Postpartum Ch. 16
A client is Rh-negative and has given birth to a newborn who is Rh-positive. Within how many hours should Rh immunoglobulin be injected in the mother?
72 hours.
A nurse is assessing a client during the postpartum period. Which of the following indicate normal postpartum adjustment? (Select all)
Active bowel sounds, passing gas, and non-distended abdomen.
During assessment of the mother during the postpartum period, what would alert the nurse that the client is likely experiencing uterine atony?
Boggy or relaxed uterus. This can be the result of bladder distention, which displaces the uterus upward and toward the right, or retained placental fragments.
A nurse is to care for a client during the postpartum period. The client complains of pain and discomfort in her breasts. What signs should a nurse look for to find out if the client has engorged breasts? (Select all)
Breast and hard and tender.
What nutritional recommendations can a nurse provide to a client during the postpartum period?
Eat a wide variety of foods w/high nutritional density; foods & recipes that require little to no preparation; avoid high-fat fast food and fad weight-loss diets; drink plenty of fluids; avoid excessive intake of fat, salt, sugar & caffeine
A nurse is applying ice packs to the perineal area of a client who has had a vaginal delivery. Which of the following interventions should the nurse perform to ensure that the client gets the optimum benefits of the procedure?
Ensure ice pack is changed frequently. Ice packs should be wrapped in a disposable covering or clean washcloth, not applied directly. They should be applied for 20 minutes and used for the first 24 hours.
A nurse has been assigned to the care of a client who has just given birth. How frequently should the nurse perform the assessments during the first hour after delivery?
Every 15 minutes. After the second hour, assessment is performed every 30 minutes.
A nurse, assigned to check the pulse, discerns tachycardia in a postpartum client. Which of the following does it suggest?
Excessive blood loss. It may also suggest anxiety, excitement, fatigue, pain, infection, or underlying cardiac problems.
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. Which of the following classifications will the nurse use to describe the laceration?
Fourth-degree laceration. First-degree = only skin & superficial structures above muscle; second-degree extends through perineal muscles; third-degree extends through the anal sphincter muscle but not through the anterior rectal wall.
Which of the following exercises should a nurse suggest to the client during the first day of postpartum?
Kegel exercises. Abdominal, buttock, & thigh-toning exercises may be resumed during the 2nd week after delivery in most cases.
A client who has a breast-feeding newborn complains of sore nipples. Which of the following interventions can the nurse suggest to alleviate the client's condition?
Offer suggestions based on observation to correct positioning or latching.
What are the causes of postpartum stress?
Physical stress of pregnancy & birth, the required care-giving tasks assoc. w/the newborn, meeting the demands of other family members, and fatigue.
A client who has given birth is being discharges from the the health care facility. She wants to know how safe it would be for her to have intercourse. Which of the following instructions should the nurse provide to the client regarding intercourse after childbirth?
Resume intercourse if bright-red bleeding stops.
When teaching the new mother about breast-feeding, the nurse is correct when providing what instructions? (Select all)
Show mothers how to initiate breast-feeding within 30 minutes of birth; Encourage breast-feeding of the newborn infant on demand; Place baby in uninterrupted skin-to-skin contact with the mother.
What does the postpartum assessment of the mother include?
Vital signs, pain level, & a systematic head-to-toe review of the body systems: breasts, uterus, bladder, bowels, lochia, episiotomy/perineum, extremities, and emotional status.
What are the postpartum physiologic danger signs?
Fever more than 38 C (100.4 F) after the first 24 hours; foul-smelling lochia or an unexpected change in color or amount; visual changes, such as blurred vision or spots, or headaches; calf pain experienced with dorsiflexion of the foot; swelling, redness, or discharge at the episiotomy site; dysuria, burning, or incomplete emptying of the bladder; shortness of breath or difficulty breathing; depression or extreme mood swings.
A first-time mother is nervous about breast-feeding. Which of the following interventions should the nurse perform to reduce maternal anxiety about breast-feeding?
Reassure the mother that some newborns "latch on and catch on" right away, and some newborns take more time and patience.
The nurse observes a 2-inch lochia stain on the perineal pad of postpartum client. Which of the following terms should the nurse use to describe the amount of lochia present?
Scant would describe a 1 - 2-inch lochia stain or approx. 10 mL loss. Light describes an approx. 4-inch stain or a 10-25 mL loss. Moderate is a 4-6-inch stain w/approx. 25-50 mL loss. Heavy is pad saturation within an hour after changing it.
A client has been discharges from the hospital after a cesarean birth. Which of the following is the most appropriate time for scheduling a follow-up appointment for the client?
Within 2 weeks of hospital discharge. For clients with an uncomplicated vaginal birth, an office visit is usually scheduled for between 4-6 weeks after childbirth.
