Chapter 12: Postpartum Physiological Assessments and Nursing Care

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?

The nurse assesses the client's perineum for edema and ecchymoses.

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.

True

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:

Uterine inversion

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.

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.)

b. Instruct patient to slowly rise to a standing position. d. Explain to the patient the cause and incidence of orthostatic hypotension.

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

overdistended

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

pink; brown; scant

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

vascular; lymphatic

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?

2 cm below the umbilicus

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:

300 ug

On day four following the birth of an average size baby, the nurse would expect the fundus to be at:

4 cm below umbilicus

The postpartum period is the first __________ weeks following childbirth.

6

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:

Afterpains

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?

Apply warm soaks to the reddened area.

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:

Ask Heather where she is experiencing this headache and to identify the pain score that best describes the intensity of the pain.

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:

Assess the location and firmness of the fundus.

Mastitis is an inflammation of the __________.

Breast

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?

Confirm that the client is Rh negative.

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?

Intrauterine device

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?

Estrogen

Which of the following clients is most likely to complain of afterbirth pains during her postpartum period?

G3 P2, gave birth to a 4100-gram baby

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?

Impaired skin integrity

During a postpartum assessment, the nurse notes that the uterus is midline and boggy. The immediate nursing action is:

Massage the fundus until firm and reevaluate within 30 minutes

Which of these medications is commonly used to control postpartum bleeding related to uterine atony?

Oxytocin