Ch 14 - High-Risk Postpartum Nursing Care

The nurse is aware the greatest source of bleeding during childbirth occurs following detachment of the placenta. Which physiological change takes place immediately after the expulsion of the placenta to decrease the amount of blood loss? 1. Contractions of the uterine myometrium 2. Factor VIII complex increases during gestation 3. Platelet activity increases before labor and delivery 4. Fibrin formation increases before the birth occurs

ANS: 1 1 This is correct. After placenta detachment, contractions of the myometrium compress the blood vessels at the placental site, thus decreasing the amount of blood loss. 2 This is incorrect. Factor VIII complex increases during gestation and contributes to the hypercoagulability of the blood. However, the physiological change does not occur at the point of the placenta detaching. 3 This is incorrect. Platelet activity increases before labor and delivery and contributes to the hypercoagulability of the blood. However, the physiological change does not occur at the point of the placenta detaching. 4 This is incorrect. Fibrin formation increases before the birth occurs and contributes to the hypercoagulability of the blood. However, the physiological change does not occur at the point of the placenta detaching.

The nurse is providing postpartum care for a patient after a vaginal delivery. Which assessment finding causes the nurse to suspect endometritis from beta-hemolytic streptococcus? 1. Scant amount of odorless lochia 2. Presence of headache, malaise, and chills 3. Pain or discomfort in the midline lower abdomen 4. Elevated temperature greater than 100.4°F (38°C)

ANS: 1 1 This is correct. Endometritis from beta-hemolytic streptococcus specifically exhibits scant, odorless lochia in addition to the more universal signs of infection. 2 This is incorrect. The presence of headache, malaise, and chills is not specific to beta-hemolytic streptococcus infection. 3 This is incorrect. Pain or discomfort in the midline lower abdomen is not specific to beta-hemolytic streptococcus infection. 4 This is incorrect. Elevated temperature greater than 100.4°F (38°C) is not specific to beta-hemolytic streptococcus infection.

A postpartum patient informs the nurse of a frequent urge and burning when attempting to urinate. The nurse reviews the patient's medical record and associates which risk factors related to a possible urinary tract infection (UTI)? Select all that apply. 1. Neonatal macrosomia 2. Use of a vacuum extractor 3. Poor oral fluid intake 4. Urinary catheter during labor 5. Low-grade fever (101.3°F [38.5°C])

ANS: 1, 2, 3, 4 1 This is correct. Neonatal macrosomia, which can cause edema around the urethra, is a risk factor for UTI. 2 This is correct. Operative vaginal deliveries, forceps, or vacuum extractor, which can cause edema around the urethra, is a risk factor for UTI. 3 This is correct. The postpartum patient needs to drink a minimum of 3,000 mL/day; poor oral fluid intake is a risk factor for UTI. 4 This is correct. Urinary catheter inserted during the labor process is a risk factor for UTI. 5 This is incorrect. A low-grade fever (101.3°F [38.5°C]) is a symptom of UTI and not a cause or risk factor.

The nurse is aware of concern about the increasing numbers of severe maternal morbidity (SMM). It is believed to be related to changes in the overall health of the population of women giving birth. Which reasons does the nurse identify as causes of SMM? Select all that apply. 1. Increases in maternal age 2. Prepregnancy obesity 3. Cesarean deliveries 4. Inability to pay for health care 5. Preexisting chronic medical conditions

ANS: 1, 2, 3, 5 1 This is correct. Documented increases in maternal age is a likely cause for SMM; older women have increased risk. 2 This is correct. Obesity is a general health risk in the United States; prepregnancy obesity causes increased incidences of SMM. 3 This is correct. Due to improved diagnostic technology and increased litigation related to childbirth, cesarean deliveries are increasing. Surgical procedures always carry a risk for complications. 4 This is incorrect. The inability to pay for health care may or may not impact the increasing incidence of SMM. 5 This is correct. Preexisting chronic medical conditions are a contributor to the increasing rates of SMM. Due to a decrease in overall general health of women, complications are more likely.

The nurse is collecting information during a follow-up OB appointment with a patient who delivered 3 months ago. The patient reports her partner has become cynical, irritable, and verbally abusive. The nurse will screen for which risks related to paternal postnatal depression (PPND)? Select all that apply. 1. The father exhibited depression during the pregnancy. 2. The birth of this fourth child was unexpected and unplanned. 3. The father expresses feeling bored and underappreciated in his job. 4. The father is recently estranged from his parents and siblings. 5. The mother experienced a prolonged labor and a cesarean birth.

ANS: 1, 2, 4 1 This is correct. Exhibiting paternal depression during the pregnancy can be a risk factor for the development of PPND. 2 This is correct. An unexpected or unplanned pregnancy can be a risk factor for the development of PPND. 3 This is incorrect. Job dissatisfaction is not likely to be a risk factor for the development of PPND. 4 This is correct. The father's estrangement from his parents and siblings can be a stressful life event and/or indicate a lack of social support. Both manifestations can be a risk factor for the development of PPND. 5 This is incorrect. The mother experiencing a prolonged labor that ended in a cesarean birth can be a source of maternal postpartum depression; however, it is not likely to be a risk factor for PPND

The nurse is preparing a postpartum patient for discharge. For which reasons does the nurse instruct the patient to call the primary care provider? Select all that apply. 1. Foul-smelling lochia 2. Hot, red, painful breasts 3. Mild headache 4. Not sleeping well 5. Frequent, painful urination

ANS: 1, 2, 5 1 This is correct. Foul-smelling lochia is a sign of infection. 2 This is correct. Hot, red, painful breasts are a sign of infection. 3 This is incorrect. Call the provider for a severe headache. 4 This is incorrect. New parents are frequently unable to sleep due to caring for a new baby. 5 This is correct. Frequent, painful urination is a sign of infection.

The labor and delivery unit nurses are adopting methods to reduce the number of women who develop postpartum depression. Research from Dennis and Dowswell (2013) provides evidence-based suggestions regarding beneficial interventions. Which suggestions do the nurses consider? Select all that apply. 1. Telephone-based peer support 2. Partner report of symptoms 3. Interpersonal psychotherapy 4. Teaching for self-recognition of problems 5. Professionally based postpartum home visits

ANS: 1, 3, 5 1 This is correct. Research from Dennis and Dowswell (2013) reveals that psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Beneficial interventions include telephone-based peer support. 2 This is incorrect. Research from Dennis and Dowswell (2013) does not address any benefit from partner report of symptoms. 3 This is correct. Research from Dennis and Dowswell (2013) reveals that psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Beneficial interventions include interpersonal psychotherapy. 4 This is incorrect. Research from Dennis and Dowswell (2013) does not address any benefit related to teaching for the self-recognition of problems. 5 This is correct. Research from Dennis and Dowswell (2013) reveals that psychosocial and psychological interventions significantly reduce the number of women who develop postpartum depression. Beneficial interventions include professionally based postpartum home visits

The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, "I think that my baby is deformed inside and we have to fix him." Which risk factor is most strongly related to possible postpartum psychosis (PPP)? 1. Separation from the baby's father 2. Personal history of bipolar disorder 3. Prolonged labor resulting in cesarean 4. Loss of first child from a heart defect

ANS: 2 1 This is incorrect. Separation from the baby's father can be a contributing factor for postpartum depression. 2 This is correct. A patient history of either bipolar disorder or affective disorder can result in postpartum psychosis (PPP). 3 This is incorrect. Prolonged labor resulting in a cesarean delivery is not a risk factor for PPP; the mother is more likely to experience postpartum depression. 4 This is incorrect. The loss of a previous child from a heart defect can cause escalated concern about the well-being for the neonate. However, the other manifestations are indicative of PPP.

The nurse works in a labor and delivery facility with new protocols for estimating postpartum blood loss. Which method for estimating blood loss is implemented in the delivery room? 1. Ask the patient how many peripads she considered to be "soaked." 2. Collect blood in calibrated, under-buttocks drapes for vaginal birth. 3. Place a basin at the foot of the delivery table to catch any blood. 4. Rely on the primary health care provider's estimate of blood loss.

ANS: 2 1 This is incorrect. The inquiry to the patient calls for subjective judgment. The nurse is responsible for patient assessment. The situation is not related to blood loss in the delivery room. 2 This is correct. Collecting blood in calibrated, under-buttocks drapes for vaginal birth and then weighing the drapes is the easiest way to estimate blood loss in the delivery room. 3 This is incorrect. Placing a basin at the foot of the delivery table may result in a collection of no blood. During delivery, most blood will be on the drapes used on and under the patient. 4 This is incorrect. Regardless of the experience of the primary health care provider, visual estimation of blood loss is subjective and at risk for being inaccurate.

The nurse is preparing discharge teaching for a postpartum patient who exhibits signs and symptoms of an episiotomy infection and is on oral antibiotic therapy. Which discharge teaching will the nurse provide regarding pain management? 1. Application of hot packs to the perineal area 2. Information applicable to medication therapy 3. Instructions to improve circulation by ambulating 4. Medicating for pain above level 4 on a 0 to 10 scale

ANS: 2 1 This is incorrect. With a wound infection, the nurse will advise hot packs to abdominal wounds and sitz baths for perineal wounds to promote comfort and circulation. 2 This is correct. The nurse will need to provide applicable discharge teaching for both antibiotic and analgesic therapy. Antibiotics need to be taken as ordered and until they are gone. 3 This is incorrect. The nurse does not need to advise the patient to ambulate frequently to promote circulation. Sitz baths will promote circulation without increasing pain from movement. 4 This is incorrect. The nurse does not necessarily advise the patient to take medication when the pain reaches a specific level of intensity. The patient needs to take pain medication when she feels it is necessary.

The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take? 1. Continue to apply ice to the area for 24 hours. 2. Monitor vital signs and report any abnormal readings. 3. Contact the primary care provider for further evaluation. 4. Relieve pressure by placing patient in a side-lying position.

ANS: 3 1 This is incorrect. Ice can be applied to the perineal area for 24 hours after delivery to help avoid swelling; however, there are other nursing actions relative to the presence of a hematoma. 2 This is incorrect. The presence of a hematoma is indicative of hemorrhage into soft tissue. Reporting abnormal vital signs is a late sign of hemorrhage; the nurse can take other proactive actions to prevent complications. 3 This is correct. The primary care provider needs to be contacted about assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed. 4 This is incorrect. The patient may or may not be more comfortable in a side-lying position; however, this action does not address the issue of hemorrhage.

The nurse in a labor and delivery department carefully assesses postpartum patients for signs of complications related to hemorrhage. Which factor makes it most difficult to identify the risk of hemorrhage through vital sign evaluation? 1. Blood pressure may be elevated from prenatal conditions. 2. Respirations are increased due to activity of labor. 3. Changes in blood pressure may not be an immediate sign. 4. Heart rate may increase with intensity of labor.

ANS: 3 1 This is incorrect. If patients have a prenatal condition that causes an increase in blood pressure, the postpartum blood pressure will be compared with the patient's baseline readings. 2 This is incorrect. Respiration rates can be elevated during labor, but the rate should be within normal limits for the postpartum patient. 3 This is correct. Changes in blood pressure may not be an immediate sign of hemorrhage in a postpartum patient. OB patients may not show the same signs and symptoms observed in nonpregnant patients during hemorrhage until approximately one-third of the woman's entire blood volume is lost. The postpartum patient has an increased blood volume from pregnancy, which delays vital sign indications. A decrease in BP is a late sign of postpartum hemorrhage. 4 This is incorrect. Pulse rates can be elevated during labor, but the rate should be within normal limits for the postpartum patient. Tachycardia is a late sign of primary postpartum hemorrhage.

The nurse continues to monitor a patient after a vaginal delivery with an estimated blood loss of 1,000 mL. Which assessment finding does the nurse recognize as requiring Stage 3 hemorrhage protocol? 1. Increased patient restlessness. 2. Manifestations of severe pain. 3. Development of abnormal vital signs. 4. Patient requests water for extreme thirst.

ANS: 3 1 This is incorrect. Increased restlessness can be a sign of hypovolemia; however, this is not an indicator used in the protocol for staging postpartum hemorrhage. 2 This is incorrect. Severe pain may indicate the source of hemorrhage, but it is not an indicator used in the protocol for staging postpartum hemorrhage. 3 This is correct. Vital signs will remain normal during Stages 1 and 2. The evidence of abnormal vital signs is one indicator of Stage 3 hemorrhage. Other Stage 3 indicators include continued bleeding, more than 2 units red blood cells (RBCs) given, patient at risk for occult bleeding/coagulopathy, abnormal laboratory values, or oliguria. 4 This is incorrect. Patients will experience extreme thirst as a result of hemorrhage; however, this is not used in the protocol for staging postpartum hemorrhage.

The nurse is assisting the primary care provider with the third stage of a vaginal delivery. The patient is multiparous, experienced a precipitous birth, and has a history of hypertension. Which medical prescription does the nurse anticipate for this patient? 1. Methylergonovine 2. Fresh frozen plasma 3. Carboprost-tromethamine 4. Magnesium sulfate

ANS: 3 1 This is incorrect. Methylergonovine directly stimulates smooth and vascular smooth muscles causing sustaining uterine contractions. This drug is used to prevent or treat PP hemorrhage/uterine atony/subinvolution. However, it is contraindicated in hypertensive patients. 2 This is incorrect. Fresh frozen plasma is administered when the patient is experiencing postpartum hemorrhage. This client is at risk but does not have the manifestations of PP. 3 This is correct. Carboprost-tromethamine is classified as a prostaglandin and is prescribed to maintain contraction of the uterine muscles. It is injected into a large muscle or directly into the uterine muscle. The nurse will expect this prescription because the patient has multiple risks for PP. 4 This is incorrect. Magnesium sulfate is administered to prevent uterine contractions and is contraindicated for this patient and this stage of labor.

The nurse is providing care for a patient who is 1 day postpartum and exhibiting symptoms of postpartum psychosis. Which medical management does the nurse expect for this patient? 1. Prescriptions for antidepressant/antipsychotic drugs 2. Discharge to home with 24-hour observation in place 3. Immediate hospitalization in a psychiatric unit 4. Prescribed neonate visits during in-patient treatment

ANS: 3 1 This is incorrect. The patient's current health care provider may or may not prescribe antidepressant/antipsychotic drugs; the medication regimen may be deferred to the psychiatric care provider. 2 This is incorrect. The patient is at risk for self-harm or harm to others, including the baby. The family is not responsible for managing the intensity of the manifestations or the safety issues in the home. 3 This is correct. The nurse expects the health care provider to immediately hospitalize the patient in a psychiatric unit. Maintaining the patient in the postpartum unit delays necessary psychiatric treatment. 4 This is incorrect. It is highly unlikely that neonatal visits will be initially prescribed while the patient is on the psychiatric unit. Neonatal care will be managed by other family members; the focus for the patient is psychiatric care.

The nurse is assessing a patient who is 36 hours postpartum following a cesarean delivery. Which findings cause the nurse to conclude that a wound infection is developing? Select all that apply. 1. Temperature increase from 99.8°F to 100.5°F 2. Incisional tenderness with palpation 3. Increased margins of incisional redness 4. Notably warm skin around the incision 5. Serosanguinous drainage from the suture line

ANS: 3, 4 1 This is incorrect. An increase in temperature from 99.8°F to 100.5°F may or may not indicate a developing wound infection. The patient is expected to have a low-grade fever related to surgical trauma; however, wound infections may cause a low-grade fever. The finding is inconclusive. 2 This is incorrect. At 36 hours, incisional tenderness with palpation is likely to be related to surgical trauma. This finding is inconclusive. 3 This is correct. An increase in redness in the incisional margins is a likely sign of developing wound infection. 4 This is correct. When the skin around a surgical incision is notably warm to the touch, it is likely a sign of a developing wound infection. 5 This is incorrect. Serosanguinous drainage from the suture line 36 hours after the surgery is an expected finding and is not indicative of a developing wound infection.

The lactation nurse takes a phone call from a mother who is breastfeeding her 2-month-old infant. The mother reports an area of redness and warmth on the breast and a painful burning sensation when breastfeeding. Which statement by the nurse is correct if mastitis is suspected? 1. "If your nipples are cracked, you will need to stop breastfeeding." 2. "Pump your milk and throw it away until the infection is gone." 3. "The baby gave you an infection and needs to be on antibiotics." 4. "Continuing to breastfeed will help clear up the condition."

ANS: 4 1 This is incorrect. Cracked nipples are a port of entry for pathogens that cause mastitis; however, the mother does not necessarily need to stop breastfeeding. The lactation nurse will provide methods of management. 2 This is incorrect. When the mother has mastitis, the milk is unaffected and the baby will not be harmed with continuing breastfeeding. There is no reason to pump and discard the milk. 3 This is incorrect. The most common organism reported in mastitis is Staphylococcus aureus. The organism usually comes from the breastfeeding infant's mouth or throat but does not require placing the infant on antibiotics. 4 This is correct. Mastitis is generally self-limiting, and continued breastfeeding can help clear up the infection and condition. If antibiotic therapy is indicated, the infection generally resolves within 24 to 48 hours of antibiotic therapy.

The nurse is closely monitoring a patient who is postpartum and at risk for PPH. Which assessment finding will cause the nurse to contact the primary care provider immediately? 1. The uterus is displaced. 2. The uterine fundus is boggy. 3. Small clots are expressed with massage. 4. Peripad weighs 100 g within 15 minutes.

ANS: 4 1 This is incorrect. When the uterus is displaced, there is an increased risk for PPH. However, the cause is often related to a full urinary bladder. The nurse needs to assist the patient to the bathroom to void. 2 This is incorrect. When the uterine fundus is boggy, the uterine muscle is not contracted and the patient is at risk for PPH. The nurse will massage and reassess every 5 to 15 minutes. Uterotonic therapy may be initiated as per facility protocol. 3 This is incorrect. Small clots may be expelled when the fundus of the uterus is massaged. The nurse will closely assess for uterine tone, amount of bleeding, and large clots. Clots the size of an egg would warrant calling the primary care provider. 4 This is correct. The nurse will monitor the amount and characteristics of each patient's lochia. If bleeding seems excessive, the nurse will weigh peripads to ascertain the amount of blood loss. This patient's EBL is 100 mL in 15 minutes (1 g = 1 mL of blood). The nurse will contact the primary care provider and report postpartum hemorrhage.

A patient who is 8 months postpartum arrives for an OB appointment. The nurse notices that both the patient and the infant appear unkempt. The nurse anticipates a diagnosis of _________________________.

ANS: postpartum depression The nurse recognizes that postpartum depression differs from postpartum blues. Postpartum blues appear within the first 2 weeks of birth; postpartum depression can occur anytime within the first year. The mother with postpartum blues continues to provide self-care and baby care. The mother with postpartum depression is unable to safely care for herself and/or her baby. Mothers with postpartum depression will require psychiatric interventions.