Nursing Management of the Postpartum Woman at Risk

Nursing Management of the Postpartum Woman at Risk 1. Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? # Perform hand washing before breastfeeding § As a primary preventive measure to prevent mastitis, the nurse should instruct the client to perform good handwashing before breastfeeding. The nurse should instruct the client to frequently breastfeed to prevent engorgement and milk stasis. If the breast is distended before feeding, the nurse should instruct the client to apply cold (not warm) moist heat to the breast. Gently massaging the affected area of the breast also helps. 2. Two weeks after giving birth, a woman is feeling sad, hopeless, and guilty because she cannot take care of the infant and partner. The woman is tired but cannot sleep and has isolated herself from family and friends. The nurse recognizes that this client is exhibiting signs of: # Postpartum depression § Feeling sad; coping poorly; being overwhelmed; being fatigued, but unable to sleep; and withdrawing for social interactions are signs of postpartum depression. Signs of postpartum blues are similar, but less severe and seen within the first week after birth. It is normal for new mothers to feel overwhelmed and unable to care for her partner, as she did prior to the pregnancy. There is no evidence of lack of partner support in this situation. 3. A client presents to the clinic with a 3-week-old infant reporting general flu-like symptoms and a painful right breast. Assessment reveals temperature 101.8¡F (38.8¡C) and the right breast nipple with a movable mass that is red and warm. The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client? # Complete the full course of antibiotic prescribed, even if you begin to feel better. § Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis, and administering antibiotics for a full 10 to 14 days. The client should empty the breasts every 1.5 to 2 hours to help prevent milk stasis and limit the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing the fluid intake will keep the client wellhydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time. 4. Which recommendation should be given to a client with mastitis who is concerned about breastfeeding her neonate? # She should continue to breastfeed; mastitis will not infect the neonate. § The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings are necessary because breastfeeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed. 5. The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? # Assess the womanÕs fundus § The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered. 6. 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? # ÒItÕs not uncommon after birth for you to have a full bladder even though you canÕt sense the fullness.Ó § 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 care provider at this time as the client is demonstrating common adaptations in the early postpartum period. Allowing the clientÕs bladder to fill for another 2 to 3 hours might cause overdistention. 7. The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize? # Palpate her fundus § The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended. 8. The nurse reviews the history of a postpartum woman G3P3 and notes it is positive for obesity and smoking. The nurse would be especially alert for the development of signs and symptoms of which complication in this client? # Deep venous thrombosis § Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 34), and multiparity. 9. Which assessment would lead the nurse to believe a postpartum woman is developing a urinary complication? # At 8 hours postdelivery she has voided a total of 100 mL in four small voidings. § Postpartum women who void in small amounts may be experiencing bladder overflow from retention. 10. The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurseÕs explanation of care? # ÒI can continue breastfeeding my infant, but it may be somewhat uncomfortable.Ó § Breastfeeding on antibiotics for mastitis is fine, and the mother is encouraged to empty the infected breast to prevent milk stasis. However, the nurse should prepare the mother for the process being somewhat painful because the breast is tender. It is recommended to start the infant nursing on the uninvolved breast first as vigorous sucking may increase the mother's pain. Unless contraindicated by the antibiotic, the breast milk will be stored for later if the mother needs to pump her breasts; she does not need to throw the milk away. 11. A nurse is caring for a client in the postpartum period. When observing the clientÕs condition, the nurse notices that the client tends to speak incoherently. The clientÕs thought process is disoriented, and they frequently indulge in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? # Postpartum psychosis § The clientÕs signs and symptoms suggest that 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 babyÕs 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 life is rapidly tumbling out of control. The client thinks of oneself as an incompetent parent. Emotional swings, crying easilyÑoften for no reasonÑand feelings of restlessness, fatigue, difficulty sleeping, headache, anxiety, loss of appetite, decreased ability to concentrate, irritability, sadness, and anger are common findings are characteristic of postpartum blues. 12. The nurse is teaching a client about mastitis. Which statement should the nurse include in her teaching? # Symptoms include fever, chills, malaise, and localized breast tenderness. § Mastitis is an infection of the breast characterized by flu-like symptoms, along with redness and tenderness in the breast. The most common causative agent is Staphylococcus aureus. Breast abscess is rarely a complication of mastitis if the client continues to empty the affected breast. Mastitis usually occurs in one breast, not bilaterally. 13. A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider? # Weak and rapid pulse § Excessive hemorrhage puts the client at risk for hypovolemic shock. Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted. 14. Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? # ÒTry applying warm compresses to your breasts to encourage the milk to be released.Ó § Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present. 15. Which factor puts a multiparous client on her first postpartum day at risk for developing hemorrhage? # Uterine atony § 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 does not increase the risk of hemorrhage during the postpartum period. The hemoglobin level and lochia flow are within acceptable limits. 16. Which situation should concern the nurse treating a postpartum client within a few days of birth? # The client feels empty since she gave birth to the neonate. § 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 would not be cause for concern. Many firsttime 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. 17. A client has had a cesarean birth. Which amount of blood loss would the nurse document as a postpartum hemorrhage in this client? # 1000 ml § Postpartum hemorrhage is defined as blood loss of 500 ml or more after a vaginal birth and 1000 ml or more after a cesarean birth. 18. A nurse is caring for a client who has had an intrauterine fetal death with prolonged retention of the fetus. For which signs and symptoms should the nurse watch to assess for an increased risk of disseminated intravascular coagulation? Select all that apply. # Bleeding gums # Tachycardia # Acute renal failure § The nurse should monitor for bleeding gums, tachycardia, and acute renal failure to assess for an increased risk of disseminated intravascular coagulation in the client. The other clinical manifestations of this condition include petechiae, ecchymosis, and uncontrolled bleeding during birth. Hypotension and amount of lochia greater than usual are findings that might suggest a coagulopathy or hypovolemic shock. 19. The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? # Drop in estrogen and progesterone levels after birth § Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology. 20. The nurse inspects the client's perineum and finds it is red, swollen, and tender. The nurse explains to the client that she needs to be monitored for blood loss, especially because of bleeding into the tissue of the perineum because of the third degree laceration sustained while giving birth. What parameters will the nurse assess to detect signs of additional blood loss? Select all that apply. # Urine output # Blood pressure # Pulse rate § Assessment findings consistent with blood loss are increased pulse rate, decreased blood pressure, and decreased urine output. Bleeding into the perineal tissue may not be visible, therefore monitoring these parameters is important. Because bleeding is related to the laceration, uterine involution is not impacted and the assessment of the fundus is not going to provide useful data. Similarly, the amount of lochia will not provide useful data about bleeding into the perineal tissue. 21. A postpartum woman is developing a thrombophlebitis in her right leg. Which assessments would the nurse make to detect this? # Assess for pedal edema § Calf swelling, erythema, warmth, tenderness, and pedal edema may be noted and are caused by an inflammatory process and obstruction of venous return. 22. A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? # Administration of platelet transfusions as prescribed § When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho(D) are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction. 23. The nurse collects a urine specimen for culture from a postpartum woman with a suspected urinary tract infection. Which organism would the nurse expect the culture to reveal? # Escherichia coli § E. coli is the most common causative organism for urinary tract infections. S. aureus is the most common causative organism for mastitis. G. vaginalis is a common cause of metritis. K. pneumoniae is a common cause of endometritis, but some species of Klebsiella may cause urinary tract infections. 24. A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? # Calf swelling § The nurse should monitor the client for swelling in the calf. Swelling in the calf, erythema, and pedal edema are early manifestations of deep vein thrombosis, which may lead to pulmonary embolism if not prevented at an early stage. Sudden change in the mental status, difficulty in breathing, and sudden chest pain are manifestations of pulmonary embolism, beyond the stage of prevention. 25. A 25-year-old nulliparous client presents in active labor. She has had no prenatal care, and her coagulation status is determined. Which result would the nurse identify as placing the client at risk for postpartum hemorrhage? # Activated partial thromboplastin time 60 seconds § Activated partial thromboplastin time of 60 seconds is increased and suggestive of a coagulopathy. The platelet count, prothrombin time, and INR are within normal parameters. 26. The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder? # Postpartum psychosis § Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs 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. 27. What would the nurse use to monitor the effectiveness of intravenous anticoagulant therapy for a postpartum woman with deep vein thrombosis? # Activated partial thromboplastin time § The activated partial thromboplastin time is used to monitor the effectiveness of intravenous anticoagulant therapy, most commonly heparin. Prothrombin time is used to monitor the effectiveness of the oral anticoagulant warfarin. Although platelets and fibrinogen are involved in blood clotting, they are not used to monitor the effectiveness of intravenous anticoagulant therapy. 28. A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? # Check the lochia § The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4¡ F (38¡ C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus. 29. A woman arrives at the office for her 4-week postpartum 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 § Subinvolution is incomplete return of the uterus to its prepregnant size and shape. With subinvolution, at a 4- or 6-week postpartal visit, the uterus is still enlarged and soft. Lochial discharge usually is still present. The symptoms in the scenario are closest to those of subinvolution. 30. A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. # Inability to concentrate # Loss of confidence # Decreased interest in life § The nurse should monitor the client for symptoms such as inability to concentrate, loss of confidence, and decreased interest in life to verify the presence of postpartum depression. Manifestations of mania and bizarre behavior are noted in clients with postpartum psychosis. 31. A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? # Uterine atony § 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. 32. Manual manipulation is used to reposition the uterus of a client experiencing uterine inversion. After the repositioning, which type of medication would the nurse administer as prescribed to the client? # Oxytocin agent § The nurse should administer a prescribed oxytocin agent to the client after repositioning the uterine fundus because it causes uterine contractions preventing reinversion and decreasing blood loss. The nurse should administer prescribed medications such as magnesium sulfate, indomethacin, and nifedipine, which are uterine relaxants that help in the repositioning of the uterus. These drugs are administered during the repositioning of the uterus and not after in case of uterine inversion. 33. What postpartum client should the nurse monitor most closely for signs of a postpartum infection? # A client who had a nonelective cesarean birth § 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. The other listed factors are not noted risk factors for infection. 34. A postpartum woman is being discharged with anticoagulant therapy for treatment of deep vein thrombosis. After teaching the woman about this therapy, the nurse determines that the teaching was successful based on which statement? # ÒI need to apply pressure to any cut for 5 to 10 minutes.Ó § Anticoagulant therapy increases the woman's risk for bleeding. The statement about applying pressure to a cut would be correct. The woman should use an electric razor for shaving and avoid aspirin-containing products while on anticoagulant therapy. Black stools are not expected but indicate bleeding and should be reported. 35. Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts? # Applying ice § Women who do not breastfeed often experience moderate to severe engorgement and breast pain when no treatment is applied. Ice promotes comfort by decreasing blood flow (vasoconstriction), numbing the area, and discouraging further letdown of milk. Restricting fluids does not reduce engorgement and should not be encouraged. Warm compresses will promote blood flow and hence, milk production, worsening the problem of engorgement. Bromocriptine has been removed from the market for lactation suppression. 36. The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about risk factors for mastitis. Which condition would the nurse most likely include in the response? # Pierced nipple § Certain risk factors contribute to the development of mastitis. These include inadequate or incomplete breast emptying during feeding or lack of frequent feeding leading to milk stasis; engorgement; clogged milk ducts; cracked or bleeding nipples; nipple piercing; and use of plastic-backed breast pads. 37. The nurse is assigned to care for a postpartum client with a deep vein thrombosis (DVT) who is prescribed anticoagulation therapy. Which statement will the nurse include when providing education to this client? # ÒYou need to avoid medications which contain acetylsalicylic acid.Ó § The nurse should caution the client to avoid products containing acetylsalicylic acid, or aspirin, and other nonsteroidal anti-inflammatory medications while on anticoagulation therapy. These medications inhibit the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. Hematuria is not expected and indicates internal bleeding. The client would be instructed to notify the primary health care provider for any prolonged bleeding. The client may not be able to breastfeed while taking anticoagulation medications. Warfarin is not thought to be excreted in breastmilk; however, most medications are excreted in breast milk. Therefore, breastfeeding is generally not recommended for the client on anticoagulation therapy. 38. An Rh-positive client gives birth vaginally to a 6 lb, 10 oz (3,005 g) neonate after 17 hours of labor. Which condition puts this client at risk for infection? # Length of labor § The prolonged length of labor places the mother at increased risk for developing an infection. The average size of the neonate, the vaginal birth, and Rh status of the client do not place this mother at increased risk. 39. One of the primary assessments a nurse makes every day is for postpartum hemorrhage. What does the nurse assess the fundus for? # Consistency, shape, and location § Assess the fundus for consistency, shape, and location. Remember that the uterus should be firm, in the midline, and decrease 1 cm each postpartum day. 40. The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client? # Anticoagulants § The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Opioid analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation. 41. It is discovered that a new mother has developed a postpartum infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? # Client's temperature remains below 100.4¡F (38.8¡C) orally. § As fever would accompany a postpartum infection, a likely expected outcome would be to reduce the client's temperature and keep it in a normal range. The other expected outcomes do not pertain as directly to postpartum infection as does the reduced temperature.