Test 5: Postpartum
A client with a newly diagnosed puerperal infection asks the nurse to explain this condition. The nurse correctly defines the condition as which of the following?
An infection in the genital tract of a postpartum client
You are admitting a patient who delivered a baby five days ago to your unit. She is being admitted with the diagnosis of a perineal infection. What can you do to provide comfort measures for this patient?
Place warm compresses to the infection site several times daily.
A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?
improves pelvic floor tone
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.)
• Estimate the size of the hematoma and report it • Administer a mild analgesic as prescribed • Apply an ice pack to the site
After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?
"Postpartum depression develops gradually, appearing within the first 6 weeks."
Your patient delivered six hours ago. She calls you to her room complaining of pain "deep inside." You medicate her per orders with no relief attained. You check her vital signs and find they are markedly different then when the CNA charted them 30 minutes ago. What would you suspect?
Pelvic hematoma
A nurse suspects that a client may be developing disseminated intravascular coagulation. The woman has a history of abruptio placenta during birth. Which finding would help to support the nurse's suspicion?
appearance of petechiae
A nurse is caring for a client in the postpartum period. The client is emotionally sensitive, feels a sense of failure, and attempts to hurt herself and the baby. The nurse understands that the client is exhibiting symptoms of which condition?
postpartum depression
Which of the following is a cause of retinopathy of prematurity (ROP)? Select all that apply.
• Oxygen saturation maintained above 95% • Presence of immature retinal blood vessels
Timeline of Postpartum mental risks:
Depression: within first 6 weeks Postpartum blues: 4-5 days PP, resolves by 10th day Psychosis: by 3 weeks of birth.
A female client who has very recently given birth arrives at a health care center complaining of painful urination. Assessment also reveals that the client has a temperature of 102 degrees Fahrenheit. The physician suspects the client has pyelonephritis. Which of the following would the nurse expect to assess? Select all that apply.
• Flank pain • Chills • Anorexia
While visiting a client at home on the 10th day postpartum, the nurse assesses the client's lochia. Which color would the nurse expect the lochia to be?
yellowish white
As part of an inservice program to a group of home health care nurses who care for postpartum women, a nurse is describing postpartum depression. The nurse determines that the teaching was successful when the group identifies that this condition becomes evident at which time after birth of the newborn?
within the first 6 weeks
A client is experiencing postpartum hemorrhage, and the nurse begins to massage her fundus. Which action would be most appropriate for the nurse to do when massaging the woman's fundus?
Wait until the uterus is firm to express clots.
A 26-year-old new mother says to her nurse, "I am so disappointed. I gained 25 pounds with my baby. Just what the doctor said I should gain. But after I had my baby I only lost 12 pounds." What is the best response by the nurse?
"It is normal to lose between 12 and 14 pounds after the baby delivers. You should be back to your pre-pregnancy weight by the time your baby is about 6 months old."
The woman adapts to her new role as mother through a series of four developmental stages:
1. Beginning attachment and preparation for the infant during pregnancy 2. Increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period 3. Moving toward a new normal in the first four months 4. Achieving a maternal identity around four months (less)
On the third day postpartum, which temperature is internationally defined as a postpartal infection?
100.4° F (38° C) A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.
A nurse is caring for a client with peritonitis. Which of the following interventions should the nurse perform when caring for this client?
Regulate client's body temperature
In which time period would the nurse expect a client who has given birth to twins to experience late postpartum hemorrhage?
24 hours to 12 weeks after birth
When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as the most common cause?
Retained placental fragments
A 29-year-old postpartum client is receiving anticoagulant therapy for deep venous thrombophlebitis. The nurse should include which instructions in her discharge teaching?
Avoid over-the-counter (OTC) salicylates.
A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy?
Avoid products containing aspirin.
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?
Check for bladder distention, while encouraging the client to void.
A postpartal woman with a thrombophlebitis tells you that her leg is very painful. Which of the following actions would be most appropriate to relieve this pain?
Keep covers off the leg.
A woman arrives at the office for her 4-week postpartal visit. Her uterus is still enlarged and soft, and lochial discharge is still present. Which nursing diagnosis is most likely for this client?
Risk for fatigue related to chronic bleeding due to subinvolution
Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?
Risk for impaired urinary elimination
When assessing a client who is 5 days pospartum, which of the following would alert the nurse to suspect that the client is experiencing late postpartum hemorrhage?
Rubra colored lochia
One of your laboring patients has experienced a fetal demise due to a true knot in the cord. You overhear the woman's mother-in-law tell your patient that this is her fault because she was "too active" during the last trimester of her pregnancy. You are very angry about what the mother-in-law said. What would be helpful for you to do?
Talk over your feeling with a coworker.
The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?
blood pressure, pulse, reports of dizziness
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 occurrence is the most likely cause of this postpartum hemorrhage?
cervical laceration
When describing the hormonal changes that occur after birth of a newborn, the nurse would identify a decrease in which hormone as being associated with breast engorgement?
estrogen
A Hispanic client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?
uterine atony
Which complication is most likely responsible for a late postpartum hemorrhage?
uterine subinvolution
The nurse assesses a postpartum woman for thromboembolism based on the understanding that her risk is increased because of which factor?
vessel damage during birth
Which of the following would the nurse expect to assess in a client to verify the development of hypovolemic shock? Select all that apply.
• Tachycardia • Cold, clammy skin • Extreme thirst
Which of the following instructions should a nurse give to a mother who is feeding an infant formula? Select all that apply.
• Tilt the bottle so that the nipple fills with formula • Interact with the infant during the feeding sessions • Hold the infant semi-upright and close to promote eye contact
A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.
• uterine infection • prolonged labor • hydramnios
A client and her infant are being discharged home after an unplanned cesarean birth. The nurse explains to her that she is at a higher risk for postpartum infection than most clients. What is the major risk factor for a postpartum infection?
a nonelective cesarean birth
When teaching a postpartum woman about possible complications during this time, the nurse would include information about which possible effect?
interference with the maternal-newborn attachment process
Uterine atony, or the inability of the uterus to effectively contract, has four major causes. What is one of them?
laceration of the cervix
A complication of abruptio placentae: disseminated intravascular coagulation (DIC) is
manifested by petechiae, ecchymoses, and other signs of impaired clotting
Disseminated intravascular coagulation is typically associated with
* premature separation of the placenta * a missed early miscarriage * fetal death
The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount?
500 mL 500 mL - vaginal birth 1000 mL - cesarean birth
Which of the following would lead the nurse to suspect that a postpartum client is experiencing hypovolemic shock?
Cyanosis and oliguria Cyanosis results from vasoconstriction and red blood cell loss, leading to a decreased level of hemoglobin available for oxygen transport. Oliguria indicates decreased renal perfusion.
A postpartum client tells the nurse that she feels like crying for no apparent reason and is unable to sleep well. Which of the following should the nurse identify as the most likely cause of the patient's condition?
Decreased progesterone levels
A nurse is caring for a pregnant client. The client has been diagnosed with uterine fibroids. The nurse knows that which of the following is likely to occur in this client in the postpartum period?
Postpartum hemorrhage
The nurse receives a report on a client with type 1 diabetes mellitus whose delivery was complicated by polyhydramnios and macrosomia. The nurse is aware of these complications and knows to monitor the client closely for which of the following?
Postpartum hemorrhage
Your patient is showing signs and symptoms of a pulmonary embolism. What should you do?
Raise the head of the bed to at least 45 degrees.
A puerperal infection is
an infection of the genital tract after delivery through the first 6 weeks postpartum.
The nurse is assisting in developing a care plan for a client who had an episiotomy. Which interventions would be included for the nursing diagnosis Acute pain related to perineal sutures? Select all that apply:
• Administer sitz baths three to four times per day • Encourage the client to do Kegel exercises
On examining a client who gave birth 3 hours ago, the nurse finds that the client has completely saturated a perineal pad within 15 minutes. Which actions should the nurse take? Select all that apply:
• Assess the client's vital signs • Palpate the client's fundus
What is the responsibility of the registered nurse (RN) after the delivery of the newborn? (Select all that apply.)
• Assessing the gestational age. • Identifying potential complications. • Initiating the plan of care.
The nurse administers methylergonovine 0.2 mg to a postpartal woman with uterine subinvolution. Which assessment should the nurse make prior to administering the medication?
Her blood pressure is below 140/90 mm Hg.
A client with postpartum hematoma is admitted to a local healthcare facility. Which of the following would the nurse assess as characteristic of this condition?
Rectal pressure
A nurse is caring for a client on her third postpartum day. The nurse identifies a foul-smelling lochia suggesting endometritis? The nurse would also expect to assess an elevation in which of the following?
Temperature
Which factors affect a woman's decision to breastfeed? Select all that apply.
• Culture • Socioeconomic • Work status • Family • Past experience
A nurse is caring for a client with a postpartum laceration. Which nursing diagnoses would be most appropriate? Select all that apply.
• Ineffective tissue perfusion • Risk for injury • Impaired tissue integrity
