ch.22
The nurse is administering a postpartal woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care?
"I can continue breastfeeding my infant, but it may be somewhat uncomfortable."
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?
"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."
A mother is experiencing postpartum hemorrhage shortly after delivery of her infant. Which nursing interventions would be appropriate for this client? Select all that apply.
- Encourage the mother to breast-feed her infant if she is breast-feeding. - Turn the mother on her side and inspect the area under her buttocks for blood. - Encourage increased fluid intake. - Monitor vital signs every 15 minutes.
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.
-loss of confidence -inability to concentrate -decreased interest in life
On the third day postpartum, which temperature is internationally defined as a postpartal infection?
100.4
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client?
1000 mL
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?
dorsiflex her right foot
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL
What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis?
Activated partial thromboplastin time
A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question?
Administration of an enema
The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
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 fundus.
Which assessment would lead the nurse to believe a postpartal woman is developing a urinary complication?
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings.
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?
Blood pressure, pulse, reports of dizziness
Why are postpartal women prone to urinary retention?
Decreased bladder sensation results from edema because of pressure of birth.
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?
how much blood was on the two pads?
Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of least help in identifying the possibility of hemorrhage?
signs of shock
A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action?
Report the finding promptly to the primary care provider.
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response?
Risk factors include nipple piercing.
A woman is 5 days post-delivery and is experiencing an increase in her lochia accompanied by pelvic pain and heaviness. What lab test would the nurse anticipate to be elevated in this client?
Serum human chorionic gonadotropin (hCG)
The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching?
Symptoms include fever, chills, malaise, and localized breast tenderness.
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?
Teach that adequate hydration helps clear the infection quicker.
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 clien's bladder is distended and is causing the uterus to deviate to the right.
A postpartal woman has a fourth-degree perineal laceration. Which of the following physician orders would you question?
administration of an enema
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
A postpartal woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this?
assess for pedal enema
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 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?
avoid products containing aspirin
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
One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for?
consistency, shape, and location
The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention?
encourage fluid intake
A patient is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period?
encourage to continue breast-feeding
A G4P4 client is recovering from dystocia for which oxytocin was administered to assist with the contractions. On assessment 24 hours later, the nurse notes moderate to heavy lochia with numerous large clots and the uterus in the midline, above the umbilicus, and boggy. Which action should the nurse prioritize?
ensure bladder is empty
The nurse is assisting a new mother who is several hours postpartum. Which reaction by the new mother should the nurse prioritize?
ignores the newborn crying
A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?
mastitis
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis?
mastitis
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 BP
What postpartum client should the nurse monitor most closely for signs of a postpartum infection?
nonelective cesarean birth
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?
oxytocin
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
palpate her fundus
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?
postpartum psychosis
Which situation should concern the nurse treating a postpartum client within a few days of birth?
the client feels empty since she gave birth
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?
uterine atony
When assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?
weak and rapid pulse
A client arrives in the emergency department accompanied by her husband and new 10-week-old infant, crying, confused, and with possible hallucinations. The nurse recognizes this could possibly be postpartum psychosis as it can appear approximately when?
within 3 months of giving birth
