Chapter 16: Nursing Management During the Postpartum Period

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 mL with each hourly void. How would the nurse interpret this finding?

The urinary output is normal

Hypercoagulability during pregnancy protects the mother against excessive blood loss during birth. It also can increase a woman's risk of developing a blood clot. It does this by which means?

-Stasis -altered coagulation -localized vascular damage

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?

2 weeks

Which finding would the nurse describe as "light" or "small" lochia?

4 inch stain or a 10-25mL loss

If a patient does not void after ____ hours they need to be catheterized.

7

A postpartum woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartum?

Assess for calf redness and edema

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

Atony

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next?

Educate the client on how to perform Kegel exercise

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth degree

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

Hematoma

One hour after birth the nurse is assessing a neonate in the nursery. The nurse begins by assessing which parameters?

Inspecting posture, color, and respiratory effort

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

Mastitis

At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of:

Postpartum Depression

Which information would the nurse emphasize in the teaching plan for a postpartum woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area.

Which factor puts a client on her first postpartum day at risk for hemorrhage?

Uterine atony

During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia?

delayed hemorrhage

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3-6 weeks

Prior to discharge is an appropriate time to evaluate the client's status for preventive measures such as immunizations and Rh status. Which test would the nurse ensure has been conducted to evaluate the Rh-negative mother?

indirect Coombs test

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

percussion revelas dullness

A nurse is auscultating the lungs of a postpartum client and notices crackles and some dyspnea. The client's respiratory rate is 12 breaths/minute; she appears in some distress. What complication should the nurse suspect based on these data?

pulmonary edema

A nursing student learns that a certain condition occurring in up to 3 in every 1,000 births is a major cause of death. What is this condition?

pulmonary embolism

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

third-degree laceration