Sherpath: Nursing Care and Education during the Postpartum period
A nurse who is called to a patient's room notes that the patient's cesarean incision has separated. Which action is the highest priority for the nurse to perform?
notify the HCP
what type of exercise should the postpartum woman do?
only light walking for 6 weeks, any other activity will need to be cleared with HCP
what position minimizes pressure on the perineum of a woman with perineal pain?
semi-Fowler or side-lying position to minimize pressure on the perineum and associated pain and edema of the perineal area.
how often should perineal care be done?
should be completed several times per day after voiding or bowel movements by spraying warm water over the perineal area. The woman should gently pat the area dry.
what does it mean if the fundus is displaced to the right of the umbilicus?
the bladder is full
for how long should the nurse assist the woman to the bathroom?
the first 12 to 24 hours because of the possibility of falls.
when should ice packs be applied to the perineum?
the first 24 hours after delivery to decrease edema and to numb pain. Ice packs should be left in place until the ice melts. They should be removed for 10 minutes, and then another ice pack should be applied.
How long can lochia last?
up to 6 weeks
should lactating mothers continue to take their prenatal vitamins?
yes, for as long as they are breastfeeding
what are some elements of nursing care plan for a woman who has had a vaginal birth?
- decreasing pain - fostering healing - promoting comfort - safety - nutrition - hydration - elimination
A nurse has provided discharge instructions to a patient who delivered a healthy infant by cesarean delivery. Which statement made by the patient indicates a need for further instructions?
"I will begin abdominal exercises by week 2."
Which nursing information is appropriate when teaching a postpartum woman about how to increase perineal muscle tone?
"Perform Kegel exercises 30 times per day."
what are some elements of nursing care plan for a woman who has had a cesarean birth?
- decreasing pain - preventing respiratory complications - promoting nutrition - hydration - elimination - preventing gas - promoting activity - preventing thrombophlebitis
increased PO fluid intake can do what for postpartum woman?
- increase peristalsis - decrease constipation - aid in milk production
Which nursing discharge instructions are appropriate to include when teaching a postpartum woman?
- "Increase your fluid intake postpartum." - "Do light walking as tolerated for the first 6 weeks."
Which educational statements are appropriate when preparing a postpartum woman for discharge from a birth center?
- "Notify your health care provider if you begin saturating a pad every hour and pass large clots." - "Perineal self-care should be performed after voiding or defecating." - "Apply breast milk to nipples to relieve dryness."
Which educational information related to activity would the nurse provide to a postpartum woman who delivered by cesarean birth?
- "Stair-climbing should be limited for the first 2 weeks." - "Leg muscles should be used to lift rather than the abdominal muscles."
Which educational information regarding breast care would the nurse provide for a mother who chooses to bottle-feed her infant?
- "Take analgesics as needed for engorgement discomfort." - "Apply ice packs to the breasts for several days."
After a primipara's admission to the labor and delivery suite, the nurse assesses her discharge needs. She will be discharged home 4 days after a cesarean delivery. Which questions would the nurse ask the patient?
- "Will you have help when you go home?" - "Are there many stairs in your home?"
Which postpartum women may require nursing care for ineffective bladder elimination?
- A woman with third-degree perineal laceration and significant edema - A woman who received epidural anesthesia during labor - A woman who delivered by cesarean birth and had an indwelling catheter removed
Which nursing interventions are appropriate when providing care to a woman who is 8 hours postpartum who reports moderate discomfort related to her perineal laceration?
- Apply an ice pack to the perineum. - Place astringent witch hazel pads directly over the perineum. - Administer nonsteroidal antiinflammatory drugs (NSAIDs).
Which nursing interventions can help prevent abdominal distention and gas discomfort for a postpartum woman who delivered by cesarean birth?
- Encourage increased ambulation. - Encourage increased oral (PO) fluid intake. - Discourage the use of drinking straws.
how can you promote healing for a woman with perineal laceration or episiotomy?
- Ice packs should be applied immediately after delivery. - Anesthetic sprays may be used four to six times per day to decrease pain and itching. - Topical astringent pads containing witch hazel may be applied directly to the perineum to decrease pain and inflammation. The woman should use after voiding. - Sitz baths may be used to cleanse and comfort the perineal area. - Women may need assistance voiding. - Stool softeners may be provided to promote bowel movement.
warning signs to report
- Localized area of redness, inflammation, or pain in either breast - Persistent abdominal tenderness - Feelings of pelvic fullness or pressure - Persistent perineal pain - Frequency, urgency, or burning on urination - Abnormal change in character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor) - Localized tenderness, redness, edema, or warmth of the legs - Redness, separation of, or foul drainage from an abdominal incision
Which interventions would the nurse use to assist the postpartum woman who has difficulty voiding?
- Pour warm water over the vulva. - Encourage the woman to urinate in the shower.
medication and vaccine education
- Provide all postpartum women with information about the Tetanus, diphtheria & acellular pertussis vaccine (Tdap) vaccination, as this vaccine is highly encouraged postpartum. - Rh-negative women are given information about Rho(D) immune globulin. - Rubella-nonimmune women should receive information about the rubella vaccination. - Women should be provided education about medications that are administered postpartum.
Which signs and symptoms would the postpartum nurse expect to see in a patient with a wound infection?
- Purulent drainage - Maternal fever greater than 100.4°F (38.0°C) - Redness around incision
suggestions for promoting rest postpartum
- Rest or nap when the newborn is asleep. - Cook simple meals. - Postpone major house projects. - Limit visitors. - Accept help from others.
Which vaccine information is appropriate for a woman with the following prenatal laboratory test results: B-positive blood type, hepatitis B negative, human immunodeficiency virus (HIV) negative, and rubella nonimmune?
- Tetanus, diphtheria & acellular pertussis vaccine (Tdap) - Rubella
Which interventions are appropriate to promote comfort and healing for a woman during the first 24 hours after a cesarean delivery?
- Use intravenous or intramuscular medication for comfort. - Use an incentive spirometer and deep breathing. - Provide extra assistance with newborn care and lactation.
when can postpartum woman have sex again?
- after the cessation of lochia and vaginal/abdominal discomfort. - may take up to 6 weeks
breast care teaching
- lactating mothers should avoid use of soap on breasts, this can cause nipple dryness - if the breast becomes engorged, apply ice packs (on for 15 minutes, off for 45 minutes) between feedings, and continue frequent feedings. Consider antiinflammatory medication to help reduce associated pain and swelling. - Breast milk, lanolin cream, or hydrogel pads may be used after feedings to relieve nipple dryness. - Instruct nonlactating mothers to avoid stimulating the breasts, as this can promote milk production. This includes not allowing hot water to directly touch the breasts while showering and wearing a supportive bra. - Manual manipulation and pumping should also be avoided for nonlactating mothers. - lactating woman should choose bras that are not too tight and that do not have underwires, especially as her milk starts to come in. Underwires on bras can cause pressure points that can lead to soreness, incomplete emptying, and even mastitis. A bra that fits too tightly can impede adequate filling of the breasts.
the 3 stages of the postpartum period are?
1. The first stage is the immediate postpartum period that begins after birth and lasts 24 hours. 2. The next stage is the early postpartum period that begins 24 hours after birth and lasts 1 week. 3. The third stage is the late postpartum period that begins 1 week after discharge and ends 6 weeks postpartum.
the woman should be doing only light housekeeping duties postpartum for how long?
6 weeks
Which nursing intervention is appropriate to help prevent thrombophlebitis in a postpartum woman who delivered by cesarean birth?
Encourage early and frequent ambulation.
The nurse is developing a standard care plan for a mother after a cesarean delivery. Which step would the nurse plan to implement?
Encourage early, frequent ambulation after the surgery.
Forty-eight hours after a patient's cesarean section, she is expressing fear of standing and picking up her newborn. The nurse recognizes these relevant cues and selects a hypothesis that the patient is experiencing which issue?
Knowledge deficit of self-care measures after cesarean section