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

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 they frequently indulge 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 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 life is rapidly tumbling out of control. The client thinks of oneself 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 characteristic of postpartum blues.

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?" The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.

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.

A postpartum 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.

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. The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

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. If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention 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 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 position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

It is discovered that a new mother has developed a postpartum 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 (38.8°C) orally. As fever would accompany a postpartum 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 postpartum infection as does the reduced temperature.

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 endometritis, but some species of Klebsiella may cause urinary tract infections.

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

Perform handwashing before breastfeeding. 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.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response?

Pierced nipple 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.

A woman arrives at the office for her 4-week postpartum 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.

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.

The nurse palpates a postpartum 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 bladder is distended If a postpartum client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.

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.

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

a client who had 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. The other listed factors are not noted risk factors for infection.

The nurse suspects that a mother who delivered her infant 2 weeks ago is experiencing postpartum depression. What is the first line of treatment for this client?

administrating a selective serotonin reuptake inhibitor Selective serotonin reuptake inhibitors are the first-line drugs for postpartum depression and will help the new mother cope with the stresses of motherhood. They are also safe for breastfeeding mothers. Electroconvulsive therapy is used on women who are not responsive to medications. Minimizing the importance of the depression is counterproductive and not supportive of the mother.

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

applying ice Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not 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.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

blood pressure, pulse, reports of dizziness 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 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.

The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?

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 34), and multiparity.

The nurse is administering methylergonovine 0.2 mg to a postpartum client with uterine subinvolution. Which assessment will the nurse need to make prior to administering the medication?

if blood pressure is lower than 140/90 mmHg Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

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 fungus 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. Ergonovine maleate 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.

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 The way to monitor for bleeding every hour is to assess pads and percentage of the 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 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.

The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain?

semi-fowler A semi-Fowler 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 not accomplish this goal and could result in the infection spreading to other parts of the body.

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

1000 ml Postpartum hemorrhage (PPH) is defined as a cumulative blood loss greater than 1,000 ml with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery. Morbidity from PPH can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization. Hemorrhage is the most common reason postpartum women are admitted to intensive care units and it is the most preventable cause of maternal death.

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?

Ambulate the client as soon as her vital signs are stable. The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

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. To help prevent the occurrence of postpartum thromboembolic complications, the nurse should instruct the client to avoid sitting or standing in one position for long periods of time. This prevents venous pooling. The nurse should instruct the client to perform postoperative deep-breathing exercises to improve venous return by relieving the negative thoracic pressure on leg veins. The nurse should instruct the client to prevent venous pooling by avoiding the use of pillows under the knees. Elevating the legs above heart level promotes venous return, and therefore the nurse should encourage it.

The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately?

Dyspnea A DVT is often suspected when an individual with an increased risk develops calf pain, pyrexia, and edema in one lower extremity. After the individual has been positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible pulmonary embolism and should be handled as an emergency. The RN and/or primary care provider should be notified immediately so emergent care can be started, as this is often fatal.

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Finish all antibiotics to decrease a genital tract infection. A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.

A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential?

Meticulous handwashing Meticulous handwashing is essential for preventing postpartum infections, including before and after each client care activity. Aseptic technique, not clean gloves, are needed when performing invasive procedures. All visitors should be screened for any signs of active infection to reduce the risk for exposure. Adequate hydration, not fluid limitations, would be appropriate.

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

Postpartum depression develops gradually, appearing within the first 6 weeks 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.

The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?

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

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. Mastitis is an infection of the breast characterized by flu-like 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 providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?

encourage fluid intake Adequate fluid intake is necessary during antibiotic therapy. Mobility should be encouraged whenever possible and safe. Small meals do not enhance healing or mitigate adverse effects. Antacids may or may not be prescribed.

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply.

The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill.

A nurse is assessing a client with postpartum 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.

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.

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 (38° 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.

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 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 woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.3°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 mental health clinical nurse specialist is teaching a postpartum nurse how to use the Postpartum Depression Predictor Scale (PDSS) to assess for postpartum depression. The nurse specialist determines the need for additional teaching when the nurse identifies which component as being screened with the scale?

family and social support system The PDSS is a self-report, 35-item Likert-type response scale divided into seven conceptual domains: anxiety/insecurity; sleep/eating disturbance; emotional lability; loss of self-esteem; guilt/shame; cognitive impairment; and suicidal thoughts.

A woman who delivered her infant by cesarean section 1 week ago called her physician's office to report chills, fever of 101.6℉ (38.7℃) and a poor appetite. She also tells the nurse that she is having strong afterbirth pains and her lochia has increased in volume and has an odor. Lab work shows an elevated WBC count. Which of these reported findings is the most significant finding related to the suspected diagnosis of endometritis?

fever Increased temperature is the most significant finding in this time period to support the suspicion of endometritis. The other findings are usually seen in this illness but the fever is the most significant finding. An elevated WBC count can be seen in a normal postpartal woman with values of up to 20,000 to 30, 000/ mm3.

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.

foul-smelling lochia tender uterus strong afterpains swollen, warm breast Endometritis is an infection of the uterine lining. Assessment findings include a tender uterus, foul-smelling lochia, and strong afterbirth pains. A fluctuant perineal mass would be consistent with a hematoma. A swollen, warm breast at day 4 would be consistent with breast engorgement.

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

lack of pleasure

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.

placental abruption severe preeclampsia septicemia DIC is not itself a specific illness; rather it is always a secondary diagnosis that occurs as a complication of placental abruption, anaphylactoid syndrome of pregnancy, intrauterine fetal death with prolonged retention of the fetus, acute fatty liver of pregnancy, severe preeclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), septicemia, and postpartum hemorrhage.

Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of:

postpartum depression Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.

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 as soon as possible.

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.