ch 17 pillitteri
A mother anticipates an identity for her child before birth. Time is spent getting to know her child upon delivery. The nurse acknowledges this initial identification process and documents which behavior?
Light fingertip touching of the newborn's hand
A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate
A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response by the nurse is appropriate?
After birth it is easier to develop an infection in the urinary system; we need to see you today. The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner
A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate?
Assist the woman in placing ice packs on her breasts If the breasts are engorged and the woman is bottle-feeding her newborn, instruct her to keep a support bra on 24 hours per day. Cool compresses or an ice pack wrapped in a towel will usually be soothing and help to suppress milk production.
For several hours after birth a multigravida client who experienced a much more difficult labor this time than any time previously, wants to talk about why the birthing process was so hard for her. She is focusing on this aspect to the point that she seems relatively indifferent to her newborn. How should the nurse handle this situation
Encourage her to discuss her experience of the birth and answer any questions or concerns she may have The client needs to explore her birth experience and clarify her questions. The nurse should allow her to ask questions, be supportive, and encourage her to express her feelings. Redirecting her attention to the baby, asking her to describe how she plans to integrate the new baby into the family, or pointing out positive features of the new baby do not meet the needs of the client at this time
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement?
Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for nonbreastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain
A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern?
It takes about 3 days after birth for milk to begin forming.
An 20-year-old primipara is getting ready to go home. She had a second-degree episiotomy with repair. She confides in the nurse that she is afraid to go to her postpartum checkup because she is afraid to have the stitches removed. Which reply by the nurse is best?
Many women have that fear after having an episiotomy. The stitches do not need to be removed because the suture will be gradually absorbed
A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance should the nurse identify as the cause of afterpains
Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation
Which maternal reaction is the most concerning?
She neglects to engage with or provide care for the baby and shows little interest in it.
A nurse is caring for a nonbreastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort?
The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently is suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse then would monitor the client for which condition?
UTI. The nurse would need to monitor the client for signs and symptoms of a urinary tract infection, a risk associated with catheterization. Stress incontinence is caused due to loss of pelvic muscle tone after birth. Increased urinary output is observed in diuresis. Catheterization does not cause loss of pelvic muscle tone, increased urine output, or stress incontinence.
A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate?
You might try using a water-soluble lubricant to ease the discomfort." Coital discomfort and localized dryness usually plague most postpartum women until menstruation returns. Water-soluble lubricants can reduce discomfort during intercourse. Although it may take some time for the woman's body to return to its prepregnant state, telling the woman this does not address her concern. Telling her that dyspareunia is normal and that it takes time to resolve also ignores her concern. Kegel exercises are helpful for improving pelvic floor tone but would have no effect on vaginal dryness.
You are doing your discharge teaching with the parents of baby who is their second child. You explain about sibling regression and you offer ways to deal with regressive behavior. What is this called?
anticipatory guidane. Anticipatory guidance is helpful when siblings are involved. Explain to the parents that it is normal for the older sibling to regress in the first few days after the birth of the baby. Tell them it helps if they do not focus undue attention on regressive behaviors, such as a return to bedwetting, sucking the thumb, or clinging to a favorite toy or blanket. It is particularly important for the parents not to criticize or belittle the older child for regressive behaviors.
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
assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
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:
assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.
A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?
attachment
On assessment of a 2-day postpartum client the nurse finds that the fundus is boggy, at the umbilicus, and slightly to the right. What is the most likely cause of this assessment finding?
bladder distention The most often cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?
bleeding. Blood pressure should also be monitored carefully during the postpartal period because a decrease in this can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartal gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?
document findings as normal. Pulse rates of 60 to 80 beats per minute at rest are normal during the first week after birth. This pulse rate is called puerperal bradycardia.
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. Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.
Twelve hours after delivery, the fundus of a woman who has just delivered her fifth child after 14 hours of labor is two fingers above the umbilicus and her uterus feels soft and spongy. What should you do first?
gently massage the fundus until it tones up. After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the patient. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.
The nurse is developing a teaching plan for a client who has decided to bottle feed her newborn. Which information would the nurse include in the teaching plan to facilitate suppression of lactation?
instructing her to apply ice packs to both breasts every other hour. If the woman is not breastfeeding, relief measures for engorgement include wearing a tight supportive bra 24 hours daily, applying ice to her breasts for approximately 15 to 20 minutes every other hour, and not stimulating her breasts by squeezing or manually expressing milk. Warm showers enhance the let-down reflex and would be appropriate if the woman was breastfeeding. Limiting fluid intake is inappropriate. Fluid intake is important for all postpartum women, regardless of the feeding method chosen
When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:
less than after a vaginal birth. Women who have had cesarean births tend to have less flow because the uterine debris is removed manually along with delivery of the placenta.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis. The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
Which factor might result in a decreased supply of breast milk in a postpartum client?
supplemental feedings with formula. Routine formula supplementation may interfere with establishing an adequate milk volume because decreased stimulation to the client's nipples affects hormonal levels and milk production. Vitamin C levels have not been shown to influence milk volume. One drink containing alcohol generally tends to relax the client, facilitating letdown. Excessive consumption of alcohol may block letdown of milk to the infant, though supply is not necessarily affected. Frequent feedings are likely to increase milk production
For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it.
true
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 Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development?
• inability of infant to empty breasts. For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
Five days after giving birth, a new mother tells her nurse that she has lost some weight but still feels as if she has a long way to go to return to her prepregnancy weight. She asks what the average weight loss at 5 days into the postpartal period is. Which of the following should the nurse mention?
•19 lb The rapid diuresis and diaphoresis during the second to fifth days after birth usually result in a weight loss of 5 lb (2 to 4 kg), in addition to the approximately 12 lb (5.8 kg) lost at birth. Lochia flow causes an additional 2- to 3-lb (1-kg) loss, for a total weight loss of about 19 lb.
A nurse is caring for a female client in the postpartum phase. The client reports "afterpains." Which intervention should the nurse complete first?
•Administer pain medications. "Afterpains" should be expected in postpartum clients. These are commonly treated with pain analgesics. The client should not stop breastfeeding. Assessing vital signs and helping the client to void are not the priority interventions for this client.
Loss of blood during and after delivery can result in which of the following findings? Select all that apply.
•Anemia •Pale conjunctiva •Orthostatic hypotension Blood loss greater than 250 to 500 mL after a vaginal delivery can produce these symptoms if the woman's hemoglobin and hematocrit were not adequate before delivery. Assessment is crucial to prevent vascular complications
During the assessment, the nurse observes a separation of the rectus muscle that is more than two fingers' wide. Which instruction should the nurse offer the client?
•Avoid lifting heavy objects The nurse should teach the client to not lift heavy objects because it could put stress on the abdominal muscles. The client should not be advised to perform regular exercise until the muscles are firmer. Sleeping on a firm mattress or avoiding sleeping on the back does not help the abdominal muscles in any way.
Given a prepartum hemoglobin value of 14 gm/dL and hematocrit of 42 percent, which postpartum measurements should you report to the health care provider?
•Hemoglobin 9 gm/dL and hematocrit 32 percent in a woman who has given birth by cesarean There was a significant change from the prepartum H/H to the postpartum H/H. The healthcare provider needs to be notified and the patient needs a complete assessment for any bleeding. Options A, B, and C are considered to be within normal limits for a postpartum H/H, given the prepartum values.
A nurse is assessing a client's abdomen following childbirth to help prevent permanent damage to the bladder from overdistention. Which of the following findings would indicate a full bladder?
A resonant sound on percussion To prevent permanent damage to the bladder from overdistention, assess a woman's abdomen frequently in the immediate postpartal period. On palpation, a full bladder is felt as a hard or firm area just above the symphysis pubis. On percussion (placing one finger flat on the woman's abdomen over the bladder and tapping it with the middle finger of the other hand), a full bladder sounds resonant, in contrast to the dull, thudding sound of non-fluid-filled tissue. Excessive sweating (diaphoresis) indicates the presence of excess fluid that has accumulated during pregnancy, but does not necessarily indicate a full bladder.
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed
A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is
taking-in, taking-hold, letting-go. The new mother makes progressive changes to know her infant, review the pregnancy and labor, validate her safe passage through these phases, learn the initial tasks of mothering, and let go of her former life to incorporate this new child
When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term?
•bonding The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other
The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?
•cannot be palpated By the end of 10 days, the fundus usually cannot be palpated because it has descended into the true pelvis.
After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity?
•commitment Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves. The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?
•frequent scant voidings Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings
Given that the first 24 hours after birth is a time for return to homeostasis, which postpartum findings are considered acceptable during this time? Select all that apply.
•fundus one fingerbreadth above umbilicus •moderate saturation of peripad every 3 hours A fundus can rise to slightly above or below the umbilicus in the first 24 hours, and moderate saturation of two-thirds of the pad is appropriate. Inverted nipples always require intervention if breastfeeding. Hypotonic bowel sounds also require assessment more frequently than routinely ordered, and 50 mL urine is inadequate given the occurrence of diuresis.
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. Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.
