OB Chapter 17
A nurse is caring for a non-breastfeeding client in the postpartum period. The client reports engorgement. What suggestion should the nurse provide to alleviate breast discomfort? Express milk frequently. Wear a well-fitting bra. Apply warm compresses. Apply hydrogel dressing.
Wear a well-fitting bra. The nurse should suggest the client wear a well-fitting bra to provide support and help alleviate breast discomfort. Application of warm compresses and expressing milk frequently are suggested to alleviate breast engorgement in breastfeeding clients. Hydrogel dressings are used prophylactically in treating nipple pain.
A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding? infection diabetes bleeding postpartum gestational hypertension
bleeding Blood pressure should also be monitored carefully during the postpartum period because a decrease in BP can also indicate bleeding. In contrast, an elevation above 140 mm Hg systolic or 90 mm Hg diastolic may indicate the development of postpartum gestational hypertension, an unusual but serious complication of the puerperium. An infection would best be indicated by an elevated oral temperature. Diabetes would be indicated by an elevated blood glucose level.
A mother anticipates an identity for her child before birth. Time is spent getting to know her child upon delivery. The nurse acknowledges this initial identification process and documents which behavior? encouraging others to hold the newborn light fingertip touching of the newborn's hand making plans for a day care facility anxiety at the first diaper change
light fingertip touching of the newborn's hand Attachment is initiated with fingertip touching and gazing into the newborn's eyes. The other behaviors are those of a mother who is farther along in the process of knowing her newborn. Focus on the word "initial" to place this behavior in the spectrum of time.
A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal? two fingerbreadths below the umbilicus two fingerbreadths above the umbilicus at the level of the umbilicus four fingerbreadths below the umbilicus
two fingerbreadths below the umbilicus During the first few days after birth, the uterus typically descends downward from the level of the umbilicus at a rate of 1 cm (1 fingerbreadth) per day so that by day 2, it is about 2 fingerbreadths below the umbilicus.
A nurse is caring for a client on the second day postpartum. The client informs the nurse that she is voiding a large volume of urine frequently. Which factor should the nurse identify as a potential cause for urinary frequency? trauma to pelvic muscles urinary tract infection postpartum diuresis urinary overflow
postpartum diuresis The nurse should identify postpartum diuresis as the potential cause for urinary frequency. Urinary overflow occurs if the bladder is not completely emptied. Urinary tract infection may be accompanied by fever and a burning sensation. Trauma to pelvic muscles does not affect urinary frequency.
What two elements play the biggest role in becoming a mother after delivery of her newborn? Confidence and happiness with the pregnancy Love and attachment to the child and engagement with the child Interactions with the child and support systems Planned and desired pregnancy and previous experience with infants
Love and attachment to the child and engagement with the child A mother begins the process of becoming a mother during the pregnancy and this continues for the rest of her life. The two critical elements of becoming a mother are developing love and attachment to the newborn and becoming engaged with the child by assuming caregiving for the child as he grows and changes.
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? Lochia is less than usual. Uterus is firm. Percussion reveals dullness. Bladder is nonpalpable.
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 caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? estrogen progesterone prolactin oxytocin
oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin, which causes lactation.
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation? Bladder distention Full bowel Uterine atony Poor bladder tone
Bladder distention Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client? Change in pregnancy hormone Body secreting the excess fluids from pregnancy The patient may be drinking too much fluid. The body is trying to get rid of the extra blood made during pregnancy.
Body secreting the excess fluids from pregnancy Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.
The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. Low self-esteem Lack of social support Low socioeconomic status Feeling overwhelmed and out of control Involving family in infant care
Low self-esteem Lack of social support Low socioeconomic status Feeling overwhelmed and out of control Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression.
The nurse is admitting to the floor a woman who just gave birth. What medical and pregnancy history would the labor and delivery nurse include in the report? The newborn's weight Apgar scores Length of labor Maternal blood type
Maternal blood type Medical and pregnancy history would include information pertinent to the mother, which would be the mother's blood type, Rh, and rubella status. History of the length of labor are part of the labor and birthing history. The infant's Apgar scores and birth weight are part of the newborn history.
A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize? "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation." "This is normal; give it a few days and then call back." "After birth it is easier to develop an infection in the urinary system; we need to see you today." "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues."
"After birth it is easier to develop an infection in the urinary system; we need to see you today." The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection. The other responses are incorrect because they do not acknowledge her in an appropriate manner.
A nurse is working with the parents of a newborn girl. The parents have a 2-year-old boy at home. Which statement would the nurse include when teaching these parents? "Ask your 2-year-old to pick out a special toy for his sister." "Expect to see your 2-year-old become more independent when the baby gets home." "Have your 2-year-old stay at home while you're here in the hospital." "Talk to your 2-year-old about the baby when you're driving him to day care."
"Ask your 2-year-old to pick out a special toy for his sister." The parents should encourage the sibling to participate in some of the decisions about the baby, such as names or toys. Typically siblings experience some regression with the birth of a new baby. The parents should talk to the sibling during relaxed family times. The parents should arrange for the sibling to come to the hospital to see the newborn.
A nurse is caring for a client who gave birth about 10 hours earlier. The nurse observes perineal edema in the client. What intervention should the nurse perform to decrease the swelling caused by perineal edema? Use a warm sitz bath or tub bath. Apply ice. Use ointments locally. Apply moist heat.
Apply ice. Ice is applied to perineal edema within 24 hours after birth. Use of ointments is not advised for perineal edema. Moist heat and a sitz or tub bath are encouraged if edema continues 24 hours after birth.
The father of a stillborn infant tells the nurse he wants to hold the child. What is the nurse's best response? Give him some photographs of the infant. Tell him that it would be better not to hold the infant. Dress the infant in a T-shirt and diaper and let him hold the infant. Encourage him to discuss this with the mother first.
Dress the infant in a T-shirt and diaper and let him hold the infant. Fathers need to grieve the loss of an infant. Seeing and holding the infant is helpful to many parents. Providing photographs is a long-term keepsake, but does not replace the opportunity to hold and view his infant. Optimally, parents will grieve as a couple, but if the mother is unable to hold the infant because of medical condition or personal choice, the father still needs the opportunity to see and say goodbye to his child.
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration? Engorgement Mastitis Excessive oxytocin Blocked milk duct
Engorgement The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.
A client is exhibiting signs of engorgement, but her milk is still flowing easily. Which suggestion should the nurse prioritize? Restrict fluid intake to 2 L each day. Ensure the baby empties the breasts at each feeding Apply ice packs before a feeding. Wear a tight fitting bra at all times.
Ensure the baby empties the breasts at each feeding Breast engorgement occurs as the breasts begin to produce milk. As the infant begins the process of breast feeding, the woman's body will begin to adjust and produce just enough milk for the infant. The mother should ensure the infant empties each side at each feeding to ensure there will be plenty of milk for each feeding. The woman should not restrict her fluid intake but ensure she gets plenty of fluids to ensure an adequate supply of milk. Wearing a tight fitting bra would be appropriate if the mother decides to bottle-feed her baby, but not if she is breastfeeding. She should wear a bra which is supportive. It would be more appropriate to apply warm compresses or take a warm shower before feeding her infant to help with engorgement as it encourages the let-down factor.
A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be prescribed? methylergonovine ferrous sulfate docusate bromocriptine
docusate A stool softener such as docusate may promote bowel elimination in a woman with a fourth-degree laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia. However, it is associated with constipation and would increase the discomfort when the woman has a bowel movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to treat hyperprolactinemia.
A postpartum mother is recovering from a cesarean birth and is reporting incisional and abdominal pain at a level of 8. Morphine sulfate is ordered as follows: morphine sulfate 8 mg IV q 4 hours prn for pain greater than 6. Morphine sulfate comes in 10 mg/ml. How many milliliters of morphine would the nurse administer to this client using slow push over 5 minutes? Record your answer using one decimal place.
0.8 The on-hand medication is morphine sulfate 10 mg/ml. The ordered dose is 8 mg, so the nurse would calculate the dose as follows: 10 mg/1 ml = 8 mg/X ml. Cross multiply, 10X = 8 ml. Divide 8 by 10 to get 0.8 ml.
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment? 1 cm above the umbilicus At the symphysis pubis At level of umbilicus 1 cm below the umbilicus
1 cm below the umbilicus The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be? red yellowish white pink yellowish pink
yellowish white The normal color of lochia on the tenth day of postpartum is yellowish white. The color of lochia changes from red to pink by approximately four or five days postpartum. The color of lochia is never yellowish pink.
A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third postpartum day. Which instruction by the nurse would be most appropriate to aid in relieving her discomfort? "Take several warm showers daily to stimulate the milk let-down reflex." "Apply ice packs to your breasts to reduce the amount of milk being produced." "Remove your bra to relieve the pressure on your sensitive nipples and breasts." "Express some milk from your breasts every so often to relieve the distention."
"Apply ice packs to your breasts to reduce the amount of milk being produced." For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the woman who was breastfeeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with engorgement who is bottle feeding.
A nurse is making an initial call on a new mother who gave birth to her third baby 5 days ago. The woman says, "I just feel so down this time. Not at all like when I had my other babies. And this one just doesn't sleep. I feel so inadequate." What is the best response to this new mother? "Every baby is different with their own temperament. Maybe this one just isn't ready to sleep when you want him to." "Tell me, are you seeing things that aren't there, or hearing voices?" "It sounds like you need to make an appointment with a counselor. You may have postpartum depression." "It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two."
"It sounds like you have the 'baby blues.' They are common after having a baby when you are not getting enough sleep, are busy with your other children, and are still a bit uncomfortable from the birth. They will most likely go away in a day or two." A combination of factors likely contributes to the baby blues. Psychological adjustment along with a physiologic decrease in estrogen and progesterone appear to be the greatest contributors. Additional contributing factors include too much activity, fatigue, disturbed sleep patterns, and discomfort.
A nurse is assessing a postpartum client and notes an elevated temperature. Which temperature protocol should the nurse prioritize? 100.3ºF (37.9ºC) at 24 hours postbirth and remains the same for the second postpartum day 100.1ºF (37.8ºC) at 24 hours postbirth and decreases the second postpartum day 99.1ºF (37.3ºC) at 12 hours postbirth and decreases after 18 hours 100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum
100.5ºF (38.1ºC) at 48 hours postbirth and remains the same the third day postpartum A temperature that is greater than 100.4ºF (38ºC) on two postpartum days after the first 24 hours puts the client at risk for a postpartum infection. A fever in the first 24 hours of birth is considered normal and could be caused by dehydration and analgesia.
A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? Provide the infant oral nystatin. Feed the baby at least every two or three hours. Apply cold compresses to the breasts. Dry the nipples following feedings.
Feed the baby at least every two or three hours. The nurse should suggest the client feed the baby every two or three hours to help her reduce and prevent further engorgement. Application of cold compresses to the breasts is suggested to reduce engorgement for non-breastfeeding clients. If the mother has developed a candidal infection on the nipples, the treatment involves application of an antifungal cream to the nipples following feedings and providing the infant with oral nystatin. The nurse can suggest drying the nipples following feedings if the client experiences nipple pain.
The nurse is checking the lochia of a new mother at her 2-week checkup. The mother reports that the lochia is a small amount, pale yellow with occasional tinges of brown. She also reports that it has fleshy odor to it. How would the nurse evaluate these findings? Lochia should have stopped by now, so this is definitely concerning for the nurse and should be reported. The brownish tinges indicate that the mother is regressing on the expected pattern of lochia and this is problematic. The lochia's odor indicates that an infection may be present and the doctor needs to be notified. The color and amount of the lochia is normal and there are no concerns.
The color and amount of the lochia is normal and there are no concerns. Lochia normally progresses through three stages: lochia rubra, lochia serosa and lochia alba. Lochia rubra lasts approximately 3 to 4 days and is bloody in appearance. Lochia serosa is brownish-pink in color, less in quantity and occurs during days 4 to 10 following delivery. Lochia alba, which this client has, is white to pale yellow in color and small in volume and occurs around week 2 after delivery. The fleshy odor is normal for lochia.
The nurse is caring for a client who underwent a cesarean birth 24 hours ago. Which assessment finding indicates the need for further action? Bowel sounds are active. The fundus is located 2 fingerbreadths above the umbilicus. The client requires assistance to ambulate in the hallway. The client is having a moderate amount of rubra lochia. The client is afebrile.
The fundus is located 2 fingerbreadths above the umbilicus. The client recovering from a cesarean birth will require frequent assessment. The client will display a moderate amount of lochia. The fundus should be in the midline position and at or just below the level of the umbilicus. The client is encouraged to ambulate. Requiring assistance is not problematic at this stage of the recovery period. The absence of a temperature elevation is also normal.
The nurse is looking at the latest lab work for her postpartum client. The client's predelivery hemoglobin and hematocrit (H & H) was 12.8 and 39, respectively. This morning, the client's values are 8.9 and 30. How would the nurse interpret these lab values? These values are expected for a 1-day postpartum mother. The client will need a transfusion, so the RN needs to be notified. The client will be tired, so encourage her to sleep whenever the baby sleeps. The health care provider needs to be notified of the latest lab values.
The health care provider needs to be notified of the latest lab values. If there is a significant drop in a postpartum mother's H & H, the health care provider needs to be notified because the client may have experienced a postpartum hemorrhage that went unreported or undetected. The health care provider will decide what measures to take.
The nurse is preparing discharge for a client who plans to bottle-feed her infant. Which instruction should the nurse prioritize for this client in the discharge teaching? Express small amounts of milk when they are too full. Wear a tight, supportive bra. Run warm water over the breast in the shower. Massage the breasts when they are painful.
Wear a tight, supportive bra. The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice. Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.
The nurse is reviewing the health records of several clients who gave birth during the previous shift. For which client would the nurse monitor more frequently for maternal hemorrhage? a client with a pulse rate of 88 beats/min and a blood pressure of 102/64 mm Hg a client diagnosed with placenta succenturiate a client who showered 12 hours after birth of a healthy term neonate a client who birthed an 8 lb 6 oz (3799 g) neonate
a client diagnosed with placenta succenturiate Placental succenturiate is a concern for maternal hemorrhage if the accessory lobes of the placenta are retained after delivery. The other conditions are not associated with a higher than usual concern for hemorrhage, although all postpartum clients are observed for hemorrhage.
Which intervention would be helpful to a bottle-feeding client who's experiencing hard or engorged breasts? administering bromocriptine applying ice restricting fluids applying warm compresses
applying ice Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression.
After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention? presence of lochia serosa fundus firm, below umbilicus milk filling in both breasts frequent scant voidings
frequent scant voidings Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.
Rubin identified a series of changes that a new mother makes during the postpartum period. The correct sequence of these changes is: taking, holding-on, letting-go. taking-in, taking-hold, letting-go. taking-in, holding-on, letting-go. taking-in, taking-on, letting-go.
taking-in, taking-hold, letting-go The new mother makes progressive changes to know her infant ("taking-in"), review the pregnancy and labor, validate her safe passage through these phases ("taking-hold"), learn the initial tasks of mothering, and let go of her former life to incorporate this new child.
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply. prolonged labor uterine infection hydramnios empty bladder breastfeeding early ambulation
prolonged labor uterine infection hydramnios Factors that inhibit involution include prolonged labor and difficult birth, uterine infection, overdistention of the uterine muscles such as from hydramnios, a full bladder, close childbirth spacing, and incomplete expulsion of amniotic membranes and placenta. Breastfeeding, early ambulation, and an empty bladder would facilitate uterine involution.
An episiotomy or a cesarean incision requires assessment. Which assessment criterion for skin integrity is not initially noted? edema redness temperature drainage
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.
A nurse is caring for a client with postpartum hemorrhage. What should the nurse identify as the significant cause of postpartum hemorrhage? hemorrhoid uterine atony iron deficiency diuresis
uterine atony Uterine atony is the significant cause of postpartum hemorrhage. Discomfort from hemorrhoids increases risk for constipation during the postpartum period. Diuresis causes weight loss during the first postpartum week, whereas iron deficiency causes anemia in the puerperium.
A woman gave birth to a healthy term neonate today at 1330. It is now 1430 and the nurse has completed the client's assessment. At which time would the nurse next assess the client? 1500 1530 1445 1830
1500 The woman is in her second hour postpartum. Typically, the nurse would assess the woman every 30 minutes. In this case, this would be 1500. During the first hour, assessments are usually completed every 15 minutes. After the second hour, assessments would be made every 4 hours for the first 24 hours and then every 8 hours.
Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. 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: call the primary care provider or the nurse-midwife. increase the flow of an IV. assess and massage the fundus. inspect the perineum for lacerations.
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.
The client, G5P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? Put on the call button to summon help. Administer oxytocics to prevent uterine atony. Gently massage the fundus until it tones up. Teach the woman to perform periodic self-fundal massage.
Gently massage the fundus until it tones up. After delivery, the fundus should be firm and at the umbilicus or lower. The more pregnancies and the larger the infant, the more at risk for complications secondary to atony of the uterus for the client. The first action is to massage the uterus until firm. The scenario described does not indicate any need to summon help. The administration of oxytocics to prevent uterine atony can only be done by order of the health care provider. Teaching the woman to perform self-fundal massage is not appropriate at this time. It would be appropriate after the atony of the uterus is corrected.
The nurse's assessment identified signs that the client is depressed. What is the nurse's greatest concern for a client who is depressed? Poor nutrition Withdrawal from others Harm to self Lack of a social network
Harm to self When a client is depressed the risk is that she will harm herself. Safety and prevention of harm is always the greatest concern. One of the nurse's interventions is to help the client identify a social network to provide support and socialization. Poor nutrition is a consequence of depression, but it can be addressed.
An Rh-negative mother delivered an Rh-positive infant. What information would the nurse need to gather prior to administering Rho (D) immune globulin injection? Select all that apply. Has the mother experienced any spontaneous abortions (miscarriages) or abortions (elective terminations of pregnancy)? Has she delivered by cesarean section or vaginally? Has the mother ever been sensitized to Rh-positive blood? What was the birth weight of the infant? Has the mother had any previous pregnancies?
Has the mother experienced any spontaneous abortions (miscarriages) or abortions (elective terminations of pregnancy)? Has the mother ever been sensitized to Rh-positive blood? Has the mother had any previous pregnancies? An Rh-negative mother must be interviewed prior to administration of Rho (D) immune globulin to ensure that she is a candidate for the medication. Pertinent questions are whether she has been previously exposed to Rh-positive blood prior to this pregnancy, which could have occurred from a previous pregnancy, spontaneous abortion (miscarriage), abortion (elective termination of pregnancy) or ectopic pregnancy. The type of delivery and the newborn's weight are not relevant.
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs? Evolution Involution Decrement Progression
Involution Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next. Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.
The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize? Assist the client in ambulation. Notify the RN who will then notify the health care provider. Continue to monitor for another hour. Administer an antipyretic.
Notify the RN who will then notify the health care provider. A temperature elevated above 100.4°F (38°C) is a sign of possible infection. The LPN should notify the RN. The RN will then notify the provider and receive further care orders for the client. Administering an antipyretic can only be done at the physician's order. Assisting in ambulation and continuing to monitor the client for another hour are not indicated interventions for this client.
A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first? Have another nurse come listen to the client's respirations and count the rate. Ask the charge nurse to look in on the client before the end of the shift. Notify the health care provider of the findings. Call the Medical Response Team to her room.
Notify the health care provider of the findings. If the nurse notes abnormal findings on her exam—such as depressed respiratory status like this client is presenting—the nurse will immediately notify a health care provider. Having a peer come in to confirm your findings is always fine but this does not preclude notification of the physician. Asking the charge nurse to look in on the client later indicates there is no urgency to the situation, which there is.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize? Apply a warm washcloth. Put on a witch hazel pad. Place an ice pack. Notify a health care provider.
Place an ice pack. The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.
Parents tell the nurse that their 3-year-old son has begun to have "accidents" at home following the arrival of his baby sister and wants to sit in his mother's lap all the time now. What advice would the nurse offer these parents? Select all that apply. Set aside time every day for the parents to focus on the big brother exclusively. Buy the older sibling a doll for him to care for, as the mother is caring for the new baby. Be aware of potential aggressive behaviors from the older sibling. Scold him whenever he wets his pants and place him back in diapers. Tell the older sibling that he is a big boy and has to share his mommy with the little sister.
Set aside time every day for the parents to focus on the big brother exclusively. Buy the older sibling a doll for him to care for, as the mother is caring for the new baby. Be aware of potential aggressive behaviors from the older sibling. When parents have a second child, the older child feels pushed aside and no longer important. Parents need to understand that regressive behaviors such as accidents, thumb-sucking or even wanting a bottle may occur. The parents need to set aside one-on-one time each day with the older child and make him feel important and loved. Sometimes buying the child a doll to care for alongside the mother also helps in the adjustment. The nurse needs to be sure to inform the parent that aggression may also be displayed and to be alert to those behaviors.
The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care? Postpartum depression only impacts women with two or more children. Symptoms occur within a week after giving birth. Symptoms of postpartum depression can easily go undetected. Only mental health professionals can detect postpartum depression.
Symptoms of postpartum depression can easily go undetected. The plan of care should acknowledge that symptoms of postpartum depression are often missed and go undetected (and therefore untreated). Postpartum blues occur within the first week after birth. Postpartum depression can develop after any pregnancy and can be assessed by providers in a variety of settings.
In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? The urinary output is inadequate and the mother needs to drinks more fluids. The urinary output is normal. The urinary output is above expected levels. The urinary output is inadequate suggestive of urinary retention.
The urinary output is normal. Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void.
During a postbirth home visit, the nurse asks the client to complete the Edinburgh Depression Scale. What information will the nurse learn from this scale? Select all that apply. To identify client at risk for perinatal depressions To identify the client's need for antidepressant medications To identify the client's attachment to the newborn To identify the need for additional support in the home To identify clients at risk for suicide
To identify clients at risk for suicide To identify client at risk for perinatal depressions The Edinburgh Depression Scale identifies the client at risk for perinatal depressions and identifies the client at risk for suicide. This scale does not assess maternal newborn attachment and the need for additional support in the home. If the scale identifies the client is at risk for depression, it does not identify the treatment modality.
When teaching parents about their newborn, the nurse describes the development of a close emotional attraction to a newborn by the parents during the first 30 to 60 minutes after birth. The nurse refers to this process by which term? reciprocity bonding engrossment attachment
bonding The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.
A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this mother's attachment to her newborn? showing a video of parents feeding their babies allowing the mother to pick the best time to hold her newborn bringing the newborn into the room talking about how the nurse held her own newborn while on the birthing table
bringing the newborn into the room Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother.
After teaching parents about their newborn, the nurse determines that the teaching was successful when they identify which concept as reflecting the enduring nature of their relationship, one that involves placing the infant at the center of their lives and finding their own way to assume the parental identity? reciprocity commitment attachment bonding
commitment Commitment refers to the enduring nature of the relationship. The components of this are twofold: centrality and parent role exploration. In centrality, parents place the infant at the center of their lives. They acknowledge and accept their responsibility to promote the infant's safety, growth, and development. Parent role exploration is the parents' ability to find their own way and integrate the parental identity into themselves. The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment refers to the process of developing strong ties of affection between an infant and significant other.
Elevation of a client's temperature is a crucial first sign of infection. However, when is elevated temperature not a warning sign of impending infection? during the first 24 hours after birth owing to dehydration from exertion when the white blood cell count is less than 10,000/mm³ after any period of decreased intake when the elevated temperature exceeds 100.4°F (38°C)
during the first 24 hours after birth owing to dehydration from exertion Rapid breathing during labor and birth and limited oral intake can cause a self-limited period of dehydration that is resolved after birth by the diuresis that shortly follows. The option of "any period" is too broad and falsely encompasses all conditions. The other options are signs of infection.
A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? her bladder for distention hematocrit level her episiotomy the size of her infant
her bladder for distention Bladder distention can cause the uterus to not contract effectively following delivery and displace to the side. This is easily checked and should be the first assessment done for a client whose uterus is not contracting as expected.
A nurse is observing the interaction between a new father and his newborn. The nurse determines that engrossment has yet to occur based on which behavior? is able to distinguish his newborn from others in the nursery demonstrates pleasure when touching or holding the newborn identifies imperfections in the newborn's appearance shows feelings of pride with the birth of the newborn
identifies imperfections in the newborn's appearance Identifying imperfections would not be associated with engrossment. Engrossment is characterized by seven behaviors: visual awareness of the newborn, tactile awareness of the newborn, perception of the newborn as perfect, strong attraction to the newborn, awareness of distinct features of the newborn, extreme elation, and increased sense of self-esteem.
A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? inability of infant to empty breasts improper positioning of infant inadequate secretion of prolactin cracking of the nipple
inability of infant to empty breasts For the breastfeeding mother, engorgement is often the result of vascular congestion and milk stasis, primarily caused by the infant not fully emptying the mother's breasts at each feeding. Cracking of the nipple could lead to infection. Improper positioning may lead to nipple tenderness or pain. Inadequate secretion of prolactin causes a decrease in the production of milk.
The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning? increased hematocrit level increased heart rate increased cardiac output increased blood pressure
increased heart rate Tachycardia in the postpartum woman warrants further investigation as it can indicate postpartum hemorrhage. Typically the postpartum woman is bradycardic for the first 2 weeks. In most instances of postpartum hemorrhage, blood pressure and cardiac output remain increased because of a compensatory increase in heart rate. Hypotension would be another concerning assessment, especially orthostatic hypotension, as it can also indicate hemorrhage. Red blood cell production ceases early in the postpartum period, causing hemoglobin and hematocrit levels to decrease slightly in the first 24 hours and then rise slowly. Hematocrit would be unreliable as an indicator of hemorrhage
The nurse is making a home visit to a woman who is 5 days' postpartum. Which finding would concern the nurse and warrant further investigation? edematous vagina diaphoresis uterus 5 cm below umbilicus lochia rubra
lochia rubra Lochia serosa is normal from days 3 to 10 postpartum. However, lochia rubra is present for about the first 3 days and is considered abnormal on the 5th postpartum day. By the fifth postpartum day, the uterus should be approximately 5 cm below the umbilicus. After birth the vagina is edematous and thin with few rugae. It eventually thickens and rugae return in approximately 3 weeks. Diaphoresis is common during the early postpartum period, especially in the first week. It is a mechanism to reduce fluids retained during pregnancy and restore prepregnant body fluid levels.
At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of: postpartum depression. postpartum psychosis. postpartum adjustment. postpartum blues.
postpartum depression. Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother.
A nurse is making a postpartum home visit to a woman who gave birth vaginally about 12 days ago. The woman's partner is present during the visit. When assessing the woman and the family, which finding related to the partner would lead the nurse to suspect that the partner may be experiencing postpartum depression? Select all that apply. reports of frequent headaches feelings of being unprepared for the role reports of feeling highly stressed use of encouraging statements about the infant statements that the woman is getting all the attention
reports of frequent headaches statements that the woman is getting all the attention reports of feeling highly stressed A partner's stress, irritability and frustration in the days, weeks, and months after the birth of the child can turn into depression, just like that experienced by the mother. Unfortunately, partners rarely discuss their feelings or ask for help, especially during a time when they are supposed to be the "strong one" for the new mother. Symptoms of depression appear 1 to 3 weeks after birth and can include feelings of high stress, anxiety, discouragement, fatigue, headaches, and resentment toward the infant and the attention he or she is getting. Partners experiencing these symptoms should understand that it is not a sign of weakness, and professional help can be helpful. Partner statements about not being prepared for the role is a common feeling and part of the role development process indicating reality.
A new mother gave birth to her baby 24 hours ago and today has been content to rest in her hospital bed, hold her baby, allow the nurse to care for her, and to discuss her labor and birth experience with visitors. Which phase of the postpartum restorative period is this client in? taking-hold phase rooming-in phase taking-in phase letting-go phase
taking-in phase The taking-in phase is largely a time of reflection. During this 1- to 3-day period, a woman is largely passive. She prefers having a nurse attend to her needs and make decisions for her, rather than do these things herself. As a part of thinking and pondering about her new role, the woman usually wants to talk about her pregnancy, especially about her labor and birth. After a time of passive dependence, a woman enters the taking-hold phase and begins to initiate action. She prefers to get her own washcloth or to make her own decisions. In the letting-go phase, a woman finally redefines her new role. She gives up the fantasized image of her child and accepts the real one; she gives up her old role of being childless or the mother of only one or two (or however many children she had before this birth). Rooming-in is a feature offered by hospitals in which the infant is allowed to stay in the same hospital room as the mother following birth; it is not a phase of the postpartum period.
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? transthoracic echocardiogram noninvasive arterial studies of the right leg venogram of the right leg venous duplex ultrasound of the right leg
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.
A woman comes to the clinic for her first postpartum visit. She gave birth to a healthy term neonate 2 weeks ago. As part of this visit, the woman has a complete blood count drawn. Which result would the nurse identify as a potential problem? hemoglobin 12.5 g/dL (125 g/L) hematocrit 42% (0.42) white blood cell count 14,000/mm3 (14 ×109/L) platelets 350,000/µL (350 ×109/L)
white blood cell count 14,000/mm3 (14 ×109/L) The white blood cell count, which increases in labor, remains elevated for the first 4 to 6 days after birth but then falls to 6,000 to 10,000/mm3 (6 to 10 ×109/L). An elevated white blood cell count would be suspicious for infection. The hemoglobin, hematocrit and platelet levels are within normal parameters for this woman.
