PrepU Maternity Chapter 22
The nurse is caring for a patient within the first four hours of her cesarean birth. Which of the following nursing interventions would be appropriate to prevent thrombophlebitis? a) Roll a bath blanket or towel and place it firmly behind the knees b) Limit oral intake of fluids for the first 24 hours to prevent nausea c) Assist client in performing leg exercises every two hours d) Ambulate the client as soon as her vital signs are stable
Ambulate the client as soon as her vital signs are stable Explanation: The best prevention for a thrombophlebitis is ambulation as soon as possible after recovery. Options A, B, and C are incorrect.
You administer methylergonovine (Methergine) 0.2 mg to a postpartal woman with uterine subinvolution. Which of the following assessments should you make prior to administering the medication? a) She can walk without experiencing dizziness. b) Her blood pressure is below 140/90. c) Her hematocrit level is over 45%. d) Her urine output is over 50 mL/h.
Her blood pressure is below 140/90. Explanation: Methylergonovine elevates blood pressure. It is important to assess that it is not already elevated before administration.
A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action? a) Administer amoxicillin, as prescribed b) Obtain a clean-catch urine specimen c) Encourage her to drink large amounts of fluid d) Suggest that she take an oral analgesic
Obtain a clean-catch urine specimen Explanation: The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.
When providing care for a postpartum patient at a 6 week check-up, which behavior would alert the nurse the patient may have postpartum psychosis? a) Tearful during appointment b) Talkative and asking questions c) Restless and agitated, concerned with self d) States being tired and happy at same time
Restless and agitated, concerned with self Explanation: When a woman has postpartum psychosis the signs may vary but a woman presenting with restlessness, irritability and concerned only for self needs further evaluation. Therefore options A, B, and D are incorrect...
On the third day postpartum, which temperature is internationally defined as a postpartal infection? a) 104.2°F (40.1°C) b) 99.6°F (37.5°C) c) 102.4°F (39.1°C) d) 100.4°F (38°C)
100.4°F (38°C) Explanation: A temperature over 100.4°F (38°C) past the first day postpartum is suggestive of infection
Which clinical manifestation in a woman with DVT should you report immediately? a) Edema b) Homan's sign c) Pyrexia d) Dyspnea
Dyspnea Explanation: Dyspnea in any patient with a DVT may be an indicator the clot has moved from the original site to the lungs. This is an emergency. A patient who has a DVT would be expected to have a positive Homan's sign, pyrexia, and edema.
Mrs. M. and her infant are being discharged home after an unplanned cesarean delivery. You explain to her that she is at a higher risk for postpartum infection than most patients. What is the major risk factor for a post-partum infection? a) Labor less than 12 hours long. b) A nonelective cesarean birth. c) A planned cesarean birth. d) Labor more than 12 hours long.
A nonelective cesarean birth. Explanation: The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity
A postpartal woman is developing a thrombophlebitis in her right leg. Which of the following assessments would you make to detect this? a) Bend her knee and palpate her calf for pain. b) Ask her to raise her foot and draw a circle. c) Blanch a toe and count the seconds it takes to color again. d) Dorsiflex her right foot and ask if she has pain in her calf.
Dorsiflex her right foot and ask if she has pain in her calf. Explanation: A Homans' sign (pain in the calf on dorsiflexion of the foot) is a common assessment for thrombophlebitis in conjunction with assessing for edema and calf redness. Having her raise her foot and draw a circle would not be an assessment for thrombophlebitis in her leg, nor would assessing capillary refill in a toe
The nurse is assisting with a birth, and the client has just delivered the placenta. Suddenly bright red blood gushes from the vagina. The nurse recognizes that which of the following is the most likely cause of this postpartum hemorrhage? a) Cervical laceration b) Retained placental fragment c) Disseminated intravascular coagulation d) Uterine atony
Cervical laceration Explanation: Lacerations of the cervix are usually found on the sides of the cervix, near the branches of the uterine artery. If the artery is torn, the blood loss may be so great that blood gushes from the vaginal opening. Because this is arterial bleeding, it is brighter red than the venous blood lost with uterine atony. Fortunately, this bleeding ordinarily occurs immediately after detachment of the placenta, when the primary care provider is still in attendance. Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, but there is no evidence for this in the scenario.
The nurse notes that a client's uterus which was firm after the fundal massage has become "boggy." Which intervention would the nurse do next? a) Offer analgesics prescribed by primary care provider b) Check for bladder distention, while encouraging the client to void c) Use semi-Fowler's position to encourage uterine drainage d) Perform vigorous fundal massage for the client
Check for bladder distention, while encouraging the client to void Explanation: If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distension and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform a vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler's position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the primary care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.
A nurse discovers a perineal hematoma in a woman who has recently given birth. Which of the following interventions should the nurse make in this case? (Select all that apply.) a) Administer methotrexate b) Apply an ice pack to the site c) Administer a mild analgesic as prescribed d) Administer an antibiotic e) Estimate the size of the hematoma and report it f) Perform fundal massage
Correct response: • Estimate the size of the hematoma and report it • Administer a mild analgesic as prescribed • Apply an ice pack to the site Explanation: Report the presence of a perineal hematoma, its estimated size, and the degree of the woman's discomfort to her primary care provider. Administer a mild analgesic as prescribed for pain relief. Applying an ice pack (covered with a towel to prevent thermal injury to the skin) may prevent further bleeding. Usually a hematoma is absorbed over the next 3 or 4 days. An antibiotic is not required, as there is no indication of infection. Fundal massage is indicated for uterine atony, and methotrexate is used to destroy retained placental fragments when removal is not possible.
A woman is two weeks postpartum when she calls the clinic and tells the nurse that she has a fever of 101°F. She complains of abdominal pain and a "bad smell" to her lochia. The nurse recognizes that these symptoms are associated with which condition? a) Mastitis b) Endometritis c) Episiotomy infection d) Subinvolution
Endometritis Explanation: The woman with endometritis typically looks ill and commonly develops a fever of 100.4°F (38°C) or higher (more commonly 101°F [38.4°C], possibly as high as 104°F [40°C]) on the third to fourth postpartum day. The rise in temperature at this specific time is the most significant finding. The woman exhibits tachycardia, typically a rise in pulse rate of 10 beats per minute for each rise in temperature of one degree. In addition, the woman may report chills, anorexia, and general malaise. She also may report abdominal cramping and pain, including strong afterpains. Fundal assessment reveals uterine subinvolution and tenderness. Lochia typically increases in amount and is dark, purulent, and foul-smelling. However, with certain microorganisms, her lochia may be scant or absent.
Over 75% of women who give birth experience postpartum depression. a) True b) False
False Explanation: Although almost every woman notices some immediate (1 to 10 days postpartum) feelings of sadness (postpartal "blues") after childbirth, these feelings develop into postpartum depression in about 20%
The majority of women who experience postpartal psychosis had no symptoms of mental illness before pregnancy. A) True b) false
False Explanation: The majority of women who experience postpartal psychosis had symptoms of mental illness before pregnancy.
Which assessment on the third postpartal day would make you evaluate a woman as having uterine subinvolution? a) Her uterus is three finger widths under the umbilicus. b) She experiences "pulling" pain while breastfeeding. c) Her uterus is at the level of the umbilicus. d) Her uterus is 2 cm above the symphysis pubis.
Her uterus is at the level of the umbilicus. Explanation: A uterus involutes at a rate of one finger width daily. On the third postpartal day, it is normally three finger widths below the umbilicus
A nurse is assessing vital signs for a postpartum patient 48 hours after delivery. The vital signs are: Temp 101.2F; HR 82; RR 18; BP 125/78. How will the nurse interpret the vital signs? a) Normal vital signs b) Dehydration c) Infection d) Shock
Infection Explanation: Temperatures elevated above 100.4F 24 hours after delivery are indicative of possible infection. All but the temperature for this patient are within normal limits, so they are not indicative of shock or dehydration
The nurse is performing a postpartum check on a 40-year-old client. Which nursing measure is appropriate? a) Perform the examination as quickly as possible b) Instruct the client to empty her bladder before the examination c) Wear sterile gloves when assessing the pad and perineum d) Place the client in a supine position with her arms overhead for the examination of her breasts and fundus
Instruct the client to empty her bladder before the examination Explanation: An empty bladder facilitates the examination of the fundus. The client should be in a supine position with her 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 aren't necessary. The postpartum examination shouldn't be done quickly. The nurse can take this time to teach the client about the changes in her body after delivery.
Two weeks after their baby is born, Tom calls to report that his wife Sylvia is behaving strangely. She is extremely talkative and energetic and he has not observed her sleeping for more than an hour or two at a time. She is also forgetting to eat and neglecting her appearance, but worse, she seems to barely be aware of the baby's needs and appears surprised when Tom asks her about the child, "As if," Tom says, "she's forgotten that we even have a baby!" You tell him to bring her in right away, because you suspect Sylvia is suffering from what condition? a) Maladjustment b) Postpartum psychosis c) Postpartum blues d) Postpartum depression
Postpartum psychosis Explanation: Postpartum psychosis can present with a patient in extreme mood changes and odd behavior. Her sudden change in behavior from normal and lack of self care and care for the infant are a sign of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact. Postpartum blues is a transitory phase of sadness and crying common among postpartum women. Maladjustment is a distracter for this question
A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which of the following conditions? a) Postpartum depression b) Postpartum blues c) Postpartum panic disorder d) Postpartum psychosis
Postpartum psychosis Explanation: The client's signs and symptoms suggest that the the client has developed postpartum psychosis. Postpartum psychosis is characterized by clients exhibiting suspicious and incoherent behavior, confusion, irrational statements, and obsessive concerns about the baby's health and welfare. Delusions, specific to the infant, are present. Sudden terror and a sense of impending doom are characteristic of postpartum panic disorders. Postpartum depression is characterized by a client feeling that her life is rapidly tumbling out of control. The client thinks of herself as an incompetent parent. Emotional swings, crying easily--often for no reason, and feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristics of postpartum blues.
Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma? a) Risk for impaired urinary elimination b) Deficient fluid volume c) Ineffective tissue perfusion d) Impaired tissue integrity
Risk for impaired urinary elimination Explanation: In addition to risk for injury and pain, another appropriate nursing diagnosis would be risk for impaired urinary elimination related to pressure from the hematoma on urinary structures. Ineffective tissue perfusion and impaired tissue integrity are nursing diagnoses associated with postpartum lacerations. Deficient fluid volume is a nursing diagnoses associated with postpartum hemorrhage.
Which recommendation should be given to a client with mastitis who's concerned about breast-feeding her neonate? a) She should stop breast-feeding until completing the antibiotic b) She should continue to breast-feed; mastitis won't infect the neonate c) She should supplement feeding with formula until the infection resolves d) She shouldn't use analgesics because they aren't compatible with breastfeeding
She should continue to breast-feed; mastitis won't infect the neonate Explanation: The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding doesn't need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed
Which situation should concern the nurse treating a postpartum client within a few days of delivery? a) The client is nervous about taking the baby home b) The client would like the nurse to take her baby to the nursery so she can sleep c) The client feels empty since she delivered the neonate d) The client would like to watch the nurse give the baby her first bath
The client feels empty since she delivered the neonate Explanation: A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and wouldn't be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery
Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? a) Hemoglobin level of 12 g/dl b) Moderate amount of lochia rubra c) Thrombophlebitis d) Uterine atony
Uterine atony Explanation: Multiparous women typically experience a loss of uterine tone due to frequent distentions of the uterus from previous pregnancies. As a result, this client is also at higher risk for hemorrhage. Thrombophlebitis doesn't increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits.
A fundal massage is sometimes performed on a postpartum woman. Which of the following is a reason for performing a fundal massage? a) Uterine subinvolution b) Uterine contraction c) Uterine prolapse d) Uterine atony
Uterine atony Explanation: Fundal massage is performed for uterine atony, which is failure of the uterus to contract and retract after birth. The nurse would place the gloved dominant hand on the fundus and the gloved nondominant hand on the area just above the symphysis pubis. Using a circular motion, the nurse massages the fundus with the dominant hand. Then the nurse checks for firmness and, if firm, applies gentle downward pressure to express clots that may have accumulated. Finally the nurse assists the woman with perineal care and applying a new perineal pad.
A nurse is assigned to care for a client with a uterine prolapse. Which of the following would be most important for the nurse to assess when determining the severity of the prolapse? a) Uterine bleeding present b) Pain in the lower abdomen c) Foul smelling lochia d) Uterine protrusion into the vagina
Uterine protrusion into the vagina Explanation: To determine if the uterine prolapse in the client is mild or severe, the nurse should assess for uterine protrusion of the cervix and uterus into the vagina. As more of the uterus descends, the vagina becomes inverted. Uterine bleeding, foul-smelling lochia, and pain or tenderness in the lower abdomen are all characteristic manifestations of late postpartum hemorrhage
When caring for a client with postpartum blues, which intervention would be most appropriate? a) Validate the client's emotions, allowing her to express them freely b) Administer antidepressants as prescribed to lessen postpartum blues c) Recommend the client to a support group or to a mental health professional d) Avoid allowing contact between the newborn and the client
Validate the client's emotions, allowing her to express them freely Explanation: When caring for a client with postpartum blues, the nurse should validate the client's emotions and allow the client to express them freely. The nurse should not administer antidepressants to the client since these drugs are administered only during depression, postpartum or otherwise. Recommending the client to a support group or a mental health professional is not an appropriate intervention when caring for a client with postpartum blues. The nurse need not avoid contact between the mother who is experiencing postpartum blues and her infant