Chapter 12: Postpartum Physiological Assessments and Nursing Care

The serosa stage of lochia usually occurs between day __________ and __________ and the lochia is a __________ or __________ color, and the amount is normally __________.

ANS: 1 - 4; 10; pink; brown; scant Lochia rubra (first stage) occurs during the first 3 days postpartum. Lochia rubra is bright red blood and is moderate to scant. Lochia alba (third stage) begins around the tenth day. The lochia is yellow to white in appearance and is scant in amount.

The postpartum period is the first __________ weeks following childbirth.

ANS: 6 Postpartum is the 6-week period of time following childbirth. It is a time of rapid physiological changes within the woman's body as it returns to a prepregnant state.

12. Maddy, a G3 P1 woman, gave birth 12 hours ago to a 9 lb. 13 oz. daughter. She experiences severe cramps with breastfeeding. The perinatal nurse best describes this condition as: a. Afterpains b. Uterine hypertonia c. Bladder hypertonia d. Rectus abdominis diastasis

ANS: A Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Patients often describe the sensation as a discomfort similar to menstrual cramps.

10. The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, "I don't expect to have any more kids, but I hate the thought of being sterile." Which of the following contraceptive methods would be best for the nurse to recommend to this client? a. Intrauterine device b. Contraceptive patch c. Bilateral tubal ligation d. Birth control pills

ANS: A An intrauterine device (IUD) is an excellent contraceptive method for women who have had at least one delivery, are in a monogamous relationship, and wish to have long-term contraception. The contraceptive patch is not recommended for women over 35 or for women who smoke. A bilateral tubal ligation is a sterilization procedure. Birth control pills are not recommended for women over 35 or for women who smoke.

9. The nurse is providing discharge counseling to a woman who is breastfeeding her baby. The nurse advises the woman that if she experiences unilateral breast inflammation, she should do which of the following? a. Apply warm soaks to the reddened area. b. Consume an herbal galactagogue. c. Bottle feed the baby during the next day. d. Take expressed breast milk to the laboratory for analysis.

ANS: A The client may be developing mastitis. She should apply warm soaks to the area. There is no need for a galactagogue. It is essential that the client continue to breastfeed. If she were to stop feeding, she could develop a breast abscess. Unless ordered by the physician, the milk need not be cultured.

7. A woman is 2 days postpartum from a normal vaginal delivery over an intact perineum of a 3000-gram baby. Where would the nurse expect to palpate the client's fundus? a. At the umbilicus b. 2 cm below the umbilicus c. 2 cm above the symphysis d. At the symphysis

ANS: B Expected location for 6 to 12 hours postpartum. The firm fundus should be 2 cm below the umbilicus. This is an abnormal finding and may be related to subinvolution of the uterus. Expected location for 6 days postpartum.

3. During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is:a. To notify the patient's midwife or physician b. Massage the fundus until firm and reevaluate within 30 minutes c. Give Syntocinon as per orders d. Assist the patient to the bathroom and ask her to void

ANS: B If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. The first nursing action for a boggy uterus is to massage the fundus. If the uterus does not respond to massage, then the nurse would give Syntocinon and notify the primary health provider. You would assist the woman to the bathroom if the uterus is boggy and displaced to the side.

11. The perinatal nurse demonstrates for the student nurse the correct technique of postpartum uterine palpation. Support for the lower uterine segment is critical, as without it, there is an increased risk of: a. Uterine edema b. Uterine inversion c. Incorrect measurement d. Intensifying the patient's level of pain

ANS: B Placing the hand over the base of the uterus does not cause uterine edema. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. It should feel like a firm, globular mass located at or slightly above the umbilicus during the first hour after birth. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. Measurement is the same with or without the hand supporting the lower uterine segment. Not supporting the lower uterine segment has no effect on the level of pain felt by the patient.

1. A 25 year-old woman gave birth to her second child 6 hours ago. She informs the nurse that she is bleeding more than with her previous birth experience. The initial nursing action is to: a. Explain that this is normal for second-time moms. b. Assess the location and firmness of the fundus. c. Change her pad and return in 1 hour and reassess. d. Give her 10 units of oxytocin as per standing order.

ANS: B The nurse should not inform the patient that this is normal until she has assessed for the degree and potential cause of bleeding. It is important to first assess for uterine atony or displaced uterus from full bladder. If the uterus is firm and midline, then the nurse should change the pad and return within 30 minutes to assess the amount of lochia. The nurse would give oxytocin if the uterus is boggy and does not respond to uterine massage.

16. During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration, vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan? a. Fluid volume deficit b. Impaired skin integrity c. Impaired urinary elimination d. Ineffective breastfeeding

ANS: B There is nothing in the scenario that indicates that this client has had a significant blood loss. The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate. The client is voiding well. There is no indication of impaired urinary elimination. The client is feeding q 2 h. There is no indication of impaired breastfeeding.

Mastitis is an inflammation of the __________.

ANS: Breast Mastitis is an inflammation or infection of the breast. This can occur when bacteria enter the breast through cracks around the nipple area

2. Which of these medications is commonly used to control postpartum bleeding related to uterine atony? a. Magnesium sulfate b. Phytonadione c. Oxytocin d. Warfarin

ANS: C Magnesium sulfate is commonly used for PIH and preterm labor. It is a smooth muscle relaxant and can cause the uterus to relax. Phytonadione (vitamin K) is important for clotting but will not cause the uterus to contract. Oxytocin is commonly used to control postpartum bleeding related to uterine atony. Warfarin is an anticoagulant and will increase the risk of hemorrhage.

13. A 35-year-old G1 P0 postpartum woman is Rh0(D)-negative and needs Rh0(D) immune globulin to be administered. The most appropriate dose that the perinatal nurse would expect to be ordered would be: a. 120 ug b. 250 ug c. 300 ug d. 350 ug

ANS: C Nonsensitized women who are Rh0(D)-negative and have given birth to an Rh(D)-positive infant should receive 300 ug of Rh0(D) immune globulin (RhoGAM) within 72 hours after giving birth. RhoGAM should be given whether or not the mother received RhoGAM during the antepartum period. In some situations, depending on the extent of hemorrhage and exchange of maternal-fetal blood, a larger dose of RhoGAM may be indicated.

6. A nurse is performing a postpartum assessment 30 minutes after a vaginal delivery. Which of the following actions indicates that the nurse is performing the assessment correctly? a. The nurse measures the fundal height in relation to the symphysis pubis. b. The nurse monitors the client's central venous pressure. c. The nurse assesses the client's perineum for edema and ecchymoses. d. The nurse performs a sterile vaginal speculum exam.

ANS: C The fundal height should be measured in relation to the umbilicus. The central venous pressure is not monitored during postpartum assessments. The nurse should assess the perineum for signs of edema and ecchymoses. If a speculum exam were needed, a physician or midwife would perform the procedure. Speculum exams are rarely needed postpartum.

8. Which of the following clients is most likely to complain of afterbirth pains during her postpartum period? a. G1 P0, diagnosed with preeclampsia b. G2 P0, group B streptococci in the vagina c. G3 P2, gave birth to a 4100-gram baby d. G4 P1, diagnosed with preterm labor

ANS: C This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a primipara. The nurse would not expect her to complain excessively of afterbirth pains. This client is a multipara and she delivered a macrosomic baby. She is likely to complain of severe afterbirth pains. Although this client is a gravida 4, she is a para 1. The nurse would not expect her to complain excessively of afterbirth pains.

4. On day four following the birth of an average size baby, the nurse would expect the fundus to be at: a. 1 cm below umbilicus b. 2 cm below umbilicus c. 3 cm below umbilicus d. 4 cm below umbilicus

ANS: D Correct. The uterus on the average descends 1 centimeter per day.

15. The perinatal nurse teaches the postpartum woman about the normal process of diuresis that she can expect to occur approximately 6 to 8 hours after birth. A decrease in which of the following hormones is primarily responsible for the diuresis? a. Prolactin b. Progesterone c. Oxytocin d. Estrogen

ANS: D Maternal diuresis occurs almost immediately after birth and urinary output reaches up to 3000 mL each day by the second to fifth postpartum days. After childbirth, a decrease in the level of estrogen naturally occurs and contributes to the diuresis.

5. A nurse is preparing to administer RhoGam to a client who delivered a fetal demise. Which of the following must the nurse check before giving the injection? a. Verify that the direct Coombs test results are positive. b. Check that the fetus was at least 28 weeks' gestation. c. Make sure that the client is at least 3 days postdelivery. d. Confirm that the client is Rh negative.

ANS: D The direct Coombs test is irrelevant, and because the baby has died, the Coombs will likely not be performed. RhoGam should be given no matter how old the fetus was. RhoGam must be administered before 72 hours postpartum. RhoGam is contraindicated for clients who are Rh+ (positive). The nurse must confirm that any client receiving RhoGam is Rh negative.

14. Heather, a postpartum woman who experienced a spontaneous vaginal birth 12 hours ago, describes a headache that is worsening. Heather was given two regular strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. Several friends and family members are presently visiting Heather. The nurse notes that Heather's pain relief during labor consisted of a single dose of an IM narcotic. The most appropriate nursing action at this time is to: a. Notify Heather's health-care provider about Heather's headache. b. Dim the lights in Heather's room so that she is able to get some rest. c. Ask Heather's visitors to leave now to decrease Heather's environmental stimuli. d. Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.

ANS: D The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort in order to provide interventions in a timely manner and enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0 to 10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale.

The perinatal nurse teaches the postpartum woman that the most critical time to achieve effectiveness from the application of ice packs to the perineum is during the first 24 hours following birth. (T/F)

ANS: True To reduce perineal swelling and pain that result from bruising, ice packs may be applied every 2 to 4 hours. Patients obtain the most relief when ice packs are applied within the first 24 hours after childbirth

A woman who gave birth 2 hours ago has a temperature of 37.9°C. Select all of the immediate nursing actions. a. Have patient drink two glasses of fluid over the next hour. b. Explain to the patient that she needs to rest and assist her into a comfortable position. c. Medicate the patient with 500 mg of acetaminophen as per orders. d. Call the patient's physician or midwife to report the elevated temperature.

ANS: a, b A mild temperature elevation within a few hours of birth can be related to dehydration and exhaustion. Acetaminophen is given if the temperature remains elevated after the woman has been hydrated and rested. The physician or midwife is notified if temperature remains elevated after initial interventions.

Which of the following nursing actions are important in the care of a postpartum woman who is at risk for orthostatic hypotension? (Select all that apply.) a. Have patient remain in bed for the first 4 hours postbirth. b. Instruct patient to slowly rise to a standing position. c. Open an ammonia ampule and have the patient smell the ammonia prior to getting out of bed. d. Explain to the patient the cause and incidence of orthostatic hypotension.

ANS: b, d Postpartum women are at risk for orthostatic hypotension during the first few hours postdelivery. Orthostatic hypotension is a sudden drop in the blood pressure when the woman stands up due to decreased vascular resistance in the pelvis. The woman should be instructed to sit on the edge of her bed for a few minutes and then slowly stand up. The nurse or aide should be with the woman the first few times she ambulates. Ammonia ampules are used when the woman faints and is not given prior to fainting.

When reviewing potential causes for postpartum hemorrhage with the student nurse, the nurse is sure to include the finding of a(n) __________ bladder.

ANS: overdistended An overdistended bladder, which displaces the uterus above and to the right of the umbilicus, can cause uterine atony and lead to hemorrhage

Primary breast engorgement is an increase in the __________ and __________ systems that precedes the initiation of milk production.

ANS: vascular; lymphatic Primary breast engorgement is an increase in the vascular and lymphatic systems that precedes the initiation of milk production. Subsequent breast engorgement is related to distention of milk glands.