Ricci, Kyle & Carman: Maternity and Pediatric Nursing, Second Edition: Chapter 16: Nursing Management During the Postpartum Period; prep u

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 working with the parents of a newborn. 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." 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 postpartal woman has a history of thrombophlebitis. Which action would help the nurse determine if she is developing this postpartally?

Assess for calf redness and edema. Calf redness and edema, especially at the ankle and along the tibia, suggest thrombophlebitis.

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 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.

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.

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.

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 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 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.

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 client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition?

Offer suggestions based on observation to correct positioning or latching. The nurse should observe positioning and latching-on technique while breastfeeding so that she may offer suggestions based on observation to correct positioning/latching. This will help minimize trauma to the breast. The client should use only water, not soap, to clean the nipples to prevent dryness. Breast pads with plastic liners should be avoided. Leaving the nursing bra flaps down after feeding allows nipples to air dry.

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.

The nurse can expect a patient who had a cesarean birth to have less lochia discharge than the patient who had a vaginal birth.

True Women who had a cesarean birth will have less lochia discharge than those who had a vaginal birth, but stages and color changes remain the same.

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 mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply.

crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep.

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.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman?

encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure.

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 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.

When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel?

fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.

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 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.

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.

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.

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.

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.

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.

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 client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated?

"It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention.