Durham - Chapter 12 Postpartum Physiological Assessments and Nursing Care

____ 1. A multiparous patient reports severe uterine cramps the first day after a vaginal delivery. The nurse is aware the patient is breastfeeding and associates the patient's pain primarily with which occurrence? 1. An increase in oxytocin release related to the newborn suckling 2. The presence of intense afterbirth pains related to multiparity 3. An expected response to the daily administration of oxytocin 4. The efforts of the uterus to return to a prepregnancy condition

1. An increase in oxytocin release related to the newborn suckling Feedback 1 This is correct. The suckling of a newborn during breastfeeding will stimulate an increased release of oxytocin, which in turn stimulates the uterus to remain contracted. 2 This is incorrect. The presence of intense afterpains is frequently related to multiparity; however, in this scenario the nurse needs to recognize the severity is likely related to breastfeeding. 3 This is incorrect. Oxytocin is not administered unless the patient's uterus is not remaining contracted. The presence of severe cramps does not support the need of oxytocin. 4 This is incorrect. Afterpains or uterine contractions are the uterine effort to return the uterus nearly to the prepregnant size. The uterus never returns completely to the size prior to pregnancy.

____ 4. A postpartum patient calls the OB office 8 days following a vaginal delivery. The patient reports concern regarding vaginal bleeding. Which patient-reported symptom causes the nurse concern? 1. Increased flow noticed with physical activity 2. A description of the lochia as being red in color 3. Discharge that is noted to have a fleshy odor 4. Bleeding that is described as scant

2. A description of the lochia as being red in color Feedback 1 This is incorrect. When the patient reports an increased flow with physical activity, the nurse recognizes this as being normal in the period of 4 to 10 days after delivery. 2 This is correct. The lochia during the period of 4 to 10 days is described as lochia serosa (pink or brown color). The nurse will be concerned if the patient reports lochia that is red in color, which is indicative of bleeding. 3 This is incorrect. Normally, lochia has a fleshy odor. A foul odor is indicative of an infection. 4 This is incorrect. During this postpartum stage, the lochia is expected to be scant in amount.

____ 6. The nurse is preparing a postpartum patient for discharge. Which patient teaching is most important for the nurse to provide? 1. The signs and symptoms of uterine infection 2. The signs and symptoms of secondary hemorrhage 3. The signs and symptoms of postpartum depression 4. The signs and symptoms of a boggy uterus

2. The signs and symptoms of secondary hemorrhage Feedback 1 This is incorrect. It is important for the nurse to provide teaching regarding the signs and symptoms of infection; however, one other topic is most important. 2 This is correct. It is most important for the nurse to provide teaching regarding the signs and symptoms of secondary hemorrhage, which often occurs after the patient is discharged. The patient needs to understand the normal progression of lochia and uterine involution, and report abnormal amounts of bleeding. 3 This is incorrect. It is important for the nurse to provide teaching regarding the signs and symptoms of postpartum depression. However, one other topic is most important. 4 This is incorrect. It is important for the nurse to provide teaching to the patient about how to identify a boggy uterus and how to perform uterine massage. The patient also needs to know that the health care provider should be contacted. However, this is not the most important teaching.

____ 5. The nurse is collecting the urine of a postpartum patient who is passing large clots. For which reason does the nurse examine the large collected clots? 1. To validate the presence of clotting 2. To determine the presence of tissue 3. To obtain an accurate description 4. To document the number of clots

2. To determine the presence of tissue Feedback 1 This in incorrect. The nurse does not collect the large clots to validate the presence of clotting. 2 This is correct. The nurse collects the large clots in order to examine them for the presence of tissue, which indicates retained placenta tissue. Retained placental tissue can interfere with uterine involution and lead to excessive bleeding. 3 This is incorrect. The nurse can determine the size and appearance of the clots through a visual examination. 4 This in incorrect. The nurse can document the number of clots after visual examination.

____ 9. Prior to discharge from the birthing center, the nurse informs the patient that she will receive vaccines for rubella, hepatitis B, pertussis, and influenza. For which reason does the nurse explain the need for the vaccinations? 1. Discharge with a neonate is discouraged if the mother is not vaccinated. 2. Vaccinating the mother will protect the neonate from serious illnesses. 3. The mother's immune system has been suppressed during pregnancy. 4. Vaccination is more easily accomplished while the mother is under medical care.

2. Vaccinating the mother will protect the neonate from serious illnesses. Feedback 1 This is incorrect. The nurse does not inform the patient that discharge with a neonate is discouraged if the mother is not vaccinated. This reason threatens the patient's autonomy. 2 This is correct. When the mother is vaccinated for rubella, hepatitis B, pertussis, and influenza, the neonate is also less likely to be infected with or affected by these diseases. Hepatitis B, pertussis, and influenza can be life-threatening for a neonate. The mother should be immunized for rubella to avoid contracting the disease during a future pregnancy. 3 This is incorrect. The mother's immune system has been suppressed during pregnancy; however, it is expected to return to normal during the postpartum period. 4 This is incorrect. Vaccination may or may not be more easily accomplished while the mother is under medical care. This depends entirely on the attitude of the mother.

____ 8. The nurse is providing care to a patient who is postpartum. Using anatomy and physiology knowledge, which expectation does the nurse relate to the cardiovascular system? 1. Patient reporting of being cold related to blood loss 2. WBC laboratory level of 30,000/mm a few hours after delivery 3. Risk for hemorrhage due to decrease in circulating clotting factors 4. A normal postpartum hemoglobin laboratory value of less than 11 g/dL

2. WBC laboratory level of 30,000/mm a few hours after delivery Feedback 1 This is incorrect. An average blood loss of 200 to 500 mL is expected with a vaginal birth, which has a minimal effect on a woman's system due to pregnancy-induced hypervolemia. 2 This is correct. The nurse is aware that a WBC lab level of 30,000/mm a few hours after delivery is normal and as the result of the stress of labor and birth. 3 This is incorrect. The nurse understands that postpartum patients are at risk for thromboembolism related to the increase of circulating clotting factors during pregnancy. 4 This is incorrect. Hemoglobin and hematocrit are expected to be within normal ranges postpartum. Anemia is diagnosed if the hemoglobin is less than 11 g/dL and the hematocrit is less than 32%.

____ 3. The nurse is providing postpartum care to a patient 24 hours after a vaginal delivery. Which action does the nurse perform prior to assessing the patient's uterus? 1. Place the patient on the left side. 2. Assess the passage of lochia. 3. Ask the patient to void. 4. Administer a dose of oxytocin.

3. Ask the patient to void. Feedback 1 This is incorrect. The patient is positioned in a flat supine position. Side-lying will interfere with the assessment of the uterus. 2 This is incorrect. The passage of lochia is assessed as the nurse is palpating the uterus. 3 This is correct. The nurse needs to have the patient void prior to palpating the uterus in order to accurately assess uterine placement and tone. An overdistended bladder can result in uterine displacement and atony. 4 This is incorrect. Oxytocin is administered as prescribed if the uterus is boggy and uncontracted. The drug is not administered prior to uterus palpation.

____ 11. The nurse is discussing contraception with a couple before discharge following the birth of a first child. The couple are uncertain about the method but are certain about avoiding pregnancy for at least 2 years. Which method does the nurse recommend? 1. Emergency contraceptives 2. Oral estrogen/progesterone pill 3. Depo-Provera 4. Natural family planning

3. Depo-Provera Feedback 1 This is incorrect. The nurse does not suggest emergency contraceptives for this couple. The failure rate is only 9%, but it is not recommended as a regular form of birth control. 2 This is incorrect. The oral estrogen/progesterone combination contraceptive has many side effects (some are serious). There also some non-contraceptive advantages such as reduced risk for endometrial and ovarian cancer, benign breast disease, anemia, and may improve acne. Failure rate is 9%. This method may or may not be recommended depending on the patient's health and identified risk factors. 3 This is correct. Depo-Provera is a likely suggestion by the nurse. This method has a 3% failure rate, is injectable every 3 months, and has few non-life threatening side effects. It may result in delayed fertility. 4 This is incorrect. Natural family planning has a 24% failure rate and requires a regular menstrual cycle and the knowledge/willingness to frequently monitor body functions such as temperature and vaginal mucus production and consistency.

____ 7. The nurse in a postpartum unit frequently teaches patients regarding breast care. Which teaching is most helpful to the breastfeeding patient? 1. Run warm water over breasts while in the shower. 2. Wear a supportive bra for 24 hours a day. 3. Express milk by a breast pump or manually. 4. Take analgesics for breast pain management.

3. Express milk by a breast pump or manually. Feedback 1 This is incorrect. Running warm water over the breasts in the shower will stimulate milk production, which should be avoided by the patient who is not breastfeeding. However, the breastfeeding patient can achieve the same stimulation with warm compresses and breast massage. 2 This is incorrect. Wearing a supportive bra 24 hours a day is helpful to both the breastfeeding patient and the non-breastfeeding patient. The breastfeeding patient may wear bras until breastfeeding is discontinued; the non-breastfeeding patient until the breasts soften. 3 This is correct. Expressing milk with a breast pump or manually is specifically helpful to the breastfeeding patient. The process can help relieve breast engorgement, maintain a milk supply for the neonate/infant who cannot suckle at the breast, and/or provide breast milk for the neonate/infant who is separated from the mother. 4 This is incorrect. Managing breast pain with the use of analgesics is appropriate for both the breastfeeding and non-breastfeeding patient.

____ 17. In an attempt to improve the effectiveness of postpartum teaching, the nurse uses the AWHONN acronym POST BIRTH. Which teaching points require the patient to call for 911 assistance? Select all that apply. 1. Bleeding that soaks a pad per hour 2. A bad headache with vision changes 3. Thoughts of hurting self or baby 4. Signs an incision is not healing 5. A red, swollen leg painful to touch

3. Thoughts of hurting self or baby Feedback 1 This is incorrect. The AWHONN acronym states the health care provider is called if bleeding that soaks one pad an hour occurs. 2 This is incorrect. The AWHONN acronym states the health care provider is called if the mother experiences a bad headache with vision changes that does not respond to headache medication. 3 This is correct. The AWHONN acronym states the mother should call 911 immediately if she has thoughts of self-harm or harm to her baby. This can be indicative of severe postpartum depression or psychosis. 4 This is incorrect. The AWHONN acronym states the health care provider is called about signs indicative of an incision not healing. This is true of a perineal incision as well as one from a cesarean delivery. 5 This is incorrect. The AWHONN acronym states the health care provider is called if the mother notices a red or swollen leg that is painful to the touch; this is indicative of a blood clot in a lower extremity.

____ 10. A patient who is 12 hours postpartum after a vaginal delivery continues to have difficulty in initiating urination. The nurse is aware that an integrative method used when a woman is unable to void is peppermint oil. In which manner will the peppermint oil be used? 1. A thin layer is applied to the urinary meatus. 2. A small amount on a cotton ball is left at the bedside. 3. A small amount is added to the water of a vaporizer. 4. A saturated cotton ball is placed in a "hat" on the toilet.

4. A saturated cotton ball is placed in a "hat" on the toilet. Feedback 1 This is incorrect. The nurse understands that peppermint oil aids in urination because the vapors of the peppermint oil have a relaxing effect on the urinary sphincter. The oil is not applied to the urinary meatus. 2 This is incorrect. Leaving a small amount of peppermint oil on a cotton ball at the bedside is not effective; the peppermint vapors are effective when attempting to void. 3 This is incorrect. Adding a small amount of peppermint oil to the water of a vaporizer is not effective; the peppermint vapors are effective when attempting to void. 4 This is correct. The nurse will place a cotton ball saturated with peppermint oil in a "hat" used to collect urine when the patient voids in the toilet. A small amount of water is added to the "hat," and the resulting vapors have a relaxing effect on the urinary sphincter.

____ 2. The nurse is palpating a patient's uterus 12 hours after a vaginal delivery. For which reason does the nurse place one hand just above the symphysis pubis? 1. To prevent uterine prolapse. 2. To prevent uterine movement 3. To prevent uterine hemorrhage 4. To prevent uterine inversion

4. To prevent uterine inversion Feedback 1 This is incorrect. The nurse does not place a hand just above the symphysis pubis to prevent uterine prolapse. 2 This is incorrect. The nurse does not place a hand just above the symphysis pubis to prevent uterine movement. 3 This is incorrect. The process of assessing the uterus through palpation will provide information that can prevent uterine hemorrhage. 4 This is correct. When palpating the patient's uterus 12 hours postpartum, the nurse supports the lower uterine segment by placing one hand just above the symphysis pubis. Pregnancy stretches the ligaments that hold the uterus in place, and fundal pressure could result in uterine inversion.

____ 18. The nurse is providing teaching to a patient who is breastfeeding a newborn. The patient expresses interest in maintaining a healthy nutritional status for both her and her baby. Which information does the nurse present to meet the patient's need? Select all that apply. 1. Increase caloric intake by 500 to 1,000 per day. 2. Drink 2 to 3 liters of fluid each day. 3. Abstain from the intake of alcohol. 4. Eat fresh fruits and vegetables. 5. Avoid the intake of processed foods.

ANS: 1, 2 Feedback 1 This is correct. The lactating mother should increase her calorie intake by 500 to 1,000 calories daily. 2 This is correct. The lactating mother will need to drink approximately 2 to 3 liters of fluid daily. 3 This is incorrect. There is no evidence that an occasional alcoholic drink is harmful for the lactating mother; however, the long-term effects of daily alcohol use on breastfeeding infants is unknown, so alcoholic beverages should be kept to a minimum. The mother should wait 2 to 2.5 hours per drink before breastfeeding. 4 This is incorrect. Eating fresh fruits and vegetables is healthy for the mother; however, the mother needs to be alert that some fruits and vegetables may give the baby gas, cramps, and/or loose stools. 5 This is incorrect. There is no particular reason the mother should avoid processed foods completely; however, the mother should be conscious of consuming a healthy, balanced diet.

____ 14. A postpartum patient states, "I am really in pain." For which sources of pain will the nurse specifically assess the patient? Select all that apply. 1. Uterine contractions 2. Perineal trauma 3. Breast engorgement 4. Hemorrhoids 5. General soreness

ANS: 1, 2, 3, 4, 5 Feedback 1 This is correct. The nurse will specifically assess for uterine contractions or afterpains being a source of pain. 2 This is correct. The nurse will specifically assess for perineal trauma being a source of pain. Perineal trauma includes episiotomy, lacerations, and/or ecchymosis. 3 This is correct. The nurse will specifically assess for breast engorgement as being a source of pain. Breastfeeding mothers may also have nipple pain caused by improper nipple latching by the neonate. 4 This is correct. The nurse will specifically assess for hemorrhoids as being a source of pain. 5 This is correct. The nurse will specifically assess for general soreness as being a source of pain.

____ 12. The nurse is performing a uterus assessment on a patient who is 20 hours postpartum. The nurse finds the fundus of the uterus to be soft and boggy. In addition, the uterus is displaced to the left and moderate bleeding is noted. If the uterus does not respond to uterine massage, which actions does the nurse implement? Select all that apply. 1. Assist the patient to the bathroom to void. 2. Reassess to determine response to treatment. 3. Administer oxytocin as prescribed. 4. Place an emergency call to the HCP. 5. Make the patient NPO for surgery.

ANS: 1, 2, 3, 5 Feedback 1 This is correct. Because of the displacement of the uterus to the left, the nurse concludes that a full bladder may be the cause. The nurse needs to assist the patient to the bathroom to void. 2 This is correct. After the nurse implements all nursing and prescribed interventions, the nurse will reassess the uterus to evaluate and determine the response to treatment. 3 This is correct. When the uterus is boggy and bleeding is moderate, the nurse will administer oxytocin as prescribed in the HCP's postpartum orders. 4 This is incorrect. The nurse will contact the HCP after interventions are implemented and reassessment has taken place. There is no need to place an emergency call to the HCP prior to this. An emergency call is appropriate if improvement is not noted. 5 This is correct. If the patient does not respond to nursing and prescribed interventions, the nurse may make the patient NPO for anticipated surgery. The lack of response may indicate complications such as retained placental tissue or birth trauma. Continued uterine atony can lead to postpartum hemorrhage and requires assessment and potentially further treatment by the woman's health care provider.

____ 13. The nurse is preparing to perform a visual assessment of the perineum of a postpartum patient. The nurse will use the REEDA acronym. Which specific assessments are covered by REEDA? Select all that apply. 1. Perineal coloration 2. Suture line appearance 3. Amount of swelling 4. Description of pain 5. Soft tissue trauma

ANS: 1, 2, 3, 5 Feedback 1 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Redness is indicative of perineal coloration. 2 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Suture line appearance is indicative of approximation of edges of episiotomy or laceration. 3 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. The amount of swelling is indicative of edema. 4 This is incorrect. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. The patient's description of pain is not specifically addressed by a REEDA assessment. 5 This is correct. The acronym REEDA stands for redness, edema, ecchymosis, discharge, approximation of edges of episiotomy or laceration. Soft tissue trauma is frequently accompanied by bruising and is indicative of ecchymosis.

____ 16. The nurse is reviewing the medical record for a patient who is postpartum. The nurse notices the patient is rubella-nonimmune. Which information does the nurse present to the patient? Select all that apply. 1. The risks to the fetuses of any future pregnancies. 2. The patient will need to be immunized before discharge. 3. Breastfeeding should be avoided for 24 hours after immunization. 4. Maternal immunization carries over to the neonate. 5. Pregnancy should be avoided for 4 weeks.

ANS: 1, 2, 5 Feedback 1 This is correct. Fetuses exposed to rubella during the first trimester are at risk for birth defects that include deafness, blindness, heart defects, and mental retardation. 2 This is correct. The patient should be immunized before discharge so that immunity is established before the possibility of another pregnancy. Women cannot be immunized during pregnancy. 3 This is incorrect. There is no reason to refrain from breastfeeding for any period of time after a rubella vaccine is received. 4 This is incorrect. Maternal immunity to rubella does not carry over to the neonate. The infant will be immunized for rubella and other diseases at designated times. 5 This is correct. Although the risk of a fetus developing birth defects from the vaccine is extremely low, the patient is advised to avoid pregnancy for 4 weeks.

____ 15. The nurse is assessing patients who are postpartum. Which patients does the nurse identify as being at increased risk for respiratory complications? Select all that apply. 1. The patient who was placed on bedrest for threatened abortion 2. The patient with preeclampsia treated with magnesium sulfate 3. The patient with a preexisting diagnosis of diabetes mellitus 4. The patient who delivered a neonate after regional anesthesia 5. The patient who received large amounts of IV fluid due to blood loss

ANS: 1, 2, 5 Feedback 1 This is correct. The nurse recognizes that the patient placed on bedrest for a threatened abortion is a risk for developing a pulmonary embolus. 2 This is correct. Treating a patent with preeclampsia with magnesium sulfate places the patient at an increased risk for respiratory system complications. 3 This is incorrect. The patient with a preexisting diagnosis of diabetes mellitus is not at risk for the development of a respiratory system complication. 4 This is incorrect. The nurse does not expect the patient who delivers after the administration of regional anesthesia to develop respiratory system complications. 5 This is correct. The patient who receives a large amount of IV fluids because of blood loss is at risk for respiratory system complications related to the potential for fluid overload.

19. After pregnancy and birth, a mother may notice a condition called diastasis recti abdominis, which is a(n) ____________________ of the rectus muscle.

separation Feedback: After birth, the abdominal muscles experience reduced tone and the abdomen appears soft and flabby. Some women experience a separation of the rectus muscle, which is noted as diastasis recti abdominis. This separation becomes less apparent as the body returns to a prepregnant state.