PostPartum/Newborn
Two days after having a cesarean birth, a client tells a nurse that she has pain in her right leg, and after an assessment the nurse suspects that the client has a thrombus. What is the nurse's initial response? 1. Maintain bedrest. 2. Apply warm soaks. 3. Perform leg exercises. 4. Massage the affected area.
Correct 1. Maintain bedrest. Although thrombophlebitis is suspected, before a definitive diagnosis the client should be confined to bed so that further complications may be avoided. Applying warm soaks may cause vasodilation, which could allow a thrombus to dislodge and circulate freely. If a thrombus is present, massage may dislodge it and lead to a pulmonary embolism.
A nurse is assessing several postpartum clients. Which conditions increase the risk for postpartum hemorrhage? Select all that apply. 1. Twin birth 2. Overdistended bladder 3. Hypertonic uterine dystocia 4. Retained placental fragments 5. Mild gestational hypertension
Correct 1. Twin birth 2. Overdistended bladder 4. Retained placental fragments Overdistention of the uterus may lead to delayed or inadequate uterine contractions. An overdistended bladder may inhibit uterine contractions. Retained placental fragments inhibit uterine contractions. Clients with ineffective uterine contractions are treated with rest and sedatives; although labor is prolonged, postpartum hemorrhage is not expected. Mild gestational hypertension does not interfere with uterine involution.
While caring for a client who gave birth 1 day ago, the nurse determines that the client's uterine fundus is firm at one fingerbreadth below the umbilicus, blood pressure is 110/70 mm Hg, pulse is 72 beats/min, and respirations are 16 breaths/min. The client's perineal pad is saturated with lochia rubra. What is the priority nursing action? 1. Recording these expected findings 2. Obtaining a prescription for an oxytocic medication 3. Asking the client when she last changed the perineal pad 4. Notifying the primary health care provider that the client may be hemorrhaging
Correct 3. Asking the client when she last changed the perineal pad The amount of lochia would be excessive if the pad were saturated in 15 minutes; saturating the pad in 2 hours is considered heavy bleeding. If the pad has not been changed for a longer period, this could account for the large quantity of lochia. These findings cannot be supported without additional information. Oxytocics are administered for uterine atony; the need for this is not supported by the assessment of a firm fundus. The vital signs do not indicate hemorrhage; further assessment is needed before the nurse comes to this conclusion.
A primigravida client gave birth in a vaginal delivery 24 hours ago. Which findings would be considered normal? 1. Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present 2. Fundus firm, one fingerbreadth above the umbilicus; scant lochia alba; voided twice, 500 mL, 400 mL; breasts heavy 3. Fundus firm, two fingerbreadths above the umbilicus; moderate lochia serosa; voided once, 200 mL; colostrum present 4. Fundus firm, 2 fingerbreadths below the umbilicus; moderate serosa alba; voiding quantity sufficient; breasts engorged
Correct 1 Fundus firm at the umbilicus; moderate lochia rubra; voiding quantity sufficient; colostrum present. Twenty-four hours after delivery, the fundus is usually at the umbilicus and moderate lochia rubra is expected. Colostrum is present, and the breast milk usually comes in on day 3 after delivery. A fundus two fingerbreadths above the umbilicus may indicate a full bladder, and lochia serosa occurs during days 4 through 10. Voiding just 200 mL since delivery is inadequate. The presence of colostrum is normal. A fundus that is firm at two fingerbreadths under the umbilicus is acceptable, but lochia alba occurs after the 10th postpartum day. The milk would have had to come in for the breasts to be engorged, which does not typically occur until day 3. Scant lochia alba would not occur until day 10; nor would the milk supply be established.