PrepU OB assignment 5

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

100.4° F (38° C)

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

A client who had a nonelective cesarean birth

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.

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

Measure blood pressure.

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

Obtain a clean-catch urine specimen

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 nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern?

sharp stabbing chest pain with shortness of breath

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

uterine atony

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

On a follow-up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition?

delusional beliefs

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

postpartum psychosis

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

Assess the fundus.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?

Assess the woman's fundus.

The nurse is admitting a postpartum client from five days ago with diagnosis of perineal infection. What nursing intervention is most helpful to decrease pain levels from an 8 out of 10 to a 3 out of 10?

Assist the client with sitz baths

During a home visit, a postpartum patient is complaining of a painful area on one breast. The nurse notes a local area on one breast to be red and warm to touch. For which health problem should the nurse plan care for this patient?

Mastitis

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

Oxytocin Rationale: Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate.

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

Administering an enema

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad

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

Assess for pedal edema.

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

Which of the following would lead the nurse to suspect that a postpartum client is experiencing hypovolemic shock?

Cyanosis and oliguria Rationale: Cyanosis and oliguria would suggest hypovolemic shock. Cyanosis results from vasoconstriction and red blood cell loss, leading to a decreased level of hemoglobin available for oxygen transport. Oliguria indicates decreased renal perfusion. Lightheadedness is a symptom of postpartum hemorrhage. Severe localized pain and increased rectal pressure are the symptoms of post-partum hematoma.

Over 75% of women who give birth experience postpartum depression.

False

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

Her uterus is at the level of the umbilicus.

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

Impaired urinary elimination

A postpartum client calls the nurse to her room and states that she knows something awful is going to happen to her. What should the nurse do?

Report this immediately to the RN

When assessing a client who is 5 days pospartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage?

Rubra colored lochia

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

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

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

White plaques in the mouth Rationale: The patient should be instructed to observe for problems in their infant, such as white plaques or thrush in their infant's mouth that can occur when a portion of the maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant.