Chapter 25: Nursing Care of a Family Experiencing a Postpartum Complication

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? a. breast yeast b. mastitis c. plugged milk duct d. engorgement

b. mastitis 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.

Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? a. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. b. She has voided a total of 1000 mL in two voidings, each spaced 1 hour apart. c. She says she is extremely thirsty. d. Her perineum is obviously edematous on inspection.

a. At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. Postpartum women who void in small amounts may be experiencing bladder overflow from retention.

A client is receiving treatment for a postpartum complication. Which action should the nurse perform to support the 2020 National Health Goals during the postpartum period? a. Encourage to continue breastfeeding. b. Suggest breastfeeding be discontinued. c. Instruct on supplementing feedings with formula. d. Explain how breastfeeding will weaken the client's condition.

a. Encourage to continue breastfeeding. The postpartal period is a time when clients are susceptible to complications and may choose not to breastfeed. Nurses can help the nation achieve the 2020 National Health Goals by encouraging women to breastfeed even in the face of a postpartal complication. Suggesting that breastfeeding be discontinued or using supplemental feedings will not support the national goals. Breastfeeding is not known to weaken the client's condition while being treated for a complication.

A nurse is caring for a client who has had a cesarean birth and has developed a wound infection. What precautions should be taken by the nurse as a primary prevention measure? a. Apply ice packs every 12 to 24 hours. b. Keep the incisions clean and dry. c. Use a sitz bath once every 24 hours. d. Apply ice and heat alternatively.

b. Keep the incisions clean and dry. When caring for a client who has developed a wound infection, the nurse should keep the incision clean and dry to eliminate the opportunity for bacterial growth and proliferation. The nurse should apply ice and heat alternatively to decrease swelling when caring for a client who has undergone incision and drainage of a hematoma. Sitz baths are performed every 4 to 6 hours, not every 24 hours. Sitz baths aid in promoting comfort to the perineum after vaginal delivery. The nurse should apply ice packs every 12 to 24 hours when caring for a client with postpartum lacerations.

A nurse is caring for a postpartum client with urinary tract infection. Which instruction would the nurse include in the teaching plan for the client to help prevent future infections? a. "Empty your bladder frequently." b. "Wear your elastic compression stockings." c. "Avoid foods that are salty." d. "Apply ice to the infected area."

a. "Empty your bladder frequently." The nurse should instruct the client to empty her bladder frequently to prevent urinary stasis. In addition, the nurse would instruct the client to practice good perineal hygiene, and wipe from meatus to rectum to prevent bacterial contamination. Elastic compression stockings are helpful in preventing venous stasis, which is associated with venous thrombosis. Avoiding foods that are salty have no effect on urinary tract infections. Applying ice packs to the infected area would be appropriate for a client with mastitis.

A postpartal client is receiving heparin as treatment for thrombophlebitis. What should the nurse instruct the client about breastfeeding during this time? a. Breastfeeding can continue. b. The baby will need weekly blood work. c. The effect of anticoagulants is counteracted by infant gastric juices. d. All anticoagulants pass in breast milk so breastfeeding will have to stop.

a. Breastfeeding can continue. A client can continue to breastfeed while receiving heparin. The baby is not going to need weekly blood work. Infant gastric juices do not impact the effect of anticoagulants. Medications do affect breast milk; however, breastfeeding can continue while receiving heparin.

The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client? a. NSAIDS b. Anticoagulants c. Opioid analgesics d. Beta-blockers

b. Anticoagulants The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Opioid analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation.

When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? a. in the milk ducts b. in the reproductive tract c. in the urinary bladder d. within the blood stream

b. in the reproductive tract The most common site for a postpartum infection is the reproductive tract. This is important for teaching and education of clients.

Which assessment on the third postpartum day would indicate to the nurse that a woman is experiencing uterine subinvolution? a. Her uterus is 2 cm above the symphysis pubis. b. Her uterus is three finger widths under the umbilicus. c. Her uterus is at the level of the umbilicus. d. She experiences "pulling" pain while breastfeeding.

c. Her uterus is at the level of the umbilicus. A uterus involutes at a rate of one finger width daily. On the third postpartum day, it is normally three finger widths below the umbilicus.

A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? a. Bend her knee, and palpate her calf for pain. b. Ask her to raise her foot and draw a circle. c. Blanch a toe, and count the seconds it takes to color again. d. Assess for pedal edema.

d. Assess for pedal edema. Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return.

Why are postpartum women prone to urinary retention? a. Catheterization at the time of delivery reduces bladder tonicity. b. Decreased bladder sensation results from edema because of pressure of birth. c. Frequent partial voiding never relieve the bladder pressure. d. Mild dehydration causes a concentrated urine volume in the bladder.

b. Decreased bladder sensation results from edema because of pressure of birth. As the fetal head passes behind the bladder, bladder edema with loss of sensation can result

The nurse administers methylergonovine 0.2 mg to a postpartum woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication? a. Her urine output is over 50 ml/h. b. Her blood pressure is below 140/90 mm Hg. c. She can walk without experiencing dizziness. d. Her hematocrit level is over 45%.

b. Her blood pressure is below 140/90 mm Hg. Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.

The nurse is instructing a postpartum client on observations to report to the health care provider that could signify retained placental fragments. Which client statement indicates that teaching has been effective? a. "If the drainage changes from clear to bright red, I am to call the doctor." b. "I will have large amount of vaginal drainage for at least several months." c. "An elevated temperature is normal during the first few weeks after delivery." d. "My drainage will fluctuate between bright red and dark red for several weeks."

a. "If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the client is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. The client will not have large amounts of drainage for several months. An elevated temperature indicates an infection. The drainage should not fluctuate between bright and dark red and could indicate retained placental fragments.

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? a. Encourage fluid intake. b. Encourage the client to limit mobility. c. Provide several small meals daily rather than three larger meals. d. Administer antacids with each dose of antibiotics.

a. Encourage fluid intake. 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.

A postpartum client has a swollen area of purplish discoloration in the perineal area that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for this client? a. acute pain b. risk for injury c. risk for infection d. ineffective peripheral tissue perfusion

a. acute pain The nursing diagnosis of acute pain would be appropriate because of a collection of blood in traumatized tissue secondary to birth trauma. Risk for injury would be appropriate if the client was demonstrating signs of postpartum depression or psychosis. Risk for infection would be appropriate if the client had an elevated temperature. Ineffective peripheral tissue perfusion would be appropriate if the client was demonstrating signs of thrombophlebitis.

The nurse is concerned that a postpartum client with a cervical laceration is developing hypovolemic shock. What did the nurse assess in this client? a. weak and rapid pulse b. warm and flushed skin c. elevated blood pressure d. decreased respiratory rate

a. weak and rapid pulse If the loss of blood is extremely copious, a woman will quickly begin to exhibit symptoms of hypovolemic shock such as a weak and rapid pulse. The skin will be pale and clammy, and the blood pressure will fall. Respiratory rate will be increased and shallow.

A postpartum client is diagnosed with a vaginal laceration. What intervention will the nurse provide to the client at this time? a. Monitor vital signs every 30 minutes. b. Insert an indwelling urinary catheter. c. Provide stool softeners as prescribed. d. Weigh vaginal packing to estimate blood loss.

b. Insert an indwelling urinary catheter. An indwelling urinary catheter may be placed following a vaginal repair because the packing causes such pressure on the urethra it can interfere with voiding. Vital signs do not need to be monitored every 30 minutes. Stool softeners are not indicated for this type of laceration. The packing is not removed for 24 to 48 hours.

A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? a. Assess vital signs. b. Assess the fundus. c. Notify the health care provider. d. Begin an IV infusion of Ringer's lactate solution.

b. Assess the fundus. The best safeguard against uterine atony is to palpate the fundus at frequent intervals to be assured that the uterus is remaining contracted. If bleeding persists, then a vital signs assessment and notification to the health care provider may be indicated. An intravenous infusion might be prescribed if bleeding continues.

A postpartum client with thrombophlebitis states that her leg is very painful. Which nursing instruction is most appropriate to decrease the pain? a. Massage the calf of her leg. b. Keep covers off the leg. c. Apply ice above the knee. d. Encourage ambulation every two hours.

b. Keep covers off the leg. Any restriction, including tight-fitting clothes or blankets on the leg, can interfere with blood circulation. Uncovering or removing the constriction relieves the pain. Ice impairs circulation further exacerbating pain. Massaging the leg or encouraging ambulation could cause a clot to move and become a pulmonary embolus.

The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue? a. Ibuprofen b. Oxytocin c. Penicillin d. Digoxin

b. Oxytocin Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.

Which instruction would the nurse include in the teaching plan for a postpartum client with a history of thromboembolism to reduce the risk of a recurrence? a. Refrain from performing leg exercises. b. Wear support hose or antiembolic stockings. c. Flex the muscles at the groin. d. Avoid pressure on the thigh muscles.

b. Wear support hose or antiembolic stockings. When caring for a postpartum client with a history of a thromboembolic disorder, the nurse should instruct the client to wear support hose or antiembolic stockings. The nurse should instruct the client specifically to perform leg exercises such as flexion and extension of the feet. Another therapeutic exercise is for the client to push the back of the knees into the mattress and then flex slightly. The nurse should instruct the client to refrain from flexing the muscles at the groin, and the nurse should instruct the client to avoid pressure at the back of the knees, not on the thigh muscles.

The nurse is reviewing orders written for a postpartum client with a fourth-degree perineal laceration. Which order should the nurse question before implementing? a. providing a sitz bath b. administering an enema c. urging to drink all the milk provided during meals d. administering acetaminophen and codeine for pain

b. administering an enema A fourth-degree perineal laceration involves the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum. Any client who has a fourth-degree laceration should not have an enema prescribed because the hard tips of equipment could open sutures near to or including those of the rectal sphincter.

A nurse is assigned to care for a client with lacerations. The nurse knows that which factor would be the most likely cause of lacerations of the genital tract? a. history of hypertension b. birth of a large newborn c. excessive traction on umbilical cord d. development of endometritis

b. birth of a large newborn The nurse knows that lacerations of the genital tract may occur with the birth of a large infant. Other risk factors for lacerations include forceps or vacuum birth, precipitous second stage, and rapid expulsion. Scarring from prior gynecologic or birth events and vulvar, perineal, or vaginal varicosities increase the incidence of lacerations. When the client experiences excessive traction on the umbilical cord coupled with rapid expulsion of the uterine contents, it leads to uterine inversion and not lacerations of the genital tract. Endometritis is the primary cause of postpartum infections; it is not known to lead to lacerations of the genital tract.

Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? a. "Stop breastfeeding until the pain and swelling subside." b. "You'll need to take this medication to stop the milk from being produced." c. "Try applying warm compresses to your breasts to encourage the milk to be released." d. "Limit the amount of fluid you drink so your breasts don't get much fuller."

c. "Try applying warm compresses to your breasts to encourage the milk to be released." Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present.

A postpartum client is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the client? a. Assess ambulation. b. Measure urine output. c. Measure blood pressure. d. Evaluate current hematocrit level.

c. Measure blood pressure. Methylergonovine can increase blood pressure and must be used with caution in clients with hypertension. The nurse should assess the blood pressure prior to administrating and about 15 minutes afterward to detect this side effect. Methylergonovine does not affect ambulation, urine output, or hematocrit level.

A postpartum woman is placed on an anticoagulant to prevent further clot formation. She asks the nurse if she will be able to continue breastfeeding. The nurse's best response would be that: a. all anticoagulants pass in breast milk, so she will have to stop. b. anticoagulants pass in breast milk, but not in amounts great enough to cause harm. c. the effect of anticoagulants is counteracted by infant gastric juices. d. it depends on the type of anticoagulant she is taking.

d. it depends on the type of anticoagulant she is taking. Advice will differ based on the drug prescribed. Heparin, for example, does not pass into breast milk, yet warfarin (coumadin) does.

A postpartum client is receiving antibiotics for endometritis. What should the nurse instruct the client to observe in the infant with breastfeeding? a. jaundice b. irritability c. decreased sleep levels d. white plaques in the mouth

d. white plaques in the mouth The client who is breastfeeding should not be prescribed antibiotics that are incompatible with breastfeeding. The client should be instructed to observe for problems in their infant, such as white plaques or thrush in their infant's mouth that can occur when a portion of the maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant. Antibiotics will not typically cause jaundice. Irritability may or may not be because of the mother taking antibiotics. Decreased sleep levels are not typically associated with maternal antibiotic use.