Chapter 22 Prep U- Parent/Child Nursing
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
The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client?
Call her caregiver if lochia moves from serosa to rubra.
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.
A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis?
Perform hand-washing before and after breastfeeding.
Which situation should concern the nurse treating a postpartum client within a few days of birth?
The client feels empty since she gave birth to the neonate.
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?
Applying ice
The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?
Bladder distention
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
Uterine atony
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?"
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?
Infection
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.
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?
Ambulate the client as soon as her vital signs are stable.
A client presents to the clinic with her 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101°8F (38.8°C) and the right breast nipple with a movable mass that is red and warm. Which instruction should the nurse prioritize for this client?
Complete the full course of antibiotic prescribed, even if you begins to feel better.
The nurse reviews the history of a postpartum woman, G3, P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client?
Deep venous thrombosis
A postpartum woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis?
Dorsiflex her right foot and ask if she has pain in her calf.
A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching?
"I should brush my teeth vigorously to stimulate the gums."
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."
Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate?
She should continue to breastfeed; mastitis will not infect the neonate.
Every postpartum client has the potential of hemorrhage. While assessing a client's status, which finding would be of little benefit in identifying the possibility of hemorrhage?
Signs of shock
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.
