Exam #4 ?s
a 4 hour postpartum pt is experiencing excessive bleeding. She complains of severe pain, dizziness, and weakness. What should the nurse's first action be when postpartum hemorrhage from uterine atony is suspected?
begin massaging the fundus while another person notifies the physician.
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?
birth of a large newborn
the nurse is making a follow-up home visit to a woman who is 2 weeks postpartum. Which finding would the nurse expect when assessing the client's fundus?
cannot be palpated
what would the nurse teach the postpartum woman about perineal self-care while assisting her to the bathroom to void following her delivery?
cleanse with warm water in a squeeze bottle from front to back
a woman gave birth vaginally approx 12 hours ago, and her temp is now 100*F. Which action would be most appropriate?
continue to monitor the woman's temp q 4 hours; this finding is normal
a woman has had persistent lochia rubra containing large clots for 2 weeks after her delivery and is experiencing pelvic discomfort. On ultrasound, a piece of placenta is found in the uterus. What does the nurse explain is the usual treatment for sub involution caused by retained placental fragments
dilation & curettage
Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
distended bladder
a woman is 2 weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101*F. She reports abdominal pain and a "Bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition?
endometritis
a G 4 P4 mother calls the nurse's station reporting uterine pain following delivery. When the nurse responds to the call, the mother reports that she is experiencing intermittent labor-like cramping. What would be the nurse's response?
explain to her that women who have had several babies prior to this delivery often experience more severe afterpains, which is where the uterus is contracting and relaxing at intervals.
which of the following is the most likely sign of puerperal infection?
fever of 100.4*F lasting for 2 days
when doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel?
fundus two fingerbreaths below umbilicus and firm
which assessment on the third day postpartum would make the nurse evaluate a woman as having uterine subinvolution?
her uterus is at the level of the umbilicus
the nursing instructor is leading a discussion on the physical changes to a woman's body after delivery of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
involution
the nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what typeof lochia?
lochia rubra
a woman gave birth to a healthy infant boy 5 days ago. What type of lochia does the nurse expect to find when assessing this woman?
lochia serosa
the nurse is concerned that a new parent is developing a postpartum complication. What did the nurse most likely assess in the client?
lochia that has an offensive odor
the client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting as assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago?
massage the fundus until firm
the nurse is assessing the breast of a woman who 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?
mastitis
a postpartum pt is prescribed methylergonovine (Methergine) 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the pt?
measure bp
a woman who is not breastfeeding asks about resumption of her menstrual cycle after childbirth. On which information should the nurse base their response?
most non-breastfeeding women resume menstration around 2 months postpartum
a multiparous pt is admitted to the postpartum unit after a rapid labor and birth of a 4000g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the pt void and massage her fundus; however, the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take?
notify the health care provider
a woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia?
a change in lochia from pink to bright red should be reported
when assessing a postpartum client who was diagnosed with a cervical laceration that has been repaired, what sign should the nurse report as a possible development of hypovolemic shock?
a weak and rapid pulse
The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is: a. Uterine atony. b. Uterine inversion. c. Vaginal hematoma. d. Vaginal laceration.
a. Uterine atony.
a postpartal client is receiving an antipsychotic medication as treatment for postpartum psychosis. What should the nurse instruct the client about breastfeeding during this time>
all antipsychotics pass in breastmilk so breastfeeding will have to stop
a nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perfrom to decrease the swelling caused by perineal edema?
apply ice
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?
assess the fundus
the nurse is caring for a woman who had a c-section birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation.
assist the woman with ambulation for short periods of time.
a 4- week postpartum patient with mastitis ask the nurse if she can continue to breastfeed. What is the nurse's most helpful response?
"breastfeeding can continue unless there is abcess formation."
a primigravida tells the nurse, "My afterpains get worse when i am breastfeeding." What is the most appropriate nursing response?
"breastfeeding releases a hormone that causes your uterus to contract."
a postpartum mother is recovering from a cesarean delivery and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: Morphine Sulfate 8 mg IV q4 hours prn for pain greater than 6. Morphine Sulfate comes in 10 mg/mL. How many mL of morphine would the nurse administer to this client using slow push over 5 minutes?
0.8 mL
what is the best response to a postpartum woman who tells the nurse she feels "tired and sick all of the time since I had the baby 3 months ago"?
"Let's talk about this further. I am concerned about how you are feeling."
which statement indicates to the nurse on a postpartum home visit that the pt understands the signs of late postpartum hemmorhage?
"My discharge would change to read after it has been pink or white"
the nurse determine that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL
the 1-day postpartum pt reports chest pain, cough, and slight SOB on exertion. What medical diagnosis should the nurse suspect based on these symptoms?
Pulmonary embolism
a postpartum woman is prescribed Coumadin (warfarin) to treat DVT. What will the nurse know to use as an antidote for warfarin overdose in case of accidental overdose?
Vit K
fundal massage and breastfeeding have been ineffective in controlling aboggy uterus in a postpartum pt. What will the nurse anticipate might be ordered by the physician?
oxytocin
When palpating for fundal height on a postpartal woman, which technique is preferable?
placing one hand at the symphysis pubis, one on the fundus
a nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency?
postpartum diuresis
which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis?
redness and warmth in lower legs
a perinatal nurse caring for a postpartum woman understands that late postpartum hemorrhage (PPH) is most likely caused by:
subinvolution of the uterus
It has been 8 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's fundus, the nurse would expect to find it at:
the level of the umbilicus
what postpartum assessment does the acronym REEDA help a nurse remember how to complete throughly?
the perineum
about 10 days following birth, a new mother visits her primary care provider with localized symptoms of redness, swelling, warmth, and a hard, inflamed vessel in one leg. The nurse should suspect which condition?
thrombophlebitis
a fundal massage is sometimes performed on a postpartum woman. the nurse would perform this procedure to address which condition?
uterine atony
failure of the uterine musculature to contract sufficiently to compress vessels of the placenta site and control bleeding is known as:
uterine atony
a postpartum woman is experiencing subinvolution. Shen reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? SELECT ALL THAT APPLY
uterine infection prolonged labor hydramnios
A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache.
wear a well-fitting bra continuously for several days
a postpartum client, who is 24 hours post c-section, tells a nurse that she had much less lochial discharge after this birth than she has with her vaginal birth two years ago. The client asks the nurse if this is a normal response to a c-section birth. Which statement should be the basis for the nurse's response?
women normally have less lochia after c-section births as some is removed during the surgery
while visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white
