CHAPTER 15
A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?
"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?" Separation from children is often as painful for a mother as it is for her children. A chance to visit the hospital and see the new baby and their mother reduces feelings that their mother cares more about the new baby than about them. It can help to not only relieve some of the impact of separation but also to make the baby a part of the family. Assess to be certain siblings are free of contagious diseases such as upper respiratory tract illnesses or recent exposure to chickenpox before they visit. Then, have them wash their hands and, if they choose, hold or touch the newborn with parental assistance. Allowing the siblings to walk with the baby out in the hall unsupervised would be unsafe.
A mother's chart notes that she is non-immune on her rubella status. The nurse explains what this means to the client. Which statement by the mother indicates that more teaching is needed?
"I need to have three shots to get my rubella levels up." If a mother is non-immune to rubella, she will receive a rubella immunization prior to being discharged from the hospital. She will have titers drawn 6 to 8 weeks later to determine if she developed immunity to rubella. If she remains non-immune, she will receive a re-vaccination. There will only be two shots potentially, not three.
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize?
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
During a home visit, the client mentions she is still having significant of joint pain. The nurse explains that the changes that softened the pelvic joints to allow for the birth were due to the hormone relaxin. The nurse informs the client that it takes approximately how long for the joints to return to prepregnancy status?
6 to 8 weeks after pregnancy During pregnancy, the hormones relaxin, estrogen, and progesterone relax the joints. After birth, levels of these hormones decline, resulting in a return of all joints to their prepregnant state. Within 6 to 8 weeks after delivery, joints are completely stabilized and return to normal.
The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding?
A process of developing an attachment and becoming acquainted with each other Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship. Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.
A Chinese mother delivers her newborn and is ready to go home. The grandmother is present and will remain with the mother for 1 month. The grandmother tells the nurse that the mother will not be allowed to leave the house for the first month after delivery. How should the nurse respond to this statement?
Accept the grandmother's statement and do discharge teaching accordingly. In many cultures, new mothers are not allowed to leave the home for at least 1 month to allow her opportunity to rest and keep her healthy. In the Chinese, Middle Eastern and Indian cultures, this is common practice. The nurse should not try to talk the grandmother out of her beliefs on caring for both her daughter and the newborn. Asking the grandmother why she is doing this is challenging and unprofessional.
The nurse discharging a newly delivered mother and her newborn infant needs to assess the mother's knowledge about how to take care of herself and her baby. This is her second child. Which approach would be best to verify the client's understanding of these topics?
Ask her questions and observe her caring for the baby. The best way to determine if a mother understands the information given to her regarding caring for herself and her baby is to ask her and watch her as she cares for the newborn in the hospital.
The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply.
Breasts feel slightly firm. Flattened nipple on the right breast Breasts are non-painful Normal findings for a breast exam in a Day 2 postpartum mother should include non-painful breasts, slight engorgement indicative of the milk coming in, and nipples that are either erect or can be drawn out. Reddened areas and cracked nipples are abnormal findings.
A multigravida client is still focusing on her difficult labor and discusses it with the nurse at each opportunity, several hours after the birth. Which action should the nurse prioritize after noting the client's partner is spending more time with the infant than the client?
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 client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize?
Ensure the baby empties the breasts at each feeding Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take?
Let the health care provider know the condition of the incision. All of the nurse's findings are abnormal except for the intact staples. The provider needs to be made aware of the appearance of the patient's incision. Re-applying another dressing will not address the signs of infection that are present.
Which assessment finding 1 hour after birth should be reported to the health care provider?
Lochia rubra is saturating a pad every 45 to 60 minutes. The nurse should ask the woman to turn over so her buttocks can be inspected in order to ensure that blood is not pooling beneath her. If the nurse observes a constant trickle of vaginal flow or the woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. She needs to be examined by her health care provider to be certain there is no cervical or vaginal tear, or that poor uterine contraction is not causing excessive bleeding. Following perineal assessment, the nurse should assess the rectal area for the presence of hemorrhoids. If any are present, the nurse should document their number, appearance, and size in centimeters. Fundus of uterus palpable at the level of the umbilicus is a normal finding immediately after birth. When the fundus is displaced to right and bladder is hard to palpation, the bladder is full, and the nurse needs to assist the client in emptying the bladder. The health care provider should be notified if a catheter needs to be inserted and there are no standing prescriptions for an in-and-out cath following birth.
What two elements play the biggest role in becoming a mother after delivery of her newborn?
Love and attachment to the child and engagement with the child A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant.
A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first?
Notify the health care provider of the findings. If the nurse notes abnormal findings on her exam—such as depressed respiratory status like this client is presenting—the nurse will immediately notify a health care provider. Having a peer come in to confirm your findings is always fine but this does not preclude notification of the physician. Asking the charge nurse to look in on the client later indicates there is no urgency to the situation, which there is.
A postpartum woman is concerned about constipation following delivery. What factor(s) contribute to this problem? Select all that apply.
Perineal pain Hemorrhoidal discomfort Iron supplements After delivery, many women experience a great deal of perineal pain, as well as hemorrhoidal pain, which leads to constipation because the woman is reluctant to defecate, fearing pain. Additionally, iron supplements contribute to constipation also.
A postpartum client reports urinary frequency and burning. What cause would the nurse suspect?
urinary tract infection Urinary frequency and burning suggest a urinary tract infection. Uterine atony and subinvolution could cause increased blood loss and prolonged lochia. Loss of pelvic muscle tone causes stress incontinence, which results in an inability to hold urine.
The nurse is preparing a nursing care plan for an immediate postpartum client. Which nursing diagnosis should the nurse prioritize?
Risk for injury: postpartum hemorrhage related to uterine atony The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage. All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.
A nurse is assessing a postpartum woman. Which behavior would the nurse interpret as an indication that the woman is entering the taking-hold phase of the postpartum period?
She did her perineal care independently. During the taking-in phase, women tend to be dependent; during the taking-hold phase, they begin independent actions.
Which action would most make the nurse believe that a postpartum woman is accepting a child well?
She turns her face to meet the infant's eyes when she holds he An "enface" position is a mark of a woman who is interacting warmly with a newborn.
A nurse is examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give to the client?
The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." The nurse should explain to the client that lochia rubra is a deep red mixture of mucus, tissue debris, and blood. Discharge consisting of leukocytes, decidual tissue, RBCs, and serous fluid is called lochia serosa. Discharge consisting of only RBCs and leukocytes is blood. Discharge consisting of leukocytes and decidual tissue is called lochia alba.
The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values?
The health care provider needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.
The nurse is reviewing the health records of several clients who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage?
a client diagnosed with placenta succenturiate Placental succenturiate is a concern for maternal hemorrhage if the accessory lobes of the placenta are retained after delivery. The other conditions are not associated with a higher than usual concern for hemorrhage, although all postpartum clients are observed for hemorrhage.
A nurse is reviewing the history of a postpartum woman. The nurse determines that the woman is at low risk for uterine subinvolution based on which findings? Select all that apply.
breastfeeding early ambulation Factors that inhibit involution that would result in subinvolution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
While making a follow-up home visit to a client in her first week postpartum, the nurse notes that she has lost 5 pounds. Which reason for this loss would be the most likely?
diuresis Diuresis is the most likely reason for the weight loss during the first postpartum week. Lactation accelerating postpartum weight loss is a popular notion, but it is not statistically significant. Blood loss or nausea in the first postpartum week does not cause major weight loss.
The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation?
lochia rubra Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
A nurse is teaching a postpartum woman about breastfeeding. When explaining the influence of hormones on breastfeeding, the nurse would identify which hormone that is responsible for milk production?
prolactin Prolactin from the anterior pituitary gland, secreted in increasing levels throughout pregnancy, triggers the synthesis and secretion of milk after the woman gives birth. During pregnancy, prolactin, estrogen, and progesterone cause synthesis and secretion of colostrum, which contains protein and carbohydrate but no milk fat. It is only after birth takes place, when the high levels of estrogen and progesterone are abruptly withdrawn, that prolactin is able to stimulate the cells to secrete milk instead of colostrum.
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.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
uterine infection prolonged labor hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
The nurse is making a home visit to a woman who is 4 days postpartum. Which finding would indicate to the nurse that the woman is experiencing a problem?
uterus 1 cm below umbilicus By the fourth postpartum day, the uterus should be approximately 4 cm below the umbilicus. Being only at 1 cm indicates that the uterus is not contracting as it should. Lochia serosa is normal from days 3 to 10 postpartum. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
The nurse is preparing discharge training for a G2P2 client who will breastfeed her infant. The client mentions she wants more children but wants to wait a couple of years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals?
when she resumes sexual activity The woman should use mechanical means of birth control as soon as she resumes sexual activity. She can ovulate even though she is not having a normal menstrual cycle. She needs to take precaution
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem?
white blood cell count 14,000/mm3 (14 ×109/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.
