OB: Chapter 16 Nursing Management During the Postpartum Period

A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition?

atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse?

mastitis Engorged breasts are hard, tender, and taut. If the breasts have nodules, masses, or areas of warmth, they may have plugged ducts, which can lead to mastitis if not treated promptly.

Inspection of a woman's perineal pad reveals a 5-inch stain. How should the nurse document this amount?

moderate Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

A nurse is reviewing a postpartum woman's history and labor and birth record. The nurse determines the need to closely monitor this client for infection based on which factor?

placenta removed via manual extraction Manual removal of the placenta places a woman at risk for postpartum infection, as does a hemoglobin level less than 10.5 mg/dL. Precipitous labor, less than 3 hours, and multiparity, more than three births closely spaced, place a woman at risk for postpartum hemorrhage.

The nurse is performing a routine assessment of the client after birth. Inspection of a woman's perineal pad reveals a 2-inch lochia stain. This amount should be documented as which type?

scant Moderate lochia would describe a 4- to 6-inch stain, scant lochia a 1- to 2-inch stain, and light or small an approximately 4-inch stain. Heavy or large lochia would describe a pad that is saturated within 1 hour.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication?

an absence of lochia Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever.

The nurse is reviewing the medical record of a postpartum client. The nurse determines that the client is at risk for thromboembolism based on which factors from her history? Select all that apply.

previous oral contraceptive use severe varicose veins preeclampsia Risk factors associated with thromboembolism include oral contraceptive use, multiparity, age over 35 years, severe varicose veins, and preeclampsia.

A client is Rh-negative and has given birth to her newborn. What should the nurse do next?

Determine the newborn's blood type and rhesus. The nurse first needs to determine the rhesus of the newborn to know if the client needs Rh immunoglobulins. Mothers who are Rh-negative and have given birth to an infant who is Rh-positive should receive an injection of Rh immunoglobulin within 72 hours after birth; this prevents a sensitization reaction to Rh-positive blood cells received during the birthing process. Women should receive the injection regardless of how many children they have had in the past.

A nurse is instructing a client who is breastfeeding for the first time that before her milk comes in she should expect to see colostrum, which is described as which color?

creamy yellow If a woman has any discharge from her nipples postpartum, it should be described and documented if it is not colostrum (creamy yellow) or foremilk (bluish white).

A client who is 12 hours postbirth is reporting perineal pain. After the assessment reveals no signs of an infection, which measure could the nurse offer the client?

an ice pack applied to the perineum Commonly ice and/or cold measures are used in the first 24 hours following birth to help reduce the edema and discomfort. Usually an ice pack wrapped in a disposable covering or clean washcloth can be applied intermittently for 20 minutes and removed for 10 minutes. After 24 hours, then the client may use heat in the form of a sitz bath or peribottle rinse. Narcotic pain medication would not be the first choice.

A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching?

"You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge.

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them?

touching Attachment is a process that does not occur instantaneously. Touch is a basic instinctual interaction between the parent and his or her infant and has a vital role in the attachment process. While they are touching, they may also be talking, looking, and feeding the infant, but the skin-to-skin contact helps confirm the attachment process.

While assessing a postpartum client who gave birth about 12 hours ago, the nurse evaluates the client's bladder and voiding. The nurse determines that the client may be experiencing bladder distention based on which finding? Select all that apply.

rounded mass over symphysis pubis dullness on percussion over symphysis pubis fundus boggy to the right of the umbilicus If the bladder is distended, the nurse would most likely palpate a rounded mass at the the area of the symphysis pubis and note dullness on percussion. In addition, a boggy uterus that is displaced from midline to the right suggests bladder distention. If the bladder is full, lochia drainage would be more than normal because the uterus cannot contract to suppress the bleeding. An elevated temperature during the first 24 hours may be normal, however, if the elevated temperature is greater than 100.4 degrees F (38 degrees C), infection is suggested.

On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily?

500 additional calories per day The breast-feeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day.

The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day?

650 Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate?

Continue to monitor the woman's temperature every 4 hours; this finding is normal. A temperature of 100.4° F (38° C) or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor. There is no need to notify the health care provider, obtain a urine culture, or inspect the perineum (other than the routine assessment of the perineum) because this finding is normal.

The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next?

Document the lochia as scant. "Scant" would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered.

A nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment? Select all that apply.

active bowel sounds passing gas nondistended abdome Finding active bowel sounds, verification of passing gas, and a nondistended abdomen are normal assessment results. The abdomen should be nontender and soft. Abdominal pain is not a normal assessment finding and should be immediately looked into.

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to:

assess and massage the fundus. This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage.

A new mother has been reluctant to hold her newborn. A nurse can promote this mother's attachment to her newborn by:

bringing the newborn into the room. Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.

The nurse working on a postpartum client must check lochia in terms of amount, color, change with activity and time, and:

odor. The nurse when assessing lochia must do so in terms of amount, color, odor, and change with activity and time.

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing:

pulmonary embolism. These symptoms suggest a pulmonary embolism. Mitral valve collapse and thrombophlebitis would not present with these symptoms; infection would have a febrile response with changes in lung sounds.

Two days after giving birth, a client is to receive Rho(D) immune globulin. The client asks the nurse why this is necessary. The most appropriate response from the nurse is:

"Rho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood." Rho(D) immune globulin is indicated to suppress antibody formation in women with Rh-negative blood who gave birth to babies with Rh-positive blood. Rho(D) immune globulin is also given to women with Rh-negative blood after miscarriage/pregnancy termination, abdominal trauma, ectopic pregnancy, and amniocentesis.

The nurse is teaching a postpartum woman and her spouse about postpartum blues. The nurse would instruct the couple to seek further care if the client's symptoms persist beyond which time frame?

2 weeks Once postpartum blues are determined to be the likely cause of her mood symptoms, the nurse can offer anticipatory guidance that these mood swings are commonly experienced and usually resolve spontaneously within a week and offer reassurance. Women should also be counseled to seek further evaluation if these moods do not resolve within two weeks, as postpartum depression may be developing.

The client is preparing to go home after a cesarean birth. The nurse giving discharge instructions stresses to the family that the client should be seen by her primary care provider within what time interval?

2 weeks The general rule of thumb is for a woman who had a cesarean birth be seen within 2 weeks after hospital discharge, unless the primary care provider has indicated otherwise or if the client develops signs of infection or has other difficulties.

Which finding would the nurse describe as "light" or "small" lochia?

4-inch stain or a 1 to 25 ml loss Typically the amount of lochia is described as follows: scant: a 1- to 2-inch lochia stain on the pad or a 10 ml loss; light or small: 4-inch stain or a 10 to 25 ml loss; moderate: 4- to 6-inch stain with an estimated loss of 25 to 50 ml; large or heavy: a pad is saturated within 1 hour after changing it

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100.8° F (38.2° C). Which action would be most appropriate for the nurse to take?

Notify the health care provider about this elevation; this finding reflects infection. A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A hematoma would not necessarily be a cause for an elevated temperature. Cultures may be warranted after notifying the health care provider. A temperature of 100.4° F or less during the first 24 hours postpartum is normal and may be the result of dehydration due to fluid loss during labor.

A client who has given birth is being discharged from the health care facility. She wants to know how safe it would be for her to have intercourse. Which instructions should the nurse provide to the client regarding intercourse after birth?

Resume intercourse if bright red bleeding stops. The nurse should inform the client that intercourse can be resumed if bright red bleeding stops. Use of water-based gel lubricants can be helpful and should not be avoided. Pelvic floor exercises may enhance sensation and should not be avoided. Barrier methods such as a condom with spermicidal gel or foam should be used instead of oral contraceptives.

During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted?

Schedule home visits for high-risk families. To help promote parental role adaptation and parent-newborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system.

Which information would the nurse emphasize in the teaching plan for a postpartal woman who is reluctant to begin taking warm sitz baths?

Sitz baths increase the blood supply to the perineal area. Sitz baths decrease pain and aid healing by increasing blood flow to the perineum.

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits?

The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted.

A woman states that she still feels exhausted on her second postpartal day. The nurse's best advice for her would be to do which action?

Walk with the nurse the length of her room. Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged.

A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior?

attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled.

A nurse is providing care to a postpartum woman who gave birth vaginally 6 hours ago. The client is reporting perineal pain secondary to an episiotomy. Which intervention would be most appropriate for the nurse to implement at this time?

Apply an ice pack to the perineal area. Commonly, an ice pack is the first measure used after a vaginal birth to relieve perineal discomfort from edema, an episiotomy, or a laceration. An ice pack seems to minimize edema, reduce inflammation, decrease capillary permeability, and reduce nerve conduction to the site. It is applied during the fourth stage of labor and can be used for the first 24 hours to reduce perineal edema and to prevent hematoma formation, thus reducing pain and promoting healing. After the first 24 hours, a sitz bath with room temperature water may be prescribed and substituted for the ice pack to reduce local swelling and promote comfort for an episiotomy, perineal trauma, or inflamed hemorrhoids. Witch hazel compresses are used for hemorrhoidal discomfort. Glycerin-based ointments can be used to address nipple pain.

When completing the morning postpartum data collection, the nurse notices the client's perineal pad is completely saturated. Which action should be the nurse's first response?

Ask the client when she last changed her perineal pad. If the morning assessment is done relatively early, it is possible that the client has not yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, would not be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse would not want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client's status.

A nurse is caring for a postpartum woman who is Muslim. When developing the woman's plan of care, the nurse would make which action a priority?

Assign a female nurse to care for her. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Nurses give the daily bath for newborns of some Japanese-American women. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

A G1 P1001 mother is just home after giving birth to her first child 5 days ago. Her birth was complicated by an emergency cesarean birth resulting from incomplete cervical dilation and hemorrhage. The nurse determines that the mother has not slept longer than 3 hours at one time. The appropriate nursing diagnosis for this client care issue is:

At risk for postpartum depression due to inadequate rest. This scenario refers only to the issue of sleep. Information is insufficient to suggest that the other issues are problematic at this time.

A nurse is working with a group of new parents, assisting them in transitioning to parenthood. The nurse explains that this transition may take 4 to 6 months and involves four stages. Place the stages below in the order in which the nurse would explain them to the group. All options must be used.

commmitment, attachment, and preparation for an infant acquaintance with and increasing attachment to the infant moving toward a new normal routine achievement of the parental role Although the stages overlap, and the timing of each is affected by variables such as the environment, family dynamics, and the partners, transitioning to parenthood (Mercer, 2006), involves four stages: commitment, attachment, and preparation for an infant during pregnancy; acquaintance with and increasing attachment to the infant, learning how to care for the infant, and physical restoration during the first weeks after birth; moving toward a new normal routine in the first 4 months after birth; and achievement of a parenthood role around 4 months.

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature?

dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.

A client who gave birth by cesarean birth 3 days ago is bottle-feeding her neonate. While collecting data the nurse notes that vital signs are stable, the fundus is four fingerbreadths below the umbilicus, lochia are small and red, and the client reports discomfort in her breasts, which are hard and warm to touch. The best nursing intervention based on this data would be:

encouraging the client to wear a supportive bra. These assessment findings are normal for the third postpartum day. Hard, warm breasts indicate engorgement, which occurs approximately 3 days after birth. Vital signs are stable and do not indicate signs of infection. The client should be encouraged to wear a supportive bra, which will help minimize engorgement and decrease nipple stimulation. Ice packs can reduce vasocongestion and relieve discomfort. Warm water and a breast pump will stimulate milk production.

The nurse realizes that accommodating for the various cultural differences in her clients is an important aspect in providing their care. When caring for a Japanese-American postpartum woman, which action would be a priority?

ensuring that the newborn receives a daily bath In the Japanese-America culture, cleanliness and protection from cold are essential components of newborn care. Nurses should bathe the infant daily. Muslims prefer the same-sex health care provider; male-female touching is prohibited except in emergency situations. Numerous visitors can be expected to visit some women of the Filipino-American culture because families are very closely knit. Bedside prayer is common due to the strong religious beliefs of the Filipino-American culture.

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client?

fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.

A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth?

first 30 to 60 minutes Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth.

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best?

generally within 3 to 6 weeks There is no set time to resume sexual intercourse after birth; each couple must decide when they feel it is safe. Typically, once bright red bleeding has stopped and the perineum is healed from the episiotomy or lacerations, sexual relations can be resumed. This is usually by the third to sixth week postpartum.

Thirty minutes after receiving pain medication, a postpartum woman states that she still has severe pain in the perineal region. Upon assessing and palpating the site, what can the nurse expect to find that might be causing this severe pain?

hematoma If a postpartum woman has severe perineal pain despite use of physical comfort measures and medication, the nurse should check for a hematoma by inspecting and palpating the area. If one is found, the nurse needs to notify the primary care provider immediately.

A client who gave birth to twins 6 hours ago becomes restless and nervous. Her blood pressure falls from 130/80 mm Hg to 96/50 mm Hg. Her pulse drops from 80 to 56 bpm. She was induced earlier in the day and experienced abruptio placentae. Based on this information, what postpartum complication would the nurse expect is happening?

hemorrhage Some risk factors for developing hemorrhage after birth include precipitous labor, uterine atony, placenta previa and abruptio placentae, labor induction, operative procedures, retained placenta fragments, prolonged third stage of labor, multiparity, and uterine overdistention.

A client appears to be resting comfortably 12 hours after giving birth to her first child. In contrast, she labored for more than 24 hours, the primary care provider had to use forceps to deliver the baby, and she had multiple vaginal examinations during labor. Based on this information what postpartum complication is the client at risk for developing?

infection There are many risk factors for developing a postpartum infection: operative procedures (e.g., forceps, cesarean section, vacuum extraction), history of diabetes, prolonged labor (longer than 24 hours), use of Foley catheter, anemia, multiple vaginal examinations during labor, prolonged rupture of membranes, manual extraction of placenta, and HIV.

A nurse is instructing a woman that it is important to lose pregnancy weight gain within 6 months of birth because studies show that keeping extra weight longer is a predictor of which condition?

long-term obesity Women who have not returned to their prepregnant weight by 6 months postpartum are likely to retain extra weight. This inability to lose is a predictor of long-term obesity. It will not necessarily lead to diabetes, but it may decrease a woman's self-esteem and sex drive if she feels less attractive with the extra weight.

Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except:

maintain previous household routines to prevent infection. The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman.

A new mother talking to a friend states, "I wish my baby was more like yours. You are so lucky. My baby has not slept straight through the night even once. It seems like all she wants to do is breastfeed. I am so tired of her." This is an example of which behavior?

negative attachment Expressing disappointment or displeasure in the infant, failing to explore the infant visually or physically, and failing to claim the infant as part of the family are just a few examples of negative attachment behaviors

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus

one fingerbreadth below the umbilicus After a client gives birth, the height of her fundus should decrease by approximately one fingerbreadth (1 cm) each day. By the end of the first postpartum day, the fundus should be one fingerbreadth below the umbilicus. Immediately after birth, the fundus may be above the umbilicus; 6 to 12 hours after birth, it should be at the level of the umbilicus; 10 days after birth, it should be below the symphysis pubis.

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately?

oral temperature 100.8° F (38.2° C) A temperature above 100.4° F (38° C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings.

A nurse is conducting a in-service education program for a group of nurses working in the postpartum unit about postpartal infection. The nurse determines that the teaching was successful when the group identifies which factor as contributing to the risk for infection postpartally?

placenta removed via manual extraction Manual removal of the placenta, a labor longer than 24 hours, a hemoglobin less than 10.5 mg/dL, and multiparity, such as more than three births closely spaced together, would place the woman at risk for postpartum infection.

During the fourth stage of labor, the nurse assesses the client's fundal height and tone. When completing this assessment, the nurse performs which action to prevent prolapse or inversion of the uterus?

places a gloved hand just above the symphysis pubis The nurse can prevent prolapse or inversion of the uterus by placing a gloved hand just above the symphysis pubis that guards the uterus and prevents any downward displacement that may result in prolapse or inversion. To assess the client's rectus muscle, the nurse places the index and middle fingers across the muscle. Palpating the abdomen and feeling the uterine fundus or massaging the fundus carefully to expel any blood clots would be of no benefit in preventing prolapse or inversion of the uterus

The birth center recognizes that attachment is very important in the early stages after birth. Which policy would be inappropriate for the birth center to implement when assisting new parents in this process?

policies that discourage unwrapping and exploring the infant Various factors associated with the health care facility or birthing unit can hinder attachment. These may include separation of infant and parents immediately after birth; policies that discourage unwrapping and exploring the infant; intensive care environment; restrictive visiting policies; staff indifference or lack of support for the parent's. Allowing the infant and mother to room together, allowing visitors, and working with cultural differences will enable the attachment process to occur.

When an infant smiles at the mother and the mother in turn smiles and kisses her baby, this would be which phase of attachment?

reciprocity Proximity refers to the physical and psychological experience of the parents being close to their infant. Reciprocity is the process by which the infant's abilities and behaviors elicit parental responses (i.e., the smile by the infant gets a smile and kiss in return). Commitment refers to the enduring nature of the relationship.

A client who has just given birth to a baby girl demonstrates behavior not indicative of bonding when she performs which action?

talks to company and ignores the baby lying next to her Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. The mother initiates bonding when she caresses her infant and exhibits certain behaviors typical of a mother tending to her child. Ignoring the infant while talking to visitors is not an example of proper bonding.

An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted?

temperature The temperature of an incision would be determined only if the other parameters require this. A sterile glove would be used to assess skin temperature.

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. Approximately 6 to 12 hours after birth, the fundus is usually at the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

It has been 2 hours since a woman gave birth vaginally to a healthy newborn. When assessing the woman's uterine fundus, the nurse would expect to find it at:

the level of the umbilicus. The fundus is between the umbilicus and symphysis pubis 1 to 2 hours after birth. Approximately 6 to 12 hours after birth, the uterine fundus is usually at the level of the umbilicus. The fundus typically is 1 cm below the umbilicus on the first postpartum day and 2 cm below the umbilicus on the second postpartum day.

Review of a woman's labor and birth record reveals a laceration that extends through the anal sphincter muscle. The nurse identifies this laceration as which type?

third-degree laceration A third-degree laceration extends through the anal sphincter muscle. A first-degree laceration involves only skin and superficial structures above the muscle. A second-degree laceration extends through the perineal muscles. A fourth-degree laceration continues through the anterior rectal wall.

The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause?

thromboembolic disorder of the lower extremities Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted.

Postpartum infection is one event that is known to impede the recovery process of a new mother. Which characteristics after birth make a woman more susceptible to infection? Select all that apply

urinary stasis denuded endometrial arteries episiotomy The urinary system after birth is prone to infection, prompting a focus on cleanliness and frequent urination. The open uterine arteries are at risk for infection, as is any break in skin integrity. An elevated white blood cell count (from 10,000/mm³ to 30,000/mm³) is the body's defense against infection. A count greater than 30,000/mm³ or less than 10,000/mm³ prompts further investigation.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. The nurse knows to prepare the client for which test first?

venous duplex ultrasound of the right leg Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins and would not be the first choice. Transthoracic echocardiography looks at cardiac structures and is not indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply.

women on antithyroid medications women on antineoplastic medications women using street drugs While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules.

When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply.

Help the mother initiate breastfeeding within 30 minutes of birth. Encourage breastfeeding of the newborn infant on demand. Place baby in uninterrupted skin-to-skin contact with the mother. The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns.

A nurse is providing care to a postpartum woman. The woman gave birth vaginally at 2 a.m. The nurse would anticipate the need to catheterize the client if she does not void by which time?

9:00 a.m. If a woman has not voided within 4 to 6 hours after giving birth, catheterization may be needed because a full bladder interferes with uterine contraction and may lead to hemorrhage. Not voiding by 9 a.m. exceeds the 4 to 6 hour time frame.

A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention?

Percussion reveals dullness. A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual.

A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information?

"I only eat a low-fiber diet." Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate?

"It might take up to a week for your bowels return to their normal pattern." Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas to gain additional information. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the healthcare provider is not necessary, and this statement could add to the client's currrent concern.

A nurse assessing a postpartum client notices excessive bleeding. What should be the nurse's first action?

Massage the boggy fundus until it is firm. The nurse needs to report any abnormal findings when assessing the lochia. If excessive bleeding occurs, the first step would be to massage the boggy fundus until it is firm to reduce the flow of blood. Then the nurse needs to document the findings.

A postpartum client is having difficulty stopping her urine stream. Which should the nurse do next

Educate the client on how to perform Kegel exercises. Clients should begin Kegel exercises on the first postpartum day to increase the strength of the perineal floor muscles. Priority for this client would be to educate her how to perform Kegel exercises as strengthening these muscles will allow her to stop her urine stream.

A nurse is applying ice packs to the perineal area of a client who has had a vaginal birth. Which intervention should the nurse perform to ensure that the client gets the optimum benefits of the procedure?

Ensure ice pack is changed frequently. The nurse should ensure that the ice pack is changed frequently to promote good hygiene and to allow for periodic assessments. Ice packs are wrapped in a disposable covering or clean washcloth and then applied to the perineal area, not directly. The nurse should apply the ice pack for 20 minutes, not 40 minutes. Ice packs should be used for the first 24 hours, not for a week after birth.

A nurse is caring for a client who has just received an episiotomy. The nurse observes that the laceration extends through the perineal area and continues through the anterior rectal wall. How does the nurse classify the laceration?

Fourth degree The nurse should classify the laceration as fourth degree because it continues through the anterior rectal wall. First-degree laceration involves only skin and superficial structures above muscle; second-degree laceration extends through perineal muscles; and third-degree laceration extends through the anal sphincter muscle but not through the anterior rectal wall.

Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next?

Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time.

A nurse is assessing a postpartum client. Which measure is appropriate?

Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth.

The nurse has been asked to conduct a class to teach new mothers how to avoid developing stress incontinence. Which actions would the nurse include in her discussion as possible strategies for the new mothers to do? Select all that apply.

Kegel exercises avoid smoking lose weight if obese Postpartum women should consider low-impact activities such as walking, biking, swimming, or low-impact aerobics as they resume physical activity. They should also consider a regular program of Kegel exercises; losing weight, if necessary; avoid smoking; limiting intake of alcohol and caffeinated beverages; and adjusting the fluid intake to produce a 24-hourly output of 1,000 mL to 2,000 mL.