they increase the client's risk for infection.

After delivery of a large-for-gestational-age infant the nurse notes bright red blood continuously trickling from the client's vagina. Her fundus is firm and midline. The nurse suspects which of the following as the most likely cause of bleeding? 1. Lacerations 2. Hematoma 3. Uterine atony 4. Retained fragments of conception

1. Suspect lacerations if the client is bleeding and the fundus is firm. If the cause were uterine atony, the fundus would not be firm. When there are fragments of the placenta or the membranes, the uterus will not contract effectively.

A client has a temperature of 100.2F four hours after delivery. What is the appropriate action for the nurse to take? 1. Encourage increased fluid intake. 2. Do nothing since this is an expected finding at this time. 3. Check the physician's orders for an antibiotic to treat the client's infection. 4. Medicate the client for pain.

1. Temperature elevation immediately after delivery is often caused by dehydration during labor. Increasing the client's fluid intake will usually decrease the temperature to within normal limits. There is no indication for analgesia or antibiotics at this time. If the fever persists beyond 24 hours or the client has clinical signs of infection, then further investigation and perhaps treatment is warranted.

The client is a 36-year-old woman, gravid 6 and para 6, who delivered a 7 pound, 14 ounce baby girl at term after an eight-hour labor. The client's vital signs are stable, and her lochia is bright red, heavy, and contains various clots; some are half dollar size. The nurse would consider the client to be at high risk for uterine atony for which reason? 1. Grandmultiparity 2. Large for gestational age baby 3. Labor of long duration 4. Advancing maternal age

1. Women that are parity of six or above (grandmultiparity) are at the greatest risk of uterine atony because of repeated distention of uterine musculature during pregnancy. Labor leads to muscle stretching, diminished tone, and muscle relaxation. The client's age is not a factor in uterine atony, the length of labor is not considered to be prolonged or precipitous, and the size of the baby is considered appropriate for gestational age, and is not considered to be macrosomic.

If the nurse suspects a uterine infection in the postpartum client, the nurse should make which priority assessment? 1. Pulse and blood pressure 2. Odor of the lochia 3. Episiotomy site 4. The abdomen for distention

2. An abnormal odor of the lochia indicates infection in the uterus. The vital signs may be affected by an infection, but that is not definitive enough to suspect a uterine infection. A distended abdomen usually indicates a problem with gas, perhaps a paralytic ileus. Inspection of the episiotomy site would not provide information regarding a uterine infection.

The infant of a breastfeeding client was transferred to the neonatal intensive care unit because of respiratory distress. The nurse interprets that follow-up teaching has been effective when the client states which reason to pump the breasts? 1. Prevent breast engorgement 2. Stimulate the milk supply 3. Remove the infected milk 4. Keep the uterus contracted

2. Breast-milk production is based on supply and demand. The more the breasts are stimulated to produce milk, by nursing the baby or pumping the breasts, the more milk will be produced.

A client who had a vaginal delivery had an episiotomy prior to birth. The maternal newborn nurse would evaluate the client's perineum following delivery using which method? 1. REDA - redness, edema, discharge, approximation 2. REEDA - redness, edema, ecchymosis, discharge, approximation 3. REAA - redness, edema, approximation, assessment 4. RED - redness, edema, discoloration

2. Nursing assessment of the perineum includes the following observations, which are abbreviated as REEDA: redness, edema, ecchymosis, discharge, and approximation.

A client's vital signs following delivery are: (Day 1) BP 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; (Day 3) BP 114/80, T 101.6, P 80. The nurse should suspect which of the following about the client's status? 1. Is dehydrated 2. May have an infection 3. Has normal vital signs 4. Is going into shock

2. The vital signs are not normal. An elevation in body temperature greater than 100.4F after the first 24 hours postpartum could indicate maternal infection. An elevated temperature within the first 24 hours is usually related to dehydration, although the possibility of infection still exists. Rising pulse and falling blood pressure rather than rising temperature is an indicator of hypovolmeic shock.

While assessing the incision of a client two days after cesarean delivery, the nurse notes the skin edges around the incision are red, edematous, and tender to the touch. A scant amount of purulent drainage is noted. What is the most appropriate initial action by the nurse? 1. Cleanse the wound with providone iodine (Betadine). 2. Notify the physician. 3. Document this expected response. 4. Observe the incision closely for the next 24 to 48 hours.

2. This client has signs of an incisional infection. The physician needs to be notified first so that treatment can be started as soon as possible. Betadine has not yet been ordered. Documentation should follow reporting. Continued observation would be an ongoing intervention.

The nurse is assessing a client's fundus and finds it firm, two centimeters above the umbilicus, and displaced to the right. What is the most appropriate intervention at this time? 1. Massage the fundus until firm. 2. Have the client void and reassess the fundus 3. Notify the physician 4. Start a pad count

2. This client's fundus is already firm, so it is not appropriate to massage the fundus. It is also higher in the abdomen than expected, and it is displaced to the right, which is probably caused by a distended bladder. Having the client void may return the uterus to the expected position; palpating the fundus after voiding will confirm this finding. A pad count would be appropriate if bleeding is increasing; no information given implies that this action is indicated.

The nurse is caring for a client who has decided not to breastfeed. What should the nurse include in client teaching to promote lactation suppression? SELECT ALL THAT APPLY 1. Applying warm compresses 2. Pumping the breasts 3. Applying ice bags 4. Using medication to suppress lactation 5. Binding the breasts, either with a snug bra or binder

3, 5. Binding the breasts, either with a snug bra or binder, and applying cold to the breasts will help suppress lactation. Milk supply is stimulated by expressing milk and applying heat to the breasts. Medications to suppress lactation are not recommended.

The nurse is preparing to instruct a new mother on resuming sexual intercourse postpartum. The nurse should include which of the following in the teaching plan? SELECT ALL THAT APPLY 1. Pregnancy is not possible prior to the first menses postpartum. 2. An IUD is an appropriate method of birth control in the early postpartum period. 3. Wait until the episiotomy has healed and the lochia has stopped before resuming intercourse. 4. Refrain from intercourse until the first menstrual period after delivery is completed. 5. A water-soluble lubricant may be used if necessary.

3, 5. Having sexual intercourse before the episiotomy is healed or the lochia has stopped increases the risk of infection. Water-soluble lubricants can be used, if necessary. An IUD is contraindicated during the early postpartum period.

Which intervention, if medically prescribed and then carried out by the nurse, would have the most direct effect on reducing postpartum hemorrhage? 1. Continuous fundal massage to decrease bleeding and contract the uterus 2. Trendelenburg position to facilitate cardiac function 3. Bladder catheterization to maintain uterine contraction 4. Administration of a tocolytic drug

3. A full bladder may cause uterine atony and contribute to bleeding. If a client has hemorrhaged, a Foley catheter may also be needed to allow accurate measurement of urine output, which is an indicator for kidney function. Overly aggressive stimulation of the fundus may cause decreased uterine tone; this is detrimental because overstimulation of the uterine muscle fibers can contribute to uterine atony. Avoid the Trendelenburg position because it has been reported to interfere with cardiac and respiratory function by increasing pressure on chemoreceptors and decreasing the area for lung expansion. A tocolytic agent relaxes the uterus; in this case, an oxytocic drug to contract the uterus would be indicated.

On the client's third postpartum day, the nurse enters the room and finds the client crying. The client states that she does not know why she is crying and she cannot stop. What is the most appropriate reply by the nurse? 1. "There is no need to cry, you have a healthy baby." 2. "Are you dissatisfied with your care? I will see that any issues are addressed." 3. "Many new mothers have shared with us their same confusion of feelings, would you like to talk about them?" 4. "This happens to lots of mothers, and be reassured that it will pass with time."

3. Creating an environment where a client and her family can discuss emotional concerns is essential. Sharing time with the new mother to discuss thoughts and feelings is important to clients. Responding with patronizing answers does nothing to assist the mother to talk about her thoughts and feelings and may increase her sense of isolation and feelings of inadequacy and despair.

The nurse is reviewing infection control policies with a nursing student. The nurse knows that the teaching has been effective when the student states, "The best way to prevent postpartum infection starts 1. in the recovery room with strict use of sterile technique when palpating the fundus." 2. on the postpartum unit by teaching the client the principles of perineal care." 3. by limiting the number of sterile vaginal exams during labor." 4. when the client goes home by avoiding tub baths until the lochia stops."

3. Even when perfect sterile technique is used when doing a vaginal exam, organisms present on the perineum are transported into the vagina and close to the cervix. By limiting the number of vaginal exams, the risk is decreased. The option discussing technique is incorrect because clean technique, not sterile technique, is used when palpating the fundus. Teaching the client the principles of perineal care and avoiding tub baths until the lochia stops are correct answers, but not the earliest intervention a nurse could perform.

A woman who delivered three weeks ago calls the postpartum unit with breastfeeding questions. She wants to know if she can continue to breastfeed while she has the flu. She states that she feels achy all over and has chills and a fever of 103F. What other question is important for the nurse to ask? 1. "Have you been sleeping well?" 2. "Are you still experiencing vaginal flow?" 3. "Do you have any reddened areas or tenderness on your breasts, or unusual breast discharge?" 4. "Do you have any swelling in your legs or visual disturbances?"

3. Mastitis most frequently occurs at two to four weeks after delivery with initial flu-like symptoms plus breast tenderness and redness. The client may be describing symptoms of a breast infection. Sleep, lochia, and edema with visual disturbances are not associated with breast problems.

It is most important for the nurse to have which drug readily available when the client is being treated with heparin therapy for thrombophlebitis? 1. Calcium gluconate 2. Vitamin K 3. Protamine sulfate 4. Ferrous sulfate

3. Protamine sulfate is the drug used to combat bleeding problems related to heparin overdose. One option raises serum calcium levels; another is the antidote for warfarin, and the other option is an iron supplement.

The nurse is assessing a client 24 hours after delivery and finds the fundus to be slightly boggy and two centimeters above the umbilicus. What should be the nurse's priority nursing intervention? 1. Document this expected finding and check lochia. 2. Assess the mother's vital signs. 3. After having the mother void, gently massage the fundus until firm. 4. Notify the physician and document.

3. The fundus should remain firm after delivery to decrease the risk of postpartum hemorrhage and decrease one centimeter below the umbilicus each day. All nursing interventions presented are appropriate, but massaging the fundus until firm is the most important to prevent hemorrhage. Full urinary bladders can interfere with uterine contraction.

A new mother with mastitis is concerned about breastfeeding while she has an active infection. How should the nurse respond to the client's concern? 1. The infant is protected from infection by immunoglobulins in the breast milk. 2. The infant is not susceptible to the organisms that cause mastitis. 3. The organisms that cause mastitis are not passed in the milk. 4. The organisms will be inactivated by gastric acid.

3. The organisms are localized in breast tissue and are not excreted in the breast milk. The other answers are factually incorrect.

The home health nurse is making a home visit to a postpartal client. The nurse would document and report which of the following as a symptom of infection? 1. Lochia that is pink tinged 2. Apical pulse of 68 3. Generalized abdominal tenderness 4. Oral temperature of 99.2F

3. The signs of a postpartal infection would include a temperature of greater than 100.4F on two successive days after the first 24 postpartal hours, tachycardia, foul-smelling lochia, and pain and tenderness of the abdomen. The pinkish lochia is normal, and the temperature might indicate a cold or breast milk coming in. Bradycardia would be an unrelated finding.

Which sign of thrombophlebitis should the nurse instruct the postpartum client to look for when at home after discharge from the hospital? 1. Muscle soreness in her legs after exercise 2. Enlarging varicose veins in her legs 3. Localized posterior leg tenderness, heat, and swelling 4. New areas of ecchymosis

3. These are classic signs of thrombophlebitis that appear at the site of inflammation; the other signs listed are not.

Which of the following actions by a lactating client would the nurse support to help the client prevent mastitis? SELECT ALL THAT APPLY 1. Apply vitamin E cream to soften the nipples. 2. Wear a tight, supportive bra. 3. When the client's nipples are sore, offer the infant a bottle. 4. Encourage the client to breastfeed her infant frequently. 5. Teach breastfeeding techniques soon after birth and reinforce as needed.

4, 5. Preventing stasis of the milk and emptying the breast frequently will help prevent mastitis. Vitamin E cream will not help to prevent mastitis. A supportive bra is helpful, but a bra that is tight will not be comfortable. Offering a bottle will reduce the milk supply if it occurs frequently and will not help mastitis.

Because postpartum depression occurs in 3 to 30% of postpartum women, the prenatal nurse assesses clients for risk factors for postpartum depression during the prenatal period. Which clients would the nurse consider to be at risk for postpartum depression? SELECT ALL THAT APPLY 1. A client who is an unmarried primipara with family support 2. A client who has previously had postpartum blues 3. A client who is primipara with documented ambivalence about her pregnancy in the first trimester 4. A client who is a primipara with a history of depression and lack of a supportive relationship 5. A client who is a primipara living alone and was consistently ambivalent about pregnancy

4, 5. Risk factors for postpartum depression include primiparity, ambivalence about maintaining the pregnancy throughout the pregnancy, history of previous depression or bipolar illness, lack of a stable support system, lack of a stable relationship with parents or partner, poor body image, and lack of a supportive relationship with parents, especially her father as a child. Ambivalence regarding pregnancy is a normal response in the first and into the second trimester, but should be resolved by the third trimester. Postpartum blues occurs in approximately 50 to 80% of postpartum women; the blues does not particularly indicate that a woman will develop postpartum depression.

A postpartum client develops a temperature during her postpartum course. Which temperature measurement indicates to the nurse the presence of postpartum infection? 1. 99.0F at 12 hours post delivery that decreases after 18 hours 2. 100.2F at 24 hours post delivery that decreases the second postpartum day 3. 100.4F at 24 hour post delivery that remains until the second postpartum day 4. 100.6F at 48 hours post delivery that continues into the third postpartum day

4. A temperature elevation greater than 100.4F on two postpartum days not including the first 24 hours meets the criteria for infection. This criterion is the most common standard in the United States. It is not abnormal for a postpartum client to run a low-grade fever in the first 24 hours. This can be caused by the body's reaction to labor, dehydration, or a reaction to epidural anesthesia. Postpartum nurses should assess other signs and symptoms of infection in addition to fever and WBCs when evaluating the possibility of infection in mothers who had epidural analgesia.

Which instruction should the nurse include in the discharge teaching plan to assist the postpartum client to recognize early signs of complications? 1. Expect to pass clots, which occasionally can be the size of a golf ball. 2. Report a decrease in the amount of brownish-red lochia. 3. Palpate the fundus daily to make sure it is soft. 4. Notify the health care provider of increased lochia or bright red bleeding.

4. An increase in lochia or a return to bright red bleeding after the lochia has changed to pink indicates a complication. The other statements are false.

A client delivered a 9 pound, 10 ounce infant assisted by forceps. When the nurse performs the second 15-minute assessment, the client reports increasing perineal pain and a lot of pressure. What action should the nurse take? 1. Apply ice to the client's perineum, reassuring the client that this is normal. 2. Call for assistance from another nurse. 3. Assess the fundus for firmness. 4. Check the perineum for a hematoma.

4. Bleeding into the connective tissue beneath the vulvar skin may cause the formation of vulvar hematoma, which develop as a result of injury to tissues with spontaneous as well as operative deliveries (use of forceps). One of the first signs of a hematoma may be complaint of pressure, pain, or an inability to void. An ice pack to the perineum can be used to reduce swelling, but a hematoma is abnormal and should be reported to the physician. The fundus should be assessed, but the client's complaints warrant perineal or vaginal assessment.

Despite the nurse's attempt to massage a boggy fundus, a postpartum client continues to pass several large clots in the presence of bright red lochia. The uterine fundus remains boggy and fundal massage and oxytocin (Pitocin) are not successful. What medication does the nurse expect to be prescribed next? 1. Dinoprostone (Cervidil) 2. Terbutaline sulfate (Brethine) 3. Magnesium sulfate 4. Carboprost (Prostin 15-M or Hemabate)

4. Cervidil is used to ripen the cervix before labor, terbutaline sulfate is a tocolytic, and could cause further muscle relaxation; magnesium sulfate is used to decrease contractions or prevent seizures; and Hemabate is a prostaglandin, used to manage uterine atony. Oxytocin remains the first-line drug, the prostaglandins now are more commonly used as the second-line drug, and Hemabate is the most commonly used uterotonin. As many as 68% of clients respond to a single Hemabate injection, with 86% responding by the second dose.

A client is in the immediate postpartal period after delivery of a 9-pound, 14-ounce baby. The client is a gravid 6, para 5. The nurse notices some new blood stains on the top sheet and discovers the client lying in a pool of blood. The fundus is located above the umbilicus and is boggy. What would be the nurse's priority action? 1. Take the client's blood pressure 2. Have the client empty her bladder 3. Start an IV 4. Massage the uterus

4. Of the options given the only one that immediately affects the bleeding is uterine massage. It might be important to start an IV with oxytocin at a rapid rate, and to allow the client to empty her bladder; however, the first action is to massage the uterus to stop or slow down the blood flow.

The nurse is caring for a woman who gave birth to a daughter yesterday, but greatly desired a son. Today she seems withdrawn, staying in bed and staring at the wall. What is the most appropriate intervention? 1. Monitor this normal response after delivery. 2. Refer the client for a psychiatric consultation. 3. Tell the client she should be thankful her baby is healthy. 4. Encourage the mother to verbalize her disappointment.

4. The client should be encouraged to verbalize her disappointment as the first step in resolving her negative feelings. The other responses are incorrect. This is not a normal response nor is it one that requires a psychiatric referral.

A client's prenatal laboratory findings reveal that she is not immune to rubella. The healthcare provider prescribes rubella vaccine prior to discharge. The nurse concludes that teaching about this medication is effective when the client makes which statement? 1. "I'll need another shot in one month and again in six months." 2. "This shot may cause a fever and make me vomit." 3. "I'll need another shot after each baby I have with Rh-positive blood." 4. "I should not get pregnant for at least three months after the vaccine."

4. The rubella vaccine is a live virus. If a client becomes pregnant within the first three months after administration, her fetus is at risk for congenital anomalies related to the virus. Women who are not rubella immune should be vaccinated postpartum, prior to discharge. Teaching should include an effective method of birth control and the importance of avoiding pregnancy for the next three months.