woman 2-1

When the nurse performs the Ortolani maneuver, which action would be appropriate? Select all that apply.

Place the newborn in a supine position. Attempt to abduct the hips 180 degrees while applying upward pressure.

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 2-inch lochia stain. This amount should be documented as which type?

Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

Which measurement best describes delayed postpartum hemorrhage?

Postpartum hemorrhage involves blood loss in excess of 500 mL. Most delayed postpartum hemorrhages occur between the fourth and ninth days postpartum. The most common causes of a delayed postpartum hemorrhage include retained placental fragments, intrauterine infection, and fibroids.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection?

Up the reproductive tract

A new mother asks the nurse what she is allowed to do when she goes home from the hospital. Which statement by the nurse would be correct?

You should not lift anything heavier than your infant in its carrier.

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

Check for bladder distention, while encouraging the client to void.

The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client?

"You need to avoid medications which contain acetylsalicylic acid." breastfeeding is generally not recommended for the client on anticoagulation therapy.

A nurse working on the postpartum floor is mentoring a new graduate and instructs the new nurse to make sure that clients empty their bladders. A full bladder can lead to which complication?

increased lochia drainage

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?

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 is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?

Risk for injury: postpartum hemorrhage related to uterine atony

The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize?

Hand washing

A nurse is caring for a client with a postpartum laceration. Which nursing diagnoses would be most appropriate? Select all that apply.

Ineffective tissue perfusion Risk for injury Impaired tissue integrity

A nurse is conducting a prenatal class for some clients who are in their third trimester with the topic being preventing misidentification. The nurse determines the session is successful after the participates correctly choose which items will be on matching identification bracelets?

Information included on the bands is the mother's name, hospital number, care provider's name, newborn's sex, and date and time of birth. The father's name and infant's blood type would not be included on these bracelets which are put on at the time of birth.

When teaching a postpartum client about possible complications following the birth, which would be the best information to include?

Interference with the maternal-newborn attachment process

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

Many antibiotics are nephrotoxic, so the nurse would encourage liberal fluid intake each day to support a urinary output of at least 30 mL/hr. The other three actions are important but not the highest priority for this client.

When teaching a postpartum client about possible complications following the birth, which would be the best information to include?

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

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

Breastfeed or otherwise empty her breasts every 1 to 2 hours

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. Breasts are tender.

The nurse is preparing discharge teaching for a young couple and their infant. Which axillary temperatures should the nurse point out should be reported to the primary care provider?

Temperatures of less than 97.7 ° F (36.5° C) or greater than 100 ° F (37.8° C) should be reported to the primary care provider.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply.

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply.

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

Wrap the infant in a warm, dry blanket.

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply.

lethargy cyanosis jitteriness

The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis?

A woman with diabetes, vaginal birth, HR 110, temperature 101.7° F (38.7° C) on the third postpartum day. The next day, appears ill; temperature now 102.9° F (39.3° C); WBC 31,500 cells/mm&$176;3; negative blood cultures.

The nurse is caring for a client who has given birth to twins. During which time period would the nurse instruct on the possibility of a late postpartum hemorrhage?

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

The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly, bright red blood gushes from the vagina. The nurse recognizes that which occurrence is the most likely cause of this postpartum hemorrhage?

A cervical laceration Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance

Which intervention(s) will the nurse recommend for a breastfeeding mother with diagnosed with mastitis? Select all that apply.

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 to 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.

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.

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

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant.

negative attachment behaviors

Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples

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.

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.

A client who gave birth about 12 hours ago informs the nurse that she has been voiding small amounts of urine frequently. The nurse examines the client and notes the displacement of the uterus from the midline to the right. What intervention would the nurse perform next?

Perform urinary catheterization.

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 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.

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.

age greater than 35 years, obesity, cesarean birth, and a prolonged labor. Hypertension

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: You Selected:

assess and massage the fundus.

A nurse is analyzing a journal article that explains the changes at birth from fetal to newborn circulation. The nurse can point out the closure of the ductus arteriosus is related to which event after completing the article?

higher oxygen content of the circulating blood

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? Select all that apply.

bleeding gums tachycardia acute renal failure The nurse should monitor for bleeding gums, tachycardia, and acute renal failure to assess for an increased risk of disseminated intravascular coagulation in the client. The other clinical manifestations of this condition include petechiae, ecchymosis, and uncontrolled bleeding during birth. Hypotension and amount of lochia greater than usual are findings that might suggest a coagulopathy or hypovolemic shock.

A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn?

bringing the newborn into the room.

A nurse is making a home visit to the parents of a newborn. This is their first baby. During the visit, the nurse observes the parents interacting with their newborn and notes that they demonstrate responsible behaviors to promote the infant's growth and development. The nurse interprets this behavior as reflecting:

centrality.

endometritis

fever of 100.4°F (38°C) or higher, usually between the 2nd and 10th day after delivery; tachycardia, chills, anorexia, and general malaise;

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

pain on both sides of the abdomen foul-smelling lochia leukocytosis

Disseminated intravascular coagulation

premature separation of the placenta, a missed early miscarriage, or fetal death,

It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:

the level of the umbilicus. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Quickly determining the cause of postpartum hemorrhaging enables effective treatment. A nurse using the 4 Ts tool will recognize which potential causes of postpartum hemorrhage? Select all that apply.

tone, tissue, thrombin, trauma

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?

uterine atony. Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage.

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

uterine tone estimated amount of blood loss vital signs

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

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

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

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

A nurse is developing a plan of care for a woman who has had a spontaneouls vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information?

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

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

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

Impaired urinary elimination Due to the nature and location of a postapartum hematoma, impaired urinary elimination would be the best choice. Urination is impaired from swelling. Ineffective tissue perfusion and impaired tissue integrity are nursing diagnoses associated with postpartum lacerations. Deficient fluid volume is a nursing diagnoses associated with postpartum hemorrhage. In addition to risk for injury and pain, another appropriate nursing diagnosis would be risk for impaired urinary elimination related to pressure from the hematoma on urinary structures.

A woman who gave birth 10 hours ago is ambulating to the bathroom and calls for assistance with perineal care. When the nurse touches her skin, the nurse notices that she is excessively warm. After reinforcing the woman's self-care, the nurse encourages increased oral intake. Why was this the appropriate instruction to give to this client?

Increased intake will rehydrate the client and decrease her skin temperature. The perception of increased skin temperature a short time postbirth is related to dehydration from the exertion of labor. Therefore rehydration should help to decrease skin temperature. Information is insufficient to suggest the presence of infection. Goals of more frequent perineal care and ambulation, as well as reinforcement of client teaching, are not appropriate in this situation.

While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect?

Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus.

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

Postpartum psychosis generally surfaces within 3 months of giving birth.

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

A new mother tells the postpartum nurse that she thinks her baby does not like her since it cries often when she holds it. How should the nurse respond to this statement?

Tell the mother that it is natural to have feelings of uncertainty when adjusting to a new baby.

The nurse is examining a newborn and notes that there is swelling on the newborn's head, limited to the right side of the head. How should the nurse interpret this finding?

The newborn is exhibiting signs of a cephalohematoma, a collection of blood under the periosteum of the skull. It is caused by birth trauma and should resolve spontaneously. If the cephalohematoma crosses the suture lines, a skull fracture is suspected. The newborn is at higher risk of jaundice and anemia, not polycythemia. This is not a caput since there is blood accumulation under the periosteum and not tissue swelling.

A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?

This client's presentation is consistent with a hematoma, which indicates a hemorrhage and which must be treated promptly. Reporting this change in status is priority over hot/cold treatments. This is not an expected finding.

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism?

calf swelling The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention.

A nurse is conducting a refresher in-service program for a group of neonatal nurses. The nurse determines the session is successful after the participating nurses correctly choose which factor is responsible for the appearance of jaundice in the newborn?

hemolysis of erythrocytes. As the newborn takes on breathing, the extra erythrocytes are no longer needed and start to break down or hemolyze. This results in extra bilirubin now circulating in the blood stream or hyperbilirubinemia which will lead to jaundice.