Maternal/OB: Ch. 10 Nursing Care of Women with Complications After Birth

The nursing instructor asks a student nurse to explain the physiological changes of hypovolemia. Which statement by the student indicates the need for additional teaching? 1. "The blood flow to vital organs is increased." 2. "The blood flow to nonessential organs is reduced." 3. "The patient with hypovolemia has an increased heart rate." 4. "The patient with hypovolemia has pale, warm, and dry skin."

"The patient with hypovolemia has pale, warm, and dry skin." --The patient's skin becomes pale, cool, and moist. P. 248

A postpartum patient with venous thrombosis is on anticoagulant therapy. Which instruction would the nurse provide to enhance patient safety? 1. "Use a soft toothbrush." 2. "Eat plums and prunes." 3. "Maintain proper hand hygiene." 4. "Eat strawberries and cantaloupe."

"Use a soft toothbrush." --Due to having signs of excess anticoagulation that include bleeding gums and nose bleeds. **The patient should eat plums and prunes to prevent UTI. **The patient would eat strawberries and cantaloupe to promote wound healing. P. 253

Table 10.2 Medical management of Mastitis:

-Antibiotics (Usually oral, although may be IV initially if woman has abscess). -Incision and drainage of abscess.

Table 10.1 Contributing factors to Uterine Atony:

-Bladder distention -Abnormal or prolonged labor -Overdistended uterus -Multiparity (five or more births) -Use of oxytocin during labor -Medications that relax uterus -Operative birth -Low placental implantation

Table 10.2 Medical management of Urinary Tract Infections:

-Clean-catch or catheterized urine specimen for culture and sensitivity testing. -Antibiotics (initially by IV route for pyelonephritis).

Table 10.1 Characteristics of Lacerations include:

-Continuous trickle of blood that is brighter than normal lochia. -Fundus that is usually firm. -Onset of hypovolemic shock that may be gradual and easily overlooked.

Table 10.2 Medical Management of Wound infections:

-Culture and sensitivity of wound exudate -Antibiotics

Table 10.2 Medical management of Endometritis:

-Culture and sensitivity test of uterine cavity. -Antibiotics by intravenous (IV) route initially.

Table 10.2 Characteristics of Urinary tract infection include:

-Cystitis (bladder) -Low-grade fever -Burning, urgency, and frequency of urination -Pyelonephritis (Kidneys) -High fever with pattern of spikes -Chills -Pain in costovertebral angle or flank. -Nausea and vomiting.

Table 10.1 Characteristics of Hematoma include:

-If visible, appears as blue or purplish mass on vulva. -Severe and poorly relieved pain and/or pressure in vulva, pelvis, or rectum. -Large amount of blood lost into tissues, which causes signs and symptoms of hypovolemic shock -Lochia that is normal in amount and color.

Table 10.1 Contributing factors to Hematoma's:

-Prolonged or rapid labor -Large infant -Use of forceps or vacuum extractor

Table 10.1 Contributing factors to Lacerations:

-Rapid labor -Use of instruments such as forceps or vacuum extractor during birth.

Table 10.2 Characteristics of Mastitis (Breast) include:

-Reddened, tender, hot area of breast. -Edema and feeling of heaviness in breast. -Purulent drainage (may occur if an abscess forms).

Table 10.2 Characteristics of Wound infections include:

-Signs of inflammation (Redness, edema, heat, pain). -Separation of suture line -Purulent drainage

Table 10.2 Nursing care of Endometritis:

-Teach woman usually progression of lochia, because infection often occurs after discharge. -Use Fowler's position to facilitate drainage of infected lochia. -Administer analgesics. -Observe for absent bowel sounds, abdominal distention, and nausea or vomiting, which suggest spread of infection.

Table 10.2 Characteristics of Endometritis (Uterus) include:

-Tender, enlarged uterus. -Prolonged, severe cramping. -Foul-smelling lochia -Fever and other systemic signs of infection. -Signs of uterine subinvolution.

Table 10.2 Nursing care of Wound infections:

-Use aseptic or sterile technique for all wound care as indicated. -Teach proper perineal hygiene to reduce fecal contamination. -Use sitz baths for perineal wound infections.

Table 10.1 Characteristics of Uterine Atony include:

-Soft, high uterine fundus that is difficult to feel through woman's abdominal wall. -Heavy lochia, often with large clots or sometimes a persistent moderate flow. -Bladder distention that causes uterus to be high and usually displaces it to one side. -Possible signs of hypovolemic shock.

Table 10.2 Nursing care for Mastitis:

-Teach effective breast-feeding techniques. -Encourage moist heat applications with warm pack. -Use warm shower before nursing to start milk flow. -Massage affected area to reduce congestion and start milk flow. -Encourage regular and frequent nursing or pumping to keep breasts empty.

Table 10.2 Nursing care for Urinary tract infections:

-Teach perineal hygiene. -Encourage fluid intake of 3 L/day -Teach which foods increase acidity of urine such as apricots, cranberry juice, plums, and prunes.

Which complications might a patient experience following a forceps-assisted delivery? Select all that apply. 1. Lacerations 2. Hematoma 3. Endometritis 4. Uterine atony 5. Subinvolution

1 & 2 -Lacerations (As a result of tissue damage or trauma). -Hematoma (Caused by the collection of blood within the tissues). **Endometritis: Inflammation of the inner lining of the uterus that occurs as a result of infection. **Uterine atony: Occurs as a result of the retention of placental fragments or as a result of infection. --> Manifests as a soft and boggy uterus. **Subinvolution: Inability of the uterus to regain its pre-pregnant state as a result of retention of placental fragments. P. 250

Which postpartum complications require a clean-catch urine specimen for culture and sensitivity testing? Select all that apply. 1. Cystitis 2. Mastitis 3. Peritonitis 4. Endometritis 5. Pyelonephritis

1 & 5 -Cystitis -Pyelonephritis --These are Urinary tract infections and require a clean-catch specimen for culture and sensitivity testing. **Peritonitis: Inflammation of the peritoneum. **Endometritis: A culture and sensitivity test of the uterine cavity is required. P. 254

The nurse is caring for a patient diagnosed with a large hematoma. Which clinical findings would the nurse assess for in the patient? Select all that apply. 1. Increased pulse rate 2. Increased temperature 3. Increased blood glucose 4. Increased blood pressure 5. Increased respiratory rate

1 & 5 -Increased pulse rate -Increased respiratory rate --A large hematoma causes excessive loss of blood, resulting in an increase in pulse, respiratory rate and a decrease in BP. **Elevated temperature is common in patients with puerperal sepsis. P. 252

Which assessment findings are signs of mastitis? Select all that apply. 1. Breast abscess 2. Fever and chills 3. Breast erythema 4. Breast heaviness 5. Nipples leaking milk

1, 2, 3, 4 -Breast abscess -Fever and chills -Breast erythema -Breast heaviness P. 255

Review Questions for the NCLEX: A woman delivered her newborn several hours previously, and her uterus remains soft and boggy. Which of the following medications should the nurse anticipate that the health care provider would prescribe to increase uterine tone and firm the uterus? SATA. 1. Methylergonovine (Methergine) 2. Carboprost (Hemabate) 3. Magnesium sulfate 4. Oxytocin (Pitocin)

1, 2, 4 -Methylergonovine (Methergine -Carboprost (Hemabate) -Oxytocin (Pitocin) --A diluted oxytocin (Pitocin) IV infusion is the most common drug ordered to control uterine atony. --Other drugs to increase uterine tone include: Methylergonovine or prostaglandins such as Hemabate or Cytotec. **Magnesium sulfate is a tocolytic and relaxes the smooth muscle of the uterus.

The nurse is caring for a postpartum patient who has saturated one perineal pad within 1 hour of delivery. Which instruction would the nurse expect from the health care provider? Select all that apply. 1. Place an indwelling catheter. 2. Administer intravenous fluids 3. Administer heparin (Lipo-Hepin) 4. Give oxygen therapy to the patient 5. Administer vitamin K (AquaMEPHYTON)

1, 2, 4 -Place an indwelling catheter (helps monitor urinary output as the urine output may decrease as a result of decreased blood flow to kidneys). -Administer intravenous fluids (help replace the fluids and increase hydration in the patient). -Give oxygen therapy to the patient (due to reduced oxygen supply and decreased saturation of blood cells, this helps prevent hypoxia). --The patient has postpartum hemorrhage and may experience hypovolemic shock. P. 248

Which factors put a patient at risk for postpartum depression? Select all that apply. 1. Low self-esteem 2. Hormonal imbalance 3. Involvement of family 4. Unplanned pregnancy 5. Poor partner relations

1, 2, 4, 5 -Low self-esteem (May lack self-confidence to care for herself and the infant). -Hormonal imbalance (Falling estrogen levels affect dopamine production). -Unplanned pregnancy (She may not be ready to take care of the infant). -Poor partner relations (impairs communication). P. 256

Which assessment findings are associated with subinvolution of the uterus? Select all that apply. 1. Fatigue 2. Pelvic pain 3. Purplish mass on the vulva 4. Continuous trickle of blood 5. Persistence of lochia rubra

1, 2, 5 -Fatigue -Pelvic pain -Persistence of lochia rubra (due to retention of the placental fragments). --Subinvolution: The inability of the uterus to return to its non-pregnant state. --> It occurs as a result of retention of the placental fragments in the uterus or as a result of infection. --Patients with uterine subinvolution experience: Heaviness, fatigue, and pelvic pain. **Purplish mass on the vulva: Indicates hematoma. **Continuous trickle of blood: Due to vaginal lacerations. P. 252

Which complications may develop in a postpartum patient with a firm uterine fundus, severe uterine contractions, and bright red bleeding if not treated? Select all that apply. 1. Cystocele 2. Endometritis 3. Prolapsed uterus 4. Urinary incontinence 5. Deep venous thrombosis

1, 3, 4 -Cystocele (unrepaired periurethral lacerations that cause weakening of the supportive tissue between the bladder and vaginal wall, leading to further bladder bulge into the vagina). -Prolapsed uterus (Due to unrepaired periurethral lacerations also causing a weakening of the pelvic muscles). -Urinary incontinence (A common finding of both cystocele and uterine prolapse). --These are all symptoms of genital trauma. P. 251

The nurse is caring for a postpartum patient who reports frequent urination with a burning sensation, nausea, and costovertebral angle pain. Which intervention would be beneficial to the patient? Select all that apply. 1. Performing perineal hygiene. 2. Massaging the uterine fundus. 3. Including cranberry juice in diet. 4. Applying moist heat to the breasts. 5. Encouraging intake of 3 L of fluids daily.

1, 3, 5 -Performing perineal hygiene (helps reduce the infection by flushing out bacteria). -Including cranberry juice in diet (Increases the acidity of urine, which will prevent the bacteria from multiplying). -Encouraging intake of 3 L of fluids daily. --These symptoms are indicative of UTI, and a severe UTI would include nausea, vomiting, and costovertebral angle pain. P. 254

Early postpartum hemorrhage results from which causes? Select all that apply. 1. Uterine atony 2. Subinvolution of the uterus 3. Retention of placental fragments 4. Laceration of the reproductive tract 5. Hematoma with the reproductive tract

1, 4, 5 -Uterine atony -Laceration of the reproductive tract -Hematoma with the reproductive tract **Retention of placental fragments and subinvolution of the uterus are causes of late postpartum hemorrhage. P. 250

Which assessment parameters would the nurse monitor in a patient with endometritis? Select all that apply. 1. Temperature 2. Bowel sounds 3. Respiratory rate 4. Uterine contour 5. Abdominal contour

2 & 5 -Bowel sounds (Absence of) -Abdominal contour (distention of) --These indicate the spread of infection. **Uterine contour: Assessed to check for distension which may indicate uterine atony. **Temperature & Respiratory rate: Increase in patient with puerperal infection. P. 254

Which nursing intervention would provide relief to a postpartum patient who has a fever and chills as well as red and tender breasts with edema and purulent drainage? Select all that apply. 1. Weaning the infant. 2. Suggesting a warm shower. 3. Cleaning the breast with soap. 4. Asking the patient to wear a tight bra. 5. Administering intravenous antibiotics.

2 & 5 -Suggesting a warm shower. (Increases the blood flow and stimulates the flow of milk). -Administering intravenous antibiotics. (To treat the abscess affiliated with mastitis). --These symptoms indicate mastitis & abscess. --Mastitis: A breast infection that occurs 2 to 3 weeks post-delivery. P. 255-256

The nurse is caring for a patient with superficial venous thrombosis. Which intervention would the nurse expect to be beneficial for the patient? Select all that apply. 1. Light therapy 2. Application of heat. 3. Elevation of the legs. 4. Intravenous anticoagulant. 5. Oral analgesic medication

2, 3, 5 -Application of heat (helps relieve pain in the lower leg). -Elevation of the legs (promotes perfusion of the blood, facilitates venous drainage). -Oral analgesic medication (will assist with the pain associated with superficial venous thrombosis). --Superficial venous thrombosis is characterized by the presence of a reddened hard vein in the lower leg. P. 253

The nurse is caring for a patient with endometritis. Which assessment findings would the nurse anticipate? Select all that apply. 1. Nausea 2. Enlarged uterus 3. Foul-smelling lochia 4. Frequency of urination 5. Prolonged uterine cramping

2, 3, 5 -Enlarged uterus -Foul-smelling lochia -Prolonged uterine cramping P. 254

The nurse is caring for a postpartum patient with puerperal sepsis. Which food will the nurse include in the patient's diet plan to enhance healing? Select all that apply. 1. Food rich in fiber 2. Milk and legumes 3. Meat and orange juice 4. Tuberous foods and rice 5. Strawberries and cantaloupes

2, 3, 5 -Milk and legumes -Meat and orange juice -Strawberries and cantaloupes --Puerperal sepsis: An infection in postpartum patients and occurs as a result of impaired wound healing or opening at the placental insertion site. --Foods rich in proteins and vitamin C: Help in the formation of tissue and promote wound healing. P. 255

The nursing instructor is teaching a group of student nurses about postpartum hemorrhage. Which statement made by a student nurse indicates effective learning? Select all that apply. 1. "Early postpartum hemorrhage occurs in patients 24 hours after birth." 2. "Patients who undergo vaginal delivery may lose up to 300 mL of blood." 3. "Hypovolemia and anemia occur in patients after postpartum hemorrhage." 4. "Patients who undergo cesarean section may lose more than 1000 mL of blood." 5. "Late postpartum hemorrhage occurs in patients within 6 weeks after delivery."

3, 4, 5 -"Hypovolemia and anemia occur in patients after postpartum hemorrhage." -"Patients who undergo cesarean section may lose more than 1000 mL of blood." -"Late postpartum hemorrhage occurs in patients within 6 weeks after delivery." --Loss of blood in patients after cesarean birth can be greater than 1000 mL. --Major risk of hemorrhage is hypovolemic shock, which interrupts the supply of oxygen and nutrients as well as the removal of waste. --> Due to the massive loss of blood, the patient becomes anemic. --Loss of blood in patients after a vaginal birth is greater than 500 mL. --Late postpartum hemorrhage occurs after 24 hours and within 6 weeks after birth. P. 248

A postpartum patient with uterine atony and bleeding has not responded to medication. Which treatment strategy would be next in this situation? 1. A finger test 2. An episiotomy 3. A hysterectomy 4. A dilation and curettage

A hysterectomy. (The surgical removal of the uterus, which may also involve removal of the cervix, ovaries, fallopian tubes, and other surrounding structures). --This is beneficial for the patient who has bleeding in the uterus and is unresponsive to other measures. **Finger test: Helps test the laxity of vaginal muscles, which determines whether female has had intercourse for the first time. **Episiotomy: A surgical incision in the perineum to widen the opening of the vagina during childbirth. **Dilation and curettage: Performed in patients with postpartum hemorrhage to remove small blood clots and placental fragments. P. 251

The ultrasonography report of a postpartum patient with continuous vaginal bleeding indicates the presence of placental fragments in the uterus. Which treatment strategy would be beneficial? 1. Administering an oral antibiotic 2. Administering methylergonovine (Methergine). 3. Advising the patient to perform Kegel exercises. 4. Advising the patient to increase the intake of fluids.

Administering methylergonovine (Methergine). --This induces uterine contractions and helps maintain a firm uterus. --The firm uterine contractions would help to expel the retained placental fragments. P. 249

A postpartum patient with mastitis is experiencing pain but would like to avoid medication if possible. Which instruction from the nurse best meets the patient's needs? 1. Apply moist heat to affected area. 2. Apply ice to affected breast for pain relief. 3. Nurse the infant more frequently than usual. 4. Avoid breast-feeding and pumping until mastitis is resolved.

Apply moist heat to affected area. --Heat promotes blood flow to the area, comfort, and complete emptying of the breast. --Moist heat can be applied with chemical packs or by placing a warm wet cloth in a plastic bag and applying it to the breasts. --A warm shower provides warmth and cleanliness and stimulates the flow of milk if done just before nursing. P. 255

A postpartum patient has a fever, enlarged uterus, and foul-smelling lochia along with prolonged and severe cramps. Which intervention will the nurse choose to facilitate the drainage of lochia? 1. Provide a sitz bath to the patient. 2. Provide vigorous uterine massage. 3. Assist the patient into Fowler's position. 4. Instruct the patient to take 3L of fluid daily.

Assist the patient into Fowler's position. (This helps to drain the infected lochia). --This indicates the patient has endometritis. P. 254

The nurse is caring for a postpartum patient who has venous thrombosis. Which nursing intervention would be beneficial to the patient? 1. Instructing the patient to cross the legs. 2. Advising the patient to roll the stockings. 3. Assisting the patient with early ambulation. 4. Using nonpadded stirrups for episiotomy repair.

Assisting the patient with early ambulation. P. 253

Which finding, along with bright red bleeding, would the nurse associate with a laceration when assessing the perineum of a patient who delivered vaginally? 1. Firm fundus 2. Displaced uterus 3. Dramatic loss of blood 4. Blue mass on the vulva

Firm fundus. **Bladder distention can cause the uterus to become displaced. **A blue or purplish mass on the vulva is a sign of a hematoma. **Dramatic loss of blood is usually associated with uterine atony. P. 248

Review Questions for the NCLEX: The nurse should be alert to subinvolution of the uterus as a cause of late postpartum bleeding. Signs to report and document include? SATA. A. Fundal height higher than expected for date B. Persistence of lochia rubra C. Low blood pressure. D. Persistence of lochia alba 1. C and D 2. A and D 3. A and B 4. B and C

B and C. -Persistence of lochia rubra -Low blood pressure --Lochia rubra should only last for 3 days and prolonged lochia rubra may indicate subinvolution and low BP may indicate loss of blood.

Review Questions for the NCLEX: A bleeding laceration is typically manifested by: 1. A soft uterus that is difficult to locate. 2. Low pulse rate and blood pressure. 3. Bright red bleeding and a firm uterus. 4. Profuse dark red bleeding and large clots.

Bright red bleeding and a firm uterus. --The blood is usually a brighter red than lochia, and it flows in a continuous trickle.

At what pulse rate should the caregiver suspect hypovolemic shock or infection?

Greater than 100 beats/min.

Which condition in a postpartum patient would the nurse associate with lower extremity edema, calf tenderness and erythema, and a negative Homan's sign? 1. Muscle fatigue 2. Pulmonary embolism 3. Deep vein thrombosis 4. Superficial vein thrombosis

Deep vein thrombosis. --Involves veins from the feet to the femoral area and is characterized by tenderness, leg edema, color changes, pain when walking, and sometimes a positive Homan's sign. P. 253

A postpartum patient with continuous vaginal bleeding is found to have placental fragments and small blood clots in the uterus on ultrasonography. Which intervention would be beneficial for the patient? 1. Perineal hygiene 2. Dilation and curettage 3. Administering vitamin K 4. An ice pack on the perineum

Dilation and curettage. (Helps remove small blood clots and placental fragments). --Retention of placental fragments in the uterus after delivery may result in postpartum hemorrhage. **Performing perineal hygiene: Would reduce the infection by flushing out the bacteria. **Applying ice packs on the perineum: Helps relieve pain. **Vitamin K: Enhances the process of blood clotting and prevents bleeding. P. 252

Review Questions for the NCLEX: A postpartum mother who is breastfeeding has developed mastitis. She states that she does not think it is good for her infant to drink milk from her infected breast. The best response from the nurse would be to: 1. Instruct her to nurse the infant from only the unaffected breast until the infection clears up. 2. Suggest that she discontinue breastfeeding and start the infant on formula. 3. Encourage breastfeeding the infant to prevent engorgement. 4. Apply a tight breast binder to the infected breast until the infection subsides.

Encourage breastfeeding the infant to prevent engorgement. --Antibiotics and continued removal of milk from the breast are the primary treatments for mastitis. --The mother can usually continue to breastfeed unless an abscess forms. Ref: Table 10-2

Which postpartum complication is associated with severe cramping, foul-smelling lochia, and a tender, enlarged uterus? 1. Cystitis 2. Peritonitis 3. Endometritis 4. Pyelonephritis

Endometritis. **Cystitis: Inflammation of the bladder caused by infection. **Peritonitis: A localized infection of the perineum, vagina, or cervix that ascends to the reproductive tract. --> Therefore the infection spreads to the uterus, fallopian tubes, and peritoneum. **Pyelonephritis: Inflammation of the kidneys caused by an infection. P. 254

Which assessment finding is associated with puerperal sepsis? 1. WBC count of 15,000 2. Pulse of 60 beats/min 3. Fever of 38° C lasting for 2 days 4. Fever of 37.3° C lasting more than 24 hours

Fever of 38° C lasting for 2 days. --This is a sign of sepsis. P. 253

Which assessment findings are early indicators of hypovolemic shock in a postpartum patient? 1. Heart rate, 80 beats/min; BP, 125/95 mm Hg; and temperature, 101° F 2. Heart rate, 135 beats/min; BP, 100/80 mm Hg; and respiratory rate, 18 breaths/min 3. Heart rate, 90 beats/min; BP, 106/80 mm Hg; and respiratory rate, 20 breaths/min 4. Heart rate, 100 beats/min; BP, 106/80 mm Hg; and respiratory rate, 16 breaths/min

Heart rate, 135 beats/min; BP, 100/80 mm Hg; and respiratory rate, 18 breaths/min. --Tachycardia (a rapid heart rate) is usually the first sign of inadequate blood volume (hypovolemia). --The first BP change is a narrow pulse pressure (a falling systolic pressure and a rising diastolic pressure). P. 248

To prevent the risk of pulmonary embolism, which medication would the nurse expect to see on the patient's medication administration record? 1. Oxytocin (Pitocin) 2. Heparin (Lipo-Hepin) 3. Vitamin K (AquaMEPHYTON) 4. Methylergonovine (Methergine)

Heparin (Lipo-Hepin). (This is an anticoagulant that helps dislodge the blood clot and alleviates the symptoms of pulmonary embolism). **Oxytocin: Induces uterine contractions and helps treat uterine atony. **Vitamin K: Enhances the process of blood coagulation. **Methylergonovine: Induces uterine contractions and helps treat uterine atony. P. 253

A postpartum patient who has undergone a vaginal delivery has redness and edema in the leg as well as pain while walking and flexing the foot. Which medication would the nurse anticipate being added to the patient's orders? 1. Oxytocin (Pitocin) 2. Heparin (Lovenox) 3. Calcium gluconate (Kalcinate) 4. Methylergonovine (Methergine)

Heparin (Lovenox). --These are signs of Deep venous thrombosis, which also includes an increase in leg circumference by 2 cm. --The patient will have pain while walking and flexing the foot. --Heparin: A long-acting anticoagulant drug used to treat deep venous thrombosis. **Oxytocin: Induces uterine contractions and relieves uterine atony. **Calcium gluconate: Antagonizes the effects of the tocolytic drugs administered to relax the uterus. **Methylergonovine: Helps contract the uterus. P. 253

Review Questions for the NCLEX: During the postpartum period the white blood cell (leukocyte) count is normally: 1. Higher than normal. 2. Lower than normal. 3. Unchanged 4. Unimportant

Higher than normal. --The WBC are elevated during the early postpartum period to about 20,000-30,000 cells/dL. --WBC counts in the upper limits are more likely to be associated with infection than lower counts.

Which assessment finding is a sign of hypovolemic shock? 1. Bradycardia 2. Hypotension 3. Warm and dry skin 4. Increased urine output

Hypotension. --Due to a reduced amount of blood fluid that may cause hypotension. --Hypovolemic shock also manifests as tachycardia. --Due to blood loss the patient's skin turns pale, cool, and clammy. --The patient will have decreased urination due to reduced hydration from blood loss. P. 248

The nurse is collecting data on a patient 24 hours after delivery and finds that the patient's skin is pale, cold, and clammy, and her pulse rate is 120 beats/min. Which condition is the nurse concerned about? 1. Endometritis 2. Hypovolemia 3. Pyelonephritis 4. Pulmonary embolism

Hypovolemia. --Hypovolemia manifests as reduced fluid content, which in turn increases pulse and respiratory rate and will show symptoms of pale, cold, and clammy skin. **Endometritis: The inflammation of the inner lining of the uterus, it can cause fever and a high risk of infection in the patient. **Pyelonephritis: A bacterial infection, which affects the kidneys. **Pulmonary embolism: Occurs as a result of the obstruction of the pulmonary artery by a blood clot, it manifests as dyspnea and chest pain. P. 248

Which condition is a patient at risk for when suffering from a blood clotting disorder? 1. Septic shock 2. Cardiogenic shock 3. Hypovolemic shock 4. Anaphylactic shock

Hypovolemic shock. **Septic shock: May occur because of puerperal infection. **Cardiogenic shock: Affects patients with pulmonary embolism, anemia, hypertension, and other cardiac disorders. P. 248

The weight of a postpartum patient's perineal pad before applying is 15 g and after 1 hour is 600 g. Which condition would the nurse assess for based on this finding? 1. Hypovolemic shock 2. Puerperal infection 3. Normal postpartum state 4. Thromboembolic disorder

Hypovolemic shock. --Perineal pad weight of 1 g = 1 mL of blood loss. --The initial weight of the perineal pad is 15 g and after saturation it is 600 g: 600-15 = 585 g = 585 mL of blood loss after vaginal delivery meaning the patient is at risk for hypovolemic shock. **Puerperal infection: Result of tissue trauma during labor from surgical incisions, or the open wound of the placental insertion site. P. 248

Which postpartum complication is associated with assessment findings of difficulty breathing and 600 mL blood loss following vaginal delivery? 1. Septic shock 2. Cardiogenic shock 3. Anaphylactic shock 4. Hypovolemic shock

Hypovolemic shock. --Caused by postpartum hemorrhage in which blood loss is greater than 500 mL, and when the patient has difficulty breathing during vaginal delivery. **Septic shock: Occurs as a result of puerperal infection, which is due to an infection of the female reproductive system during birth. **Anemia/Pulmonary embolism: Results in cardiogenic shock. **Allergic reaction to an administered drug can cause anaphylactic shock. P. 248

The nurse provides uterine massage to a patient with a soft and boggy uterus, but notices that the patient's uterus still has not contracted. Which intervention would the nurse choose next? 1. Applying a warm pack to the abdomen. 2. Massaging the uterus more vigorously. 3. Suggesting the patient perform a sitz bath. 4. Instructing the patient to empty her bladder.

Instructing the patient to empty her bladder. --Soft and boggy uterus is an indication of uterine atony. --A full bladder may cause further distention of the uterus and interfere with uterine contraction. P. 251

A postpartum patient who underwent a vaginal delivery has been diagnosed with pyelonephritis. Which class of medication would the nurse expect to find in the patient's orders? 1. Oral analgesic 2. Intravenous antibiotic 3. Intravenous postaglandin 4. Subcutaneous anticoagulant

Intravenous antibiotic (helps reduce the inflammation of the kidneys and treat pyelonephritis). --Pyelonephritis: Inflammation of the kidneys caused by bacterial infection. **Analgesics: Help to provide pain relief. **Prostaglandin drugs: Induce uterine contractions and treat uterine atony. **Anticoagulant drugs (Heparin): Treat deep vein thrombosis. P. 254

A postpartum patient who was administered medication to relax the uterus during labor now has excessive bleeding as a result of a boggy uterus. Which medication would be beneficial for the patient? 1. Intravenous heparin 2. Subcutaneous insulin 3. Intravenous antibiotics 4. Intravenous calcium gluconate

Intravenous calcium gluconate. --It counteracts the effect of tocolytic medications administered during labor to relax the uterus. **Heparin: An anticoagulant, generally administered to prevent the risk of thromboembolic disorders. **Insulin: Helps reduce blood sugar levels. **IV antibiotics: Helps prevent various infections. P. 251

During the follow-up visit, a postpartum patient reports lack of sleep and loss of appetite. She also describes feelings of guilt and delusions about her infant's death. Which condition is the nurse concerned about? 1. Bipolar disorder 2. Major depression 3. Postpartum blues 4. Postpartum anxiety

Major depression. **Bipolar disorder: Manifests as hyperactivity, excitability, and euphoria. **Postpartum blues are common after delivery in which the patient has let-down feelings such as feeling alone, dullness, and crying for no reason. P. 257

The nurse is caring for a postpartum patient with Subinvolution of the uterus. Which medication does the nurse expect to see in the patient's orders? 1. Heparin (Lovenox) 2. Warfarin (Coumadin) 3. Vitamin K (AquaMEPHYTON) 4. Methylergonovine (Methergine)

Methylergonovine (Methergine). --It induces uterine contractions and helps maintain a firm uterus. **Heparin: Helps treat deep venous thrombosis. **Warfarin: An anticoagulant that helps minimize the risk of embolism associated with thrombosis. **Vitamin K: Helps antagonize the effects of warfarin. P. 251

A postpartum patient with vaginal bleeding saturates one perineal pad in an hour and has a grapefruit-sized uterus with a fundal height at the level of the umbilicus. Which condition would the nurse further assess for? 1. Puerperal sepsis 2. Hypovolemic shock 3. Normal postpartum state 4. Late postpartum hemorrhage

Normal postpartum state. **Puerperal sepsis: Infection or septicemia after childbirth, characterized by an increase in body temperature. **Hypovolemic shock: Occurs as a result of excessive postpartum bleeding, causing depletion of the circulatory volume of blood. **Late postpartum hemorrhage: Caused by subinvolution of the uterus and retention of placental fragments. P. 248, 250

The nurse assessing the vital signs of a newly delivered patient obtains a blood pressure of 117/63 mmHg and a pulse of 72 bpm. The nurse notes the baseline blood pressure and pulse on admission were 132/74 and 84. Which priority action should the nurse take? 1. Assess for respiratory rate 2. Perform a fundal assessment 3. Assess the quality of the lochia 4. Observe for symptoms of hypovolemia

Perform a fundal assessment. --Patient's BP and pulse should be within 10% of the admission values. --The fundus must be firm to compress the blood vessels at the placental site. --Quality of lochia would be assessed AFTER the fundal assessment. P. 249

The nurse observes erythema, tenderness, and an increase in calf circumference of 3 cm in a postpartum patient. Which intervention is the priority in this situation? 1. Perform an ultrasound scan. 2. Performing blood tests in the patient. 3. Elevating the patient's leg at an angle of 35°. 4. Applying a warm compress to the patient's leg.

Performing an ultrasound scan. (Can help to confirm these symptoms and diagnose the illness and plan an appropriate treatment strategy for the patient). --An increase in leg circumference greater than 2 cm associated with redness, calf tenderness, and leg edema are signs of Deep venous thrombosis (DVT). **A blood test may be helpful in diagnosing anemia. **Applying a warm compress to the patient's leg helps relieve pain. **Elevating the patient's leg helps prevent edema caused by superficial venous thrombosis (SVT). P. 253

Which assessment finding is associated with deep venous thrombosis? 1. Dyspnea 2. Hemoptysis 3. Shortness of breath 4. Positive Homan's sign

Positive Homan's sign. --Homan's sign is pain when the foot is dorsiflexed. --Pain while walking and positive Homan's sign indicate deep venous thrombosis. **Dyspnea (Shortness of breath): Observed in pulmonary embolism. **Hemoptysis: Blood in the sputum & a sign of pulmonary embolism. P. 253

While caring for a lactating patient with mastitis, the nurse advises the patient to avoid weaning the infant. Which patient outcome supports this instruction? 1. Preventing of nipple cracks. 2. Inducing drainage from the breast. 3. Inducing increased heat in the breast. 4. Preventing breast engorgement.

Preventing breast engorgement. P. 255

The nurse is caring for a postpartum patient who has saturated three perineal pads in 1 hour. The patient is anxious and worried. Which nursing intervention would help to reduce the patient's anxiety? 1. Leaving the patient alone. 2. Providing factual information. 3. Asking the patient not to talk and stay quiet. 4. Informing the patient that this is a normal finding.

Providing factual information. --Clarifying any myths and misconceptions to relieve the patient's anxiety. --The nurse would encourage the patient to verbalize fears as it helps alleviate her anxiety. --Saturation of three perineal pads indicates late postpartum hemorrhage. P. 250

Which term describes a condition in which a postpartum woman has an impaired sense of reality? 1. Tremors 2. Delirium 3. Dementia 4. Psychosis

Psychosis. --Psychosis is less common than postpartum depression. P. 256

A postpartum patient has a temperature of 38° C and a pulse rate of 120 beats/min 48 hours after delivery. The nurse finds that the patient's leukocyte count is 30,000 cells/mm3. Which complication would the nurse be concerned about? 1. Mastitis 2. Uterine atony 3. Puerperal sepsis 4. Venous thrombosis

Puerperal sepsis. --A postpartum infection. **Uterine atony: Reduced uterine contractions and a soft uterus. P. 254

The nurse is caring for a postpartum patient 24 hours after delivery who is experiencing shortness of breath and bloody sputum. Which complication would the nurse further assess for? 1. Hypovolemic shock 2. Pulmonary embolism 3. Deep venous thrombosis 4. Superficial venous thrombosis

Pulmonary embolism. --Occurs as a result of the obstruction of a pulmonary artery by a blood clot. --Manifests as shortness of breath, low-grade fever, and bloody sputum. **Hypovolemic shock: Occurs as a result of excessive bleeding and manifests as increased heart rate and decreased BP. **Deep venous thrombosis: A thrombotic disorder and manifests as edema in the legs. --> The patient may have pain while walking. **Superficial venous thrombosis: Occurs as a result of the presence of thrombosis in the lower leg. P. 253

Review Questions for the NCLEX: The earliest finding in postpartum hypovolemic shock is usually: 1. Low blood pressure 2. Rapid pulse rate. 3. Pale skin color. 4. Soft uterus.

Rapid pulse rate. --Tachycardia is usually the first sign of inadequate blood volume (hypovolemia). **Skin and mucous membrane changes occur after tachycardia.

Which nursing intervention would be helpful for a postpartum patient experiencing disinterest in others, feelings of guilt, constant fatigue, loss of appetite, and insomnia? 1. Remaining calm and showing empathy towards the patient. 2. Informing the patient that the feelings will end in a few weeks. 3. Arranging a caretaker for the infant until the symptoms resolve. 4. Advising the patient to avoid interaction with all but immediate family.

Remaining calm and showing empathy towards the patient. --These are signs of postpartum depression. --The nurse would listen to the patient sympathetically & attempt to calm her to reduce the feelings of depression. P. 256

A woman who is 4 weeks postpartum informs the nurse at the outpatient clinic that her lochia remains red and she feels a heaviness in her pelvic area. The nurse assesses her fundus to be firm and at the umbilical level. Which condition would the nurse attribute these symptoms to? 1. Dehydration 2. Subinvolution 3. Cervical tear 4. Viral syndrome

Subinvolution. (A slower-than-expected return of the uterus to its non-pregnant condition). --Infection and retained fragments of the placenta are the most common causes. --Typical signs of subinvolution: fundal height greater than expected for the amount of time since birth, persistence of lochia rubra or a slowed progression through the three phrases, pelvic pain, heaviness, and fatigue. P. 252

The nurse is preparing to assess assigned postpartum patients. Which patient would the nurse anticipate has the greatest risk for immediate complications? 1. The 6-hour post cesarean section who delivered a 34-week neonate. 2. The 4-hour post vaginal delivery of a large for gestational age neonate. 3. The 6-hour post vaginally delivered patient who was in stage 2 labor for 2.5 hours. 4. The 4-hour post cesarean section who delivered a small for gestational age neonate.

The 4-hour post vaginal delivery of a large for gestational age neonate. --A large for gestational age neonate can over distend the uterus, placing the patient at risk for hemorrhage. P. 248

A postpartum patient with hemorrhage is kept on nothing by mouth (NPO) status until the primary health care provider evaluates the situation for which reason? 1. Nausea and vomiting may also occur. 2. There may be a need for opioid analgesics 3. Subinvolution of the uterus may be occurring 4. There may be a need for general anesthesia

There may be a need for general anesthesia. (For the treatment of lacerations). **Opioid analgesic drugs can be given orally and do not require NPO status. **Subinvolution is a slower-than-expected return of the uterus to the non-pregnant state. P. 251

A postpartum patient has a distended bladder and excess discharge of lochia with large blood clots. An ultrasound scan reveals displacement of the uterus to one side. Which postpartum complication is the nurse concerned about? 1. Uterine atony 2. Puerperal sepsis 3. Uterine hematoma 4. Uterine lacerations

Uterine atony. --The patient with uterine atony has a full bladder that pushes the uterus higher and displaces it to one side. P. 250

Which postpartum complication in a patient who had a prolonged labor and vacuum-assisted delivery is associated with blue and purple marks on the vulva as well as bright red vaginal bleeding? 1. Uterine atony 2. Uterine hematoma 3. Uterine lacerations 4. Uterine subinvolution

Uterine hematoma. --Blue and purple marks on the vulva with severe bleeding caused by prolonged labor and use of vacuum extractor indicates uterine hematoma. **Uterine lacerations: Continuous trickling of blood, brighter than normal lochia, and a firm fundus. **Uterine atony: A soft uterine fundus with clotted lochia and bladder distention. **Uterine subinvolution: The uterus takes longer than normal to return to its non-pregnant state. P. 250

The nurse is caring for a postpartum patient who is being treated with oral anticoagulant therapy and observes that the patient has bleeding gums and epistaxis. Which medication would the nurse request be added to the patient's orders? 1. Heparin (Lovenox) 2. Oxytocin (Pitocin) 3. Vitamin K (AquaMEPHYTON) 4. Methylergonovine (Methergine)

Vitamin K (AquaMEPHYTON). --Antagonizes the effects of anticoagulant medications and alleviates the symptoms of overdose. P. 253