NUAS240T - Chapter 22 - Nursing Management of the Postpartum Woman at Risk

C. A boggy uterus that is midline and above the umbilicus suggests that the uterus is not contracting properly. Therefore, the nurse should massage the fundus to aid in stimulating the uterine muscles to contract. In addition, the nurse should assess the client's lochia.

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. Assessing vital signs immediately b. Measuring her next urinary output c. Massaging her fundus d. Notifying the woman's obstetrician

b. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? a. "I'll contact your health care provider." b. "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." c. "If you don't attempt to void, I'll need to catheterize you." d. "I'll check on you in a few hours."

a. Risk factors include nipple piercing.

The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response? a. Risk factors include nipple piercing. b. Risk factors include breast pumps. c. Risk factors include frequent feeding. d. Risk factors include complete emptying of the breast.

d. "I know you are hurting, but you can have another baby in the future."

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant? a. "Have you named your baby yet? I would like to know your baby's name." b. "Many mothers who have lost an infant want pictures of the baby. Can I make some for you?" c. "I will make handprints and footprints of the baby for you to keep." d. "I know you are hurting, but you can have another baby in the future."

d. Uterine atony

The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage? a. Perineal lacerations b. Hematoma c. Disseminated intravascular coagulation d. Uterine atony

Metritis

An infectious condition that involves the endometrium, decidua, & adjacent myometrium of the uterus

Early postpartum hemorrhage

Excessive blood loss that occurs within 24 hours after birth

Uterine atony

Failure of the uterus to contract & retract immediately after birth

thromboembolism

Obstruction of a blood vessel by a blood clot carried by the circulation from the size of origin

a. 100.4° F (38° C)

On the third day postpartum, which temperature is internationally defined as a postpartal infection? a. 100.4° F (38° C) b. 102.4° F (39.1° C) c. 99.6° F (37.5° C) d. 104.2° F (40.1° C)

b. Blood pressure, pulse, reports of dizziness

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? a. Height, level of orientation, support systems b. Blood pressure, pulse, reports of dizziness c. Degree of responsiveness, respiratory rate, fundus location d. Attachment, lochia color, complete blood cell count

a. Assess for uterine contractions

Upon assessment, the nurse notes a postpartum client has increased vaginal bleeding. The client had a forceps birth which resulted in lacerations 4 hours ago. What should the nurse do next? a. Assess for uterine contractions b. Change the client's peripad c. Obtain the client's vital signs d. Have the client void

b. Oxytocin

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. Penicillin b. Oxytocin c. Digoxin d. Ibuprofen

c. The client feels empty since she gave birth to the neonate.

Which situation should concern the nurse treating a postpartum client within a few days of birth? a. The client would like the nurse to take her baby to the nursery so she can sleep. b. The client is nervous about taking the baby home. c. The client feels empty since she gave birth to the neonate. d. The client would like to watch the nurse give the baby her first bath.

d. Large uterus with painless dark-red blood mixed with clots

A nurse finds that a client is bleeding excessively after vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? a. Soft and boggy uterus that deviates from the midline b. Firm uterus with trickle of bright-red blood in perineum c. Firm uterus with a steady stream of bright-red blood d. Large uterus with painless dark-red blood mixed with clots

b. Weak and rapid pulse

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the RN and/or health care provider? a. Elevated blood pressure b. Weak and rapid pulse c. Decreased respiratory rate d. Warm and flushed skin

d. Assess for warmth, erythema, and pedal edema.

The nurse observes an ambulating postpartal woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client? a. Bend the knee and palpate the calf for pain. b. Blanch a toe, and count the seconds it takes to color again. c. Ask the client to raise the foot and draw a circle. d. Assess for warmth, erythema, and pedal edema.

b. A client who had a nonelective cesarean birth

What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a. A client who conceived following fertility treatments b. A client who had a nonelective cesarean birth c. A primaparous client who had a vaginal birth d. A client who had an 8-hour labor

c. Calf swelling

A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? a. Sudden change in mental status b. Difficulty in breathing d c. Calf swelling d. Sudden chest pain

c. By frequently assessing uterine involution

A nurse is caring for a client who has just undergone birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? a. By assessing skin turgor b. By assessing blood pressure c. By frequently assessing uterine involution d. By monitoring hCG titers

d. Take an oral contraceptive daily

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which order would the nurse question? a. Wear compression stockings b. Plan long rest periods throughout the day c. Take aspirin as needed d. Take an oral contraceptive daily

b. Administration of platelet transfusions as ordered

A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? a. Administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) b. Administration of platelet transfusions as ordered c. Avoiding administration of oxytocics d. Continual firm massage of the uterus

c. Check the lochia.

A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? a. Assess the fundal height. b. Assess the temperature. c. Check the lochia. d. Monitor the pain level.

c. Take an oral contraceptive daily.

A nurse is caring for a postpartum client who has been treated for deep vein thrombosis (DVT). Which prescription would the nurse question? a. Plan long rest periods throughout the day. b. Take aspirin as needed. c. Take an oral contraceptive daily. d. Wear compression stockings.

b. Mastitis

A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder? a. Engorgement b. Mastitis c. Breast yeast d. Plugged milk duct

d. Assess the woman's fundus.

The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? a. Call the woman's health care provider. b. Assess the woman's vital signs. c. Initiate Ringer's lactate infusion. d. Assess the woman's fundus.

a. birth of a large newborn

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. birth of a large newborn b. excessive traction on umbilical cord c. development of endometritis d. history of hypertension

B. since manual removal of a placenta increases the risk for infection since the uterus was entered and traumatized during the procedure. This extraction places her at high risk for a subsequent infection.

Which of the following factors in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection? a. Hemoglobin of 12 mg/dL b. Manually extracted placenta c. Labor of 10 hours length d. Multiparity of 5 pregnancies

D. as this may suggest a pulmonary embolism and the health care provider needs to be notified immediately.

Which of the following findings would lead the nurse to suspect that a woman is developing a postpartum complication? a. Moderate lochia rubra for the first 24 hours b. Clear lung sounds upon auscultation c. Temperature of 100 degrees F d. Chest pain experienced when ambulating

a. decreased interest in life b. inability to concentrate e. loss of confidence

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? (Select all that apply.) a. decreased interest in life b. inability to concentrate c. manifestations of mania d. bizarre behavior e. loss of confidence

a. She should continue to breast-feed; mastitis will not infect the neonate.

Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? a. She should continue to breast-feed; mastitis will not infect the neonate. b. She should not use analgesics because they are not compatible with breast-feeding. c. She should stop breast-feeding until completing the antibiotic. d. She should supplement feeding with formula until the infection resolves.

uterine inversion

A prolapse of the uterine fundus to or through the cervix, so that the uterus is turned inside out after birth

Subinvolution

Incomplete involution of the uterus or its failure to return to its normal size & condition after birth

c. Oxytocin

What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? a. Calcium gluconate b. Magnesium sulfate c. Oxytocin d. Domperidone

D. Hemorrhage is possible if the uterus cannot contract and clamp down on the vessels to reduce bleeding. When the placenta is expelled, open vessels are then exposed and the risk of hemorrhage is great.

When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. Deep venous thrombosis b. Postpartum psychosis c. Uterine infection d. Postpartum hemorrhage

c. Up the reproductive tract

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

C. Applying compresses and giving analgesics would be helpful in providing comfort to the woman with painful breasts.

Which of the following would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. Stop breast-feeding and apply lanolin. b. Administer analgesics and bind both breasts. c. Apply warm or cold compresses and administer analgesics. d. Remove the nursing bra and expose the breast to fresh air.

a. Assess client's uterine tone b. Monitor client's vital signs d. Get a pad count

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? (Select all that apply.) a. Assess client's uterine tone b. Monitor client's vital signs c. Assess client's skin turgor d. Get a pad count e. Assess deep tendon reflexes

A. Psychotic persons tend to lose touch with reality and frequently attempt to harm themselves or others. This behavior may occur when a woman experiences postpartum psychosis.

A postpartum woman reports hearing voices and says, "The voices are telling me to do bad things to my baby." The clinic nurse interprets these findings as suggesting postpartum a. psychosis. b. anxiety disorder. c. depression. d. blues.

c. drop in estrogen and progesterone levels after birth

The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? a. lack of social support from family or friends b. medications used during labor and birth c. drop in estrogen and progesterone levels after birth d. preexisting conditions in the client

a. Foul-smelling vaginal discharge

Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection? a. Foul-smelling vaginal discharge b. Sudden onset of shortness of breath c. Pain in the lower extremity d. Apprehension and diaphoresis

d. uterine atony

Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a. moderate amount of lochia rubra b. thrombophlebitis c. hemoglobin level of 12 g/dL d. uterine atony

a. 1000 mL

A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? a. 1000 mL b. 250 mL c. 750 mL d. 500 mL

Thrombus

A blood clot within a blood vessel

b. Avoid over-the-counter (OTC) salicylates.

A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instruction in her discharge teaching? a. Wear knee-high stockings when possible. b. Avoid over-the-counter (OTC) salicylates. c. Avoid iron replacement therapy. d. Shortness of breath is a common adverse effect of the medication.

a. Inability to concentrate b. Loss of confidence d. Decreased interest in life

A client in her 7th week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? (Select all that apply.) a. Inability to concentrate b. Loss of confidence c. Manifestations of mania d. Decreased interest in life e. Bizarre behavior

Placenta accreta

A condition in which the chorionic villi adhere to the myometrium, causing the placenta to adhere abnormally to the uterus & not separate & deliver spontaneously

mastitis

A localized inflammation of the breast

d. Have the client rest with the extremity elevated

A nurse is caring for a 38-year-old overweight client 24 hours postcesarean birth. The client is reporting calf tenderness. Which should the nurse do first? a. Assess the client's respiratory rate b. Determine the severity of the pain c. Administer an anticoagulant d. Have the client rest with the extremity elevated

c. Postpartal hemorrhage

A nurse is caring for a client who delivered vaginally 2 hours ago. What postpartum complication can the nurse assess within the first few hours following birth? a. Postpartal infection b. Postpartal blues c. Postpartal hemorrhage d. Postpartum depression

c. Call her caregiver if lochia moves from serosa to rubra.

The nurse is conducting discharge teaching with a postpartum woman. What would be an important instruction for this client? a. Call her caregiver if lochia moves from serosa to alba. b. Call her caregiver if lochia moves from rubra to serosa. c. Call her caregiver if lochia moves from serosa to rubra. d. Call her caregiver if amount of lochia decreases.

a. deep venous thrombosis

In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication? a. deep venous thrombosis b. postpartum hemorrhage c. metritis d. uterine atony

decrease

In von Willebrand disease, there is a _________________ in the von Willebrand factor, which is necessary for platelet adhesion & aggregation.

b. Palpate her fundus.

The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? a. Assess her blood pressure. b. Palpate her fundus. c. Have her turn to her left side. d. Assess her perineum.

a. The client's pulse is 130 beats/min at rest and base line was 98 beat/min

The nurse is caring for a woman who experienced a vaginal birth 6 hours prior. The health care provider is concerned the woman may have retained placental tissue. What assessment finding would alert the nurse to further assess the client for complications of retained placental tissue? a. The client's pulse is 130 beats/min at rest and base line was 98 beat/min b. The client reports perineal discomfort and burning pain c. The client's blood pressure is 160/78 mm Hg with a base line of 102/62 mm Hg d. The client states being slightly nauseated and having no appetite since giving birth

b. massaging the fundus firmly

When monitoring a postpartum client 2 hours after birth, the nurse notices heavy bleeding with large clots. Which response is most appropriate initially? a. administering ergonovine b. massaging the fundus firmly c. notifying the primary care provider d. performing bimanual compressions

c. postpartum depression

A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? a. postpartum psychosis b. postpartum blues c. postpartum depression d. postpartum panic disorder

D. Methergine can cause hypertension. Therefore, if the woman's blood pressure was already elevated, the nurse would need to question the order for the drug.

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/96 mmHg

d. Perform hand washing before breast-feeding.

Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? a. Avoid massaging the breast area. b. Apply cold compresses to the breast. c. Avoid frequent breast-feeding. d. Perform hand washing before breast-feeding.

b. Bleeding gums c. Tachycardia d. Acute renal failure

A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? (Select all that apply.) a. Hypertension b. Bleeding gums c. Tachycardia d. Acute renal failure e. Lochia less than usual

c. Avoid sitting in one position for long periods of time

A nurse is caring for a postpartum client. What instruction should the nurse provide to the client as precautionary measures to prevent thromboembolic complications? a. Avoid performing any deep-breathing exercises b. Try to relax with pillows under knees c. Avoid sitting in one position for long periods of time d. Refrain from elevating legs above heart level

b. Assess for pedal edema.

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

b. Dorsiflex her right foot and ask if she has pain in her calf.

A postpartal woman is developing thrombophlebitis in her right leg. Which assessment should the nurse no longer use to assess for thrombophlebitis? a. Ask about increased pain with weight bearing. b. Dorsiflex her right foot and ask if she has pain in her calf. c. Assess for redness and warmth. d. Ask if she has pain or tenderness in the lower extremities.

b. Perform hand washing before and after breastfeeding

A postpartum client who was discharged home returns to the primary health care facility after 2 weeks with reports of fever and pain in the breast. The client is diagnosed with mastitis. What education should the nurse give to the client for managing and preventing mastitis? a. Discontinue breastfeeding to allow time for healing b. Perform hand washing before and after breastfeeding c. Avoid hot or cold compresses on the breast d. Discourage manual compression of breast for expressing milk

C. It is important to assess the situation before intervening. In addition, checking the bladder status and emptying a full bladder will correct uterine displacement so that effective contractions to stop bleeding can occur.

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. Call the client's health care provider immediately. b. Immediately set up an intravenous infusion of magnesium sulfate. c. Assess the fundus and ask her about her voiding status. d. Reassure the mother that this is a normal finding after childbirth.

a. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." c. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." d. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts."

The nurse is caring for several women in the postpartum clinic setting. Which statement(s), when made by one of the clients, would alert the nurse to further assess that client for postpartum psychosis? (Select all that apply.) a. "I believe my newborn is losing weight because I will not feed him because my milk was poisoned by the health care provider." b. "Sometimes I get tired of being with only the newborn, so I call my mom and sister to come visit." c. "The newborn is not really mine emotionally, since I was never pregnant and do not have children." d. "When the newborn is sleeping, I can see his thoughts projected on my phone and I do not like the thoughts." e. "I am sad because I am not spending as much time with my toddler now that my newborn is here."

b. Hand washing

The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize? a. Proper perineal care b. Hand washing c. Complete the antibiotic course d. Get plenty of sleep

c. applying ice

Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts? a. applying warm compresses b. restricting fluids c. applying ice d. administering bromocriptine