Ch 16 PrepU Nursing Management during Postpartum period
A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?
"It might take up to a week for your bowels to return to their normal pattern."
A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?
Atony
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?
Temperature
A nurse is assessing several postpartum clients. The nurse will notify the health care provider about which client?
Client C: 36 hours postpartum, temperature (oral): 100.6°F (38.1°C)
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 postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?
venous duplex ultrasound of the right leg
A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.
active bowel sounds passing gas nondistended abdomen
After teaching a postpartum client about postpartum blues, the nurse determines that the teaching was effective when the client makes which statement?
"I might feel like laughing one minute and crying the next."
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?
"I only eat a low-fiber diet." Explanation: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?
2 weeks
A client is Rh-negative and has given birth to her newborn. What should the nurse do next?
Determine the newborn's blood type and rhesus
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. 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:
assess and massage the fundus
The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?
policies that discourage unwrapping and exploring the infant
A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?
pulmonary embolism
When assessing the episiotomy site of a postpartum client who delivered 3 hours ago, the nurse would document which findings as expected? Select all that apply.
Edema Slight Bruising
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?
Ensure ice pack is changed frequently
A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention?
Uterus is boggy. Explanation: A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual
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? You Selected:
Ask the client when she last changed her perineal pad.
A nurse is providing care to a postpartum woman. Documentation of a previous assessment of a woman's lochia indicates that the amount was moderate. The nurse interprets this as reflecting approximately how much?
25 - 50 ml
At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:
PostPartum Depression
A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 breaths/min and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:
Pulmonary Embolism
A first-time mother is nervous about breastfeeding. Which intervention would the nurse perform to reduce maternal anxiety about breastfeeding?
Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.
A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?
Resume intercourse if bright red bleeding stops.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?
dehydration Explanation: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours
During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?
delayed hemorrhage Explanation: Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow.
Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection?
during the first 24 hours after birth owing to dehydration from exertion
Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?
hematoma Explanation: If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately
Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother?
indirect Coombs tes
When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment?
reciprocity Explanation: Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship
During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?
Schedule home visits for high-risk families
Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:
"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood."
A woman who is breastfeeding her newborn says, "He doesn't seem to want to nurse. I must be doing something wrong." After teaching the woman about breastfeeding and offering suggestions, which statement by the mother indicates the need for additional teaching?
"Some women just can't breastfeed. Maybe I'm one of these women."
The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:
odor. Explanation: The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.
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.
When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.
Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother.
A nurse is developing a plan of care for a woman who has had a spontaneous vaginal delivery of a healthy newborn. The nurse determines the need for close monitoring for postpartum hemorrhage based on which information? Select all that apply.
Labor of 1 1/2 hours Labor induction with oxytocin Forceps birth
The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care?
Symptoms of postpartum depression can easily go undetected. Explanation: The plan of care should acknowledge that symptoms of postpartum depression are often missed and go undetected (and therefore untreated). Postpartum blues occur within the first week after birth. Postpartum depression can develop after any pregnancy and can be assessed by providers in a variety of settings
During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?
generally within 3 to 6 weeks Explanation: There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum
Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:
maintaining previous household routines to prevent infection.
A nurse is inspecting the perineal pad of a client who gave birth vaginally to a healthy newborn 6 hours ago. The nurse observes a 5-inch stain of lochia on the pad. The nurse would document this as:
moderate. Explanation: Typically, the amount of lochia is described as follows: scant-a 1- to 2-inch lochia stain on the perineal pad or approximately a 10-ml loss; light or small- an approximately 4-inch stain or a 10- to 25-ml loss; moderate- a 4- to 6-inch stain with an estimated loss of 25 to 50 ml; and large or heavy-a pad is saturated within 1 hour after changing it
Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?
third-degree laceration Explanation: A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.
A nurse helps a postpartum woman out of bed for the first time postpartum and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?
The color of the flow is red.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action?
The fundus is located 2 fingerbreadths above the umbilicus
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply.
Low self-esteem Feeling overwhelmed and out of control Low socioeconomic status Lack of social support
The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus?
one fingerbreadth below the umbilicus Explanation: After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis
The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?
thromboembolic disorder of the lower extremities
In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.
women on antithyroid medications women on antineoplastic medications women using street drugs
A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?
an ice pack applied to the perineum
Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?
Sitz baths increase the blood supply to the perineal area
The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply.
vital signs of mother pain level head-to-toe assessment
One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?
Inspecting posture, color, and respiratory effort Explanation: The nurse begins by assessing the neonate's posture, color, and respiratory effort. These three parameters provide a general overview of the infant's condition and adaptation to extrauterine life. Skin condition and birthmarks as well as head and chest circumference are part of the comprehensive physical and are documented within the first day of life. Bowel sounds are not present until about 15 minutes after birth and the infant may not void until 24 hours of age
A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?
negative attachment Explanation: 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 of negative attachment behaviors
The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?
touching Explanation: Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process
Which factor puts a client on her first postpartum day at risk for hemorrhage?
uterine atony
A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:
encouraging the client to wear a supportive bra. Explanation: These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.
Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?
encouraging the woman to empty her bladder completely every 2 to 4 hours Explanation: The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.
A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?
Educate the client on how to perform Kegel exercises
When palpating for fundal height on a postpartum woman, which technique is preferable?
placing one hand at the base of the uterus, one on the fundus
A nurse is conducting discharge teaching with a first-time mother. The nurse is teaching the client about lochia flow and how to evaluate it. The nurse determines that the teaching was successful based on which client statement?
"If I saturate a perineal pad in under an hour, I need to call my provider." Explanation: Saturating a perineal pad in less than 1 hour is considered an abnormally heavy flow and should be reported. The client should not use tampons to halt the flow or this could lead to infection. Lochia should contain no exceedingly large clots as these may indicate a portion of the placenta has been retained and is preventing closure of the maternal uterine blood sinuses. In any event, large clots denote poor uterine contraction, which needs to be corrected. Lochia is red for the first 1 to 3 days (lochia rubra), pinkish-brown from days 4 to 10 (lochia serosa), and then white (lochia alba) for as long as 6 weeks after birth. The pattern of lochia (rubra to serosa to alba) should not reverse as this suggests a placental fragment has been retained or uterine contraction is decreasing and new bleeding is beginning.
