Ch 22 Post Partum High Risk
Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client? temperature of 38° C or higher after the first 24 hours after birth temperature of 39° C or higher after the first 48 hours after birth temperature of 37.5° C or higher after the first 12 hours after birth temperature of 38.5° C or higher after the first 36 hours after birth
temperature of 38° C or higher after the first 24 hours after birth
Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? "Limit the amount of fluid you drink so your breasts don't get much fuller." "Try applying warm compresses to your breasts to encourage the milk to be released." "Stop breastfeeding until the pain and swelling subside." "You'll need to take this medication to stop the milk from being produced."
"Try applying warm compresses to your breasts to encourage the milk to be released." Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 100 mL 500 mL 250 mL 300 mL
500 mL
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply. Ask if her pain that is relieved with walking. Assess for redness and warmth in the affected leg. Assess for a low-grade fever. Assess for edema in the affected leg.
Assess for redness and warmth in the affected leg. Assess for a low-grade fever. Assess for edema in the affected leg.
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid frequent breast-feeding. Perform handwashing before breast-feeding. Apply cold compresses to the breast. Avoid massaging the breast area.
Perform handwashing before breast-feeding.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? A client who conceived following fertility treatments A client who had a nonelective cesarean birth A client who had an 8-hour labor A primaparous client who had a vaginal birth
A client who had a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity.
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 vital signs. Assess the woman's fundus. Call the woman's health care provider. Begin an IV infusion of Ringer's lactate solution.
Assess the woman's fundus.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Initiate Ringer's lactate infusion. Assess the woman's fundus. Assess the woman's vital signs. Call the woman's health care provider.
Assess the woman's fundus.
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 develops gradually, appearing within the first 6 weeks." "Postpartum psychosis usually appears soon after the woman comes home." "Postpartum psychosis usually involves psychotropic drugs but not hospitalization." "Postpartum blues usually resolves by the 4th or 5th postpartum day."
"Postpartum depression develops gradually, appearing within the first 6 weeks." 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.
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 acetaminophen and codeine for pain Providing a sitz bath Administering an enema Urging to drink all the milk provided during meals
Administering an enema A fourth-degree perineal laceration involves the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum. Any patient who has a fourth-degree laceration should not have an enema prescribed because the hard tips of equipment could open sutures near to or including those of the rectal sphincter.
After delivery, a patient is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this patient? Select all that apply. Administer antihypertensive medication as prescribed. Administer magnesium sulfate as prescribed. Monitor urine output. Instruct on the purpose of a fluid restriction Maintain on bed rest.
Maintain on bed rest. Administer antihypertensive medication as prescribed. Administer magnesium sulfate as prescribed. Monitor urine output.
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. Measure urine output. Assess ambulation. Evaluate current hematocrit level.
Measure blood pressure. Methylergonovine can increase blood pressure and must be used with caution in patients with hypertension. The nurse should assess the blood pressure prior to administrating and about 15 minutes afterward to detect this side effect. Methylergonovine does not affect ambulation, urine output, or hematocrit level.
A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? administration of platelet transfusions as prescribed continual firm massage of the uterus avoiding administration of oxytocics administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs)
administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction.
The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? lack of social support from family or friends preexisting conditions in the client drop in estrogen and progesterone levels after birth medications used during labor and birth
drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution uterine atony uterine contraction uterine prolapse
uterine atony Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.
A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "I'll check on you in a few hours." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." "I'll contact your health care provider."
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first.
The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective? "I will have large amount of vaginal drainage for at least several months." "If the drainage changes from clear to bright red, I am to call the doctor." "My drainage will fluctuate between bright red and dark red for several weeks." "An elevated temperature is normal during the first few weeks after delivery."
"If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the patient is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra.
Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine
applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "Are you in any pain with your bleeding?" "How much blood was on the two pads?" "When did you last void?"
"How much blood was on the two pads?"
A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "I should brush my teeth vigorously to stimulate the gums." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "If my lochia increases, I need to call my health care provider." "I need to avoid using any aspirin-containing products."
"I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.
A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "I just feel so overwhelmed and tired." "I keep hearing voices telling me to take my baby to the river." " I cry a lot for no reason at all." "I'm feeling so guilty and worthless lately."
"I'm feeling so guilty and worthless lately."
On the third day postpartum, which temperature is internationally defined as a postpartal infection? 99.6° F (37.5° C) 102.4° F (39.1° C) 104.2° F (40.1° C) 100.4° F (38° C)
100.4° F (38° C)
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. Begin an IV infusion of Ringer's lactate solution. Notify the health care provider. Assess vital signs.
Assess the fundus.
A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy? Sit with legs crossed over each other. Avoid products containing aspirin. Avoid prolonged straining during defecation. Refrain from performing any leg exercises.
Avoid products containing aspirin. The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises.
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? Height, level of orientation, support systems Blood pressure, pulse, reports of dizziness Attachment, lochia color, complete blood cell count Degree of responsiveness, respiratory rate, fundus location
Blood pressure, pulse, reports of dizziness
A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Check the lochia. Assess the fundal height. Assess the temperature. Monitor the pain level.
Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (30.0° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus.
It is discovered that a new mother has developed a puerperal infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client's temperature remains below 100.4° F or 38° C orally. Client maintains a urinary output greater than 30 mL per hour. Fundus remains firm and midline with progressive descent. Lochia discharge amount is 6 inches or less on a perineal pad in 1 hour.
Client's temperature remains below 100.4° F or 38° C orally.
Why are postpartal women prone to urinary retention? Catheterization at the time of delivery reduces bladder tonicity. Decreased bladder sensation results from edema because of pressure of birth. Mild dehydration causes a concentrated urine volume in the bladder. Frequent partial voidings never relieve the bladder pressure.
Decreased bladder sensation results from edema because of pressure of birth. As the fetal head passes behind the bladder, bladder edema with loss of sensation can result.
The nurse is assisting a new mother who is several hours postpartum. Which reaction by the new mother should the nurse prioritize? Returns baby to the nursery because of fatigue Ignores the newborn crying Cuddles her baby close to her while feeding Is hesitant to change the diaper
Ignores the newborn crying After birth the woman would be excited and interested in the birth and the infant. Ignoring the newborn's crying may be an indication of malattachment and should be further evaluated and brought to the attention of the RN and/or health care provider. If this is a new mother, she may be hesitant to change the diaper because she is unsure of how to do it or fears she might hurt her newborn; she would need encouragement and instruction on how to do this.
A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? firm uterus with a steady stream of bright red blood Large uterus with painless dark red blood mixed with clots soft and boggy uterus that deviates from the midline firm uterus with trickle of bright red blood in perineum
Large uterus with painless dark red blood mixed with clots The presence of a large uterus with painless dark red blood mixed with clots indicates retained placental fragments in the uterus. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. A firm uterus with a trickle or steady stream of bright red blood in the perineum indicates bleeding from trauma. A soft and boggy uterus that deviates from the midline indicates a full bladder, interfering with uterine involution.
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Oxytocin Calcium gluconate Magnesium sulfate Domperidone
Oxytocin 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 assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider? Tearful during appointment Restless and agitated, concerned with self and not the infant Talkative and asking questions States being tired and happy at same time
Restless and agitated, concerned with self and not the infant
Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? She should continue to breast-feed; mastitis will not infect the neonate. She should not use analgesics because they are not compatible with breast-feeding. She should stop breast-feeding until completing the antibiotic. She should supplement feeding with formula until the infection resolves.
She should continue to breast-feed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breast-feeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse? Advise her to take acetaminophen to ease symptoms. Teach that adequate hydration helps clear the infection quicker. Instruct to use a sitz bath while voiding. Ask primary care provider to prescribe an analgesic.
Teach that adequate hydration helps clear the infection quicker. Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 mL of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth. The other choices are also options but address the symptoms and not the root cause. The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection.
The nurse palpates a postpartal woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? The soft fundus indicates that the woman's uterus is filling up with blood. The uterus is soft because there is an infection inside the uterus. The uterine placement is normal. The clien's bladder is distended and is causing the uterus to deviate to the right.
The clien's bladder is distended and is causing the uterus to deviate to the right. If a postpartal client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia.
Which situation should concern the nurse treating a postpartum client within a few days of birth? The client would like to watch the nurse give the baby her first bath. The client is nervous about taking the baby home. The client would like the nurse to take her baby to the nursery so she can sleep. The client feels empty since she gave birth to the neonate.
The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery.
A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding? Jaundice Irritability White plaques in the mouth Decreased sleep levels
White plaques in the mouth The patient who is breast-feeding should not be prescribed antibiotics that are incompatible with breast-feeding. 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. Antibiotics will not typically cause jaundice. Irritability may or may not be because of the mother taking antibiotics. Decreased sleep levels are not typically associated with maternal antibiotic use.
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? methylergonovine oxytocin carboprost misoprostol
carboprost 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.
In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication? uterine atony deep venous thrombosis postpartum hemorrhage metritis
deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity.
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. bizarre behavior inability to concentrate manifestations of mania loss of confidence decreased interest in life
inability to concentrate loss of confidence decreased interest in life
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? uterine atony hematoma laceration uterine inversion
laceration 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.
