Chapter 22 PREPU
A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? 500 ml 250 ml 750 ml 1000 ml
1000 ml Explanation: Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth.
A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. loss of confidence manifestations of mania decreased interest in life inability to concentrate bizarre behavior
inability to concentrate loss of confidence decreased interest in life The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis.
The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? breast yeast mastitis plugged milk duct engorgement
mastitis Explanation: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Mastitis needs to be assessed and treated with antibiotic therapy.
A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? She feels like eating all the time. lack of pleasure extreme periods of elation She is over her interest in her baby.
lack of pleasure Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby
A nurse is conducting a class for nurses working in the postpartum unit about ways to reduce the risk of postpartum infections. The nurse determines that the teaching was effective when the group identifies which preventive measure as essential? use of clean gloves for invasive procedures unlimited visitation from family and friends meticulous handwashing fluid intake limitations
meticulous handwashing Explanation: Meticulous handwashing is essential for preventing postpartum infections, including before and after each client care activity. Aseptic technique, not clean gloves, are needed when performing invasive procedures. All visitors should be screened for any signs of active infection to reduce the risk for exposure. Adequate hydration, not fluid limitations, would be appropriate.
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 750 ml 1000 ml 300 ml 500 ml
1000 ml Explanation: Postpartum hemorrhage (PPH) is defined as a cumulative blood loss greater than 1,000 ml with signs and symptoms of hypovolemia within 24 hours of the birth process, regardless of the route of delivery. Morbidity from PPH can be severe, with sequelae including organ failure, shock, edema, thrombosis, acute respiratory distress, sepsis, anemia, intensive care admissions, and prolonged hospitalization. Hemorrhage is the most common reason postpartum women are admitted to intensive care units and it is the most preventable cause of maternal death.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Initiate Ringer's lactate infusion. Assess the woman's vital signs. Call the woman's health care provider. Assess the woman's fundus.
Assess the woman's fundus. Explanation: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.
Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? She says she is extremely thirsty. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Her perineum is obviously edematous on inspection.
At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Explanation: Postpartum women who void in small amounts may be experiencing bladder overflow from retention.
The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately? Calf pain Edema Dyspnea Pyrexia
Dyspnea Explanation: A DVT is often suspected when an individual with an increased risk develops calf pain, pyrexia, and edema in one lower extremity. After the individual has been positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible pulmonary embolism and should be handled as an emergency. The RN and/or primary care provider should be notified immediately so emergent care can be started, as this is often fatal.
A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction? Change the perineal pad every 3 to 4 hours to decrease the uterine infection. Finish all antibiotics to decrease a genital tract infection. Drink plenty of fluids to decrease a bladder infection. Apply ice to the perineum to decrease pain of a perineal infection.
Finish all antibiotics to decrease a genital tract infection. Explanation: A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.
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? Assess her blood pressure. Palpate her fundus. Have her turn to her left side. Assess her perineum.
Palpate her fundus. Explanation: The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended.
Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Apply cold compresses to the breast. Avoid massaging the breast area. Perform handwashing before breastfeeding. Avoid frequent breastfeeding.
Perform handwashing before breastfeeding. Explanation: As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps.
A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? Warm and flushed skin Decreased respiratory rate Elevated blood pressure Weak and rapid pulse
Weak and rapid pulse Explanation: Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.
A client presents to her postpartum appointment with vague reports. The nurse suspects postpartum depression based on which assessment finding? extreme periods of elation She is over her interest in her baby. lack of pleasure She feels like eating all the time.
lack of pleasure Explanation: Some signs and symptoms of postpartum depression include feeling restless, worthless, guilty, hopeless, moody, sad, overwhelmed; crying a lot; exhibiting a lack of energy and motivation; experiencing a lack of pleasure; changes in appetite, sleep, or weight; withdrawing from friends and family; feeling negatively toward her baby; or showing lack of interest in her baby.
Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: maladjustment to parenting. lack of partner support. postpartum depression. postpartum blues.
postpartum depression. Explanation: Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation.
The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse's explanation of care? "I will stop breastfeeding until I finish my antibiotics." "When breastfeeding, it is recommended to begin nursing on the infected breast first." "I am able to pump my breast milk for my baby and throw away the milk." "I can continue breastfeeding my infant, but it may be somewhat uncomfortable."
"I can continue breastfeeding my infant, but it may be somewhat uncomfortable." Explanation: Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away.
The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention? Encourage the client to limit mobility. Administer antacids with each dose of antibiotics. Encourage fluid intake. Provide several small meals daily rather than three larger meals.
Encourage fluid intake. Explanation: Adequate fluid intake is necessary during antibiotic therapy. Mobility should be encouraged whenever possible and safe. Small meals do not enhance healing or mitigate adverse effects. Antacids may or may not be prescribed.
The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? Frequent feeding Pierced nipple Use of breast pumps Complete emptying of the breast
Pierced nipple Explanation: Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads.
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?" "What time did you last change your pad?" "When did you last void?" "Are you in any pain with your bleeding?"
"How much blood was on the two pads?" Explanation: The nurse needs to determine the amount of bleeding the client is experiencing; therefore, the best question to ask the mother is the amount of blood noted on her perineal pads when she changes them. If she had an epidural, she may not feel any pain or discomfort with the bleeding. Although a full bladder can prevent the uterus from contracting, the nurse's main concern is the amount of lochia the mother is having.
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 need to avoid using any aspirin-containing products." "If I get a cut, I need to apply direct pressure for about 5 minutes or more." "I should brush my teeth vigorously to stimulate the gums." "If my lochia increases, I need to call my health care provider."
"I should brush my teeth vigorously to stimulate the gums." Explanation: The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes.
The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Assess the woman's vital signs. Call the woman's health care provider. Initiate Ringer's lactate infusion. Assess the woman's fundus.
Assess the woman's fundus. The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of laboratory data Assessment of bowel function Assessment of the perineal pad Assessment of the lung fields
Assessment of the perineal pad Explanation: Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern.
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 rubra to serosa. Call her caregiver if lochia moves from serosa to alba. Call her caregiver if amount of lochia decreases. Call her caregiver if lochia moves from serosa to rubra.
Call her caregiver if lochia moves from serosa to rubra. Explanation: Most cases of late postpartum hemorrhage occur after the woman leaves the health care or birthing facility. Therefore, client education before discharge about expected changes and danger signs and symptoms is crucial. Instruct the woman to call her primary care provider if she experiences any signs of infection, such as fever greater than 100.4°F (38°C), chills, or foul-smelling lochia. She should also report lochia that increases (versus decreasing) in amount, or reversal of the pattern of lochia (i.e., moves from serosa back to rubra).
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Oxytocin Calcium gluconate Magnesium sulfate Domperidone
Oxytocin Explanation: Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate.
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? Discontinue breastfeeding to allow time for healing. Avoid hot or cold compresses on the breast. Discourage manual compression of breast for expressing milk. Perform handwashing before and after breastfeeding.
Perform handwashing before and after breastfeeding. Explanation: The nurse should educate the client to perform handwashing before and after breastfeeding to prevent mastitis. Discontinuing breastfeeding to allow time for healing, avoiding hot or cold compresses on the breast, and discouraging manual compression of the breast for expressing milk are inappropriate interventions. The nurse should educate the client to continue breastfeeding, because it reverses milk stasis, and to manually compress the breast to express excess milk. Hot and cold compresses can be applied for comfort.
The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider? States being tired and happy at same time Restless and agitated, concerned with self and not the infant Tearful during appointment Talkative and asking questions
Restless and agitated, concerned with self and not the infant Explanation: When a woman presents with restlessness, irritability and concern only for self needs and not the infant's needs, further evaluation for possible postpartum psychosis should be a priority. The other choices would be considered normal reactions for a postpartum woman.
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. The most common pathogen is group A streptococcus (GAS). A breast abscess is a common complication of mastitis. Mastitis usually develops in both breasts of a breastfeeding client.
Symptoms include fever, chills, malaise, and localized breast tenderness. Explanation: Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally.
The nurse inspects the client's perineum and finds it is red, swollen, and tender. The nurse explains to the client that she needs to be monitored for blood loss, especially because of bleeding into the tissue of the perineum because of the third degree laceration sustained while giving birth. What parameters will the nurse assess to detect signs of additional blood loss? Select all that apply. Uterine fundus Blood pressure Amount of lochia Urine output Pulse rate
Urine output Blood pressure Pulse rate Explanation: Assessment findings consistent with blood loss are increased pulse rate, decreased blood pressure, and decreased urine output. Bleeding into the perineal tissue may not be visible, therefore monitoring these parameters is important. Because bleeding is related to the laceration, uterine involution is not impacted and the assessment of the fundus is not going to provide useful data. Similarly, the amount of lochia will not provide useful data about bleeding into the perineal tissue.
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who had an 8-hour labor a client who had a nonelective cesarean birth a client who conceived following fertility treatments a primiparous client who had a vaginal birth
a client who had a nonelective cesarean birth Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. The other listed factors are not noted risk factors for infection.
Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? applying ice restricting fluids applying warm compresses administering bromocriptine
applying ice Explanation: Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum panic disorder postpartum depression postpartum blues postpartum psychosis
postpartum psychosis Explanation: The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the newborn, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine prolapse uterine subinvolution uterine atony uterine contraction
uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.
A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution uterine contraction uterine atony uterine prolapse
uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally, the nurse assists the woman with perineal care and applying a new perineal pad.
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? Shock Dehydration Infection Normal vital signs
Infection Explanation: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? postpartum psychosis postpartum depression postpartum panic disorder postpartum blues
postpartum psychosis Explanation: The client's signs and symptoms suggest that the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the newborn, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easily—often for no reason—and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues.
The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? Select all that apply. "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit." "I am sad because I am not spending as much time with my toddler now that my newborn is here." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." "The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts."
"The newborn is not really mine emotionally, since I was never pregnant and do not have children." "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." Postpartum psychosis is a serious and emergent condition in which the new mother has lost touch with reality and needs immediate psychiatric intervention. Visual hallucinations such as seeing the newborn's thoughts projected on her phone is a sign of postpartum psychosis. Denying the pregnancy or that the newborn is hers is a sign of postpartum psychosis. The delusion that her milk is poisoned is a sign of postpartum psychosis. Being concerned about time with the toddler is a sign of postpartum blues or possibly depression. Reaching out for family to visit is a positive coping skill.
The nurse notes uterine atony in the postpartum client. Which assessment is completed next? Assessment of the lung fields Assessment of bowel function Assessment of the perineal pad Assessment of laboratory data
Assessment of the perineal pad Explanation: Uterine atony is a cause of postpartum hemorrhage due to the inability of the uterus to contract effectively. Assessment of the perineal pad for the characteristics and amount of bleeding is essential. It is important to monitor all postpartum women for excessive bleeding because two-thirds of the women who experience postpartum hemorrhage have no risk factors. Assessment of bowel and bladder function is routine in a postpartum assessment but not included in concerns for hemorrhage. Assessment of the lungs and any laboratory work is common but not as high of a concern.