Chapter 16 Nursing Management During the Postpartum Period

Chapter 16 Nursing Management During the Postpartum Period 1. 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. 2. 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. 3. A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? ‣ Oral temperature 100.8¡ F (38.2¡ C) ➡ A temperature above 100.4¡ F (38¡ C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. Abnormal temperature readings warrant continued monitoring until an infection can be ruled out through cultures or blood studies. A pulse rate of 75 beats/minute, respiratory rate of 16 breaths/minute, and a fundus 1 cm below the umbilicus are normal findings. 4. 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. 5. 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. 6. The nurse who works on a postpartum floor is mentoring a new graduate. She informs the new nurse that a postpartum assessment of the mother includes which assessments? Select all that apply. ‣ Vital signs of mother ‣ ‣ Pain level Head-to-toe assessment ➡ Postpartum assessment of the mother usually includes vital signs, pain level, and a systematic head-to-toe assessment of the mother. The others are care of the newborn and done by the nurse in the nursery. 7. When palpating for fundal height on a postpartum woman, which technique is preferable? ‣ Placing one hand at the base of the uterus, one on the fungus ➡ Supporting the base of the uterus before palpation prevents the possibility of uterine inversion with palpation. 8. At the 6-week visit following delivery of her infant, a postpartum client reports extreme fatigue, feelings of sadness and anxiety, and insomnia. Based on these assessment findings, the nurse documents that the client is exhibiting characteristics of: ‣ Postpartum depression ➡ Extreme fatigue, feelings of sadness and anxiety, and insomnia are consistent with a diagnosis of postpartum depression. Postpartum blues occurs in the first week after birth. Postpartum psychosis is a psychiatric emergency in which symptoms of high mood and racing thoughts (mania), depression, severe confusion, loss of inhibition, paranoia, hallucinations, and delusions present following a birth. Postpartum adjustment is a positive coping experience in which the woman transitions to the role of mother. 9. A woman states that she still feels exhausted on her second postpartum day. The nurse's best advice for her would be to do which action? ‣ Walk with the nurse the length of her room ➡ Most women report feeling exhausted following birth. Ambulation is important, however, so a small amount, such as walking across a room, should be encouraged. 10. 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. 11. The new mother has decided to feed her infant formula. When teaching her about the different types of formula, the nurse should stress the infant should receive how many calories each day? ‣ 650 calories ➡ Newborns need about 108 cal/kg or approximately 650 cal/day. Therefore, they will need 2 to 4 ounces at each feeding to feel satisfied. Until about 6 months, most bottle-fed infants need six feedings a day. 12. A nurse is assessing the vital signs of a woman who delivered a healthy newborn vaginally 2 hours ago. Which temperature reading would lead the nurse to notify the health care provider? ‣ 100.8¡F (38.2¡C) ➡ Typically, the new motherÕs temperature during the first 24 hours postpartum is within the normal range or a low grade elevation. Some women experience a slight fever, up to 100.4¡F (38.0¡C), during the first 24 hours. However, A temperature above 100.4¡F (38.0¡C) at any time or an abnormal temperature after the first 24 hours may indicate infection and must be reported. 13. 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. 14. The nurse is planning care for a client at risk for postpartum depression. Which statement regarding postpartum depression does the nurse need to be aware of when attempting to formulate a plan of care? ‣ Symptoms of postpartum depression can easily go undetected. ➡ The plan of care should acknowledge that symptoms of postpartum depression are often missed and go undetected (and therefore untreated). Postpartum blues occur within the first week after birth. Postpartum depression can develop after any pregnancy and can be assessed by providers in a variety of settings. 15. During a routine assessment the nurse notes the postpartum client is tachycardic. What is a possible cause of tachycardia? ‣ Delayed hemorrhage ➡ Tachycardia in the postpartum woman can suggest anxiety, excitement, fatigue, pain, excessive blood loss or delayed hemorrhage, infection, or underlying cardiac problems. Further investigation is always warranted to rule out complications. An inability to void would suggest bladder distention. Extreme diaphoresis would be expected as the body rids itself of excess fluid. Uterine atony would be associated with a boggy uterus and excess lochia flow. 16. 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: ‣ ÒRho(D) immune globulin suppresses antibody formation in a woman with Rh-negative blood who gave birth to a baby with Rh-positive blood.Ó ➡ 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. 17. A woman gave birth yesterday to a child with a cleft palate. The newborn is in the special care nursery, and the mother has seen the newborn only at birth. Which intervention would be the priority? ‣ Provide time for the mother to grieve for the loss of the imagined baby. ➡ Grief is the response to loss. The process of mourning will take precedence over the motherÕs self-care in this initial period. The nurse will assess the mother to note her physical condition, but the mother will be focused on the child. The mother can be assisted to determine the appropriate time to see the child, and then attachment can be promoted. 18. 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. 19. 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/d (105 g/L). Precipitous labor of less than 3 hours and multiparty of more than three births closely spaced place a woman at risk for postpartum hemorrhage. 20. Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? ‣ An absence of lochia ➡ Women should have a lochia flow following birth. Absence of a flow is abnormal; it suggests dehydration from infection and fever. 21. Seven hours ago, a multigravida woman gave birth to a male infant weighing 4,133 g. She has voided once and calls for a nurse to check because she states that she feels Òreally wetÓ now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: ‣ Assess and massage the funds ➡ This woman is a multigravida who gave birth to a large baby and is at risk for hemorrhage. The other actions are to be done after the initial fundal massage. 22. A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? ‣ ÒI only eat a low-fiber diet.Ó ➡ Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function. 23. A postpartum client has decided to bottle feed her newborn. After teaching the woman about it, the nurse determines that the teaching was successful based on which client statement(s)? Select all that apply. ‣ ÒI will be sure not to use the microwave to warm the formula.Ó ‣ ÒI will make sure the nipple and neck of the bottle are filled with formula during a feeding.Ó ‣ ÒI will get my newborn to suck by touching the nipple to the lips.Ó ➡ Teaching about bottle feeding should include the following: mixing powdered formula with room temperature water to allow better mixing and quicker dissolution of lumps; storing any formula prepared in advance in the refrigerator to keep bacteria from growing but discarding any formula not taken during a feeding; making sure that the nipple and neck of the bottle are always filled with formula to prevent the newborn from taking in too much air; and stimulating the sucking reflex by placing the nipple to the newborn's lips. 24. When teaching the new mother about breastfeeding, the nurse is correct when providing what instructions? Select all that apply. ‣ Help the mother initiate breastfeeding within 30 minutes of birth. ‣ Encourage breastfeeding of the newborn infant on demand. ‣ Place baby in uninterrupted skin-to-skin contact (kangaroo care) with the mother. ➡ The nurse should show mothers how to initiate breastfeeding within 30 minutes of birth. To ensure bonding, place the baby in uninterrupted skin-to-skin contact with the mother. Breastfeeding on demand should be encouraged. Pacifiers do not help fulfill nutritional requirements and are not a part of breastfeeding instruction. The nurse should also ensure that no food or drink other than breast milk is given to newborns. 25. During the discharge planning for new parents, what would the case manager do to help provide the positive reinforcement and ensure multiple assessments are conducted? ‣ Schedule home visits for high-risk families ➡ To help promote parental role adaptation and parentÐnewborn attachment, there are several nursing interventions that can be undertaken. They can include home visits for high-risk families, monitor the parents for attachment before sending home, monitor the parents' coping skills and behaviors to determine alterations that need intervention, and encourage the parents to seek help from their support system. 26. The nurse observes a 2-in (5-cm) lochia stain on the perineal pad of a 1-day postpartum client. Which action should the nurse do next? ‣ Document the lochia as scant ➡ ÒScantÓ would describe a 1- to 2-in (2.5- to 5-cm) lochia stain on the perineal pad, or an approximate 10-ml loss. This is a normal finding in the postpartum client. The nurse would document this and continue to assess the client as ordered. 27. A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? ‣ ÒIt might take up to a week for your bowels to return to their normal pattern.Ó ➡ Spontaneous bowel movements may not occur for 1 to 3 days after giving birth because of a decrease in muscle tone in the intestines as a result of elevated progesterone levels. Normal patterns of bowel elimination usually return within a week after birth. The nurse should assess the client's abdomen for bowel sounds and ascertain if the woman is passing gas. Obtaining an order for a laxative may be appropriate, but this response does not address the client's concern. Telling the client that it is unusual is inaccurate and could cause the client additional anxiety. Notifying the health care provider is not necessary, and this statement could add to the client's current concern. 28. On a routine home visit, the nurse is asking the new mother about her breastfeeding and personal eating habits. How many additional calories should the nurse encourage the new mother to eat daily? ‣ 500 additional calories per day ➡ The breastfeeding mother's nutritional needs are higher than they were during pregnancy. The mother's diet and nutritional status influence the quantity and quality of breast milk. To meet the needs for milk production, the woman should eat an additional 500 calories per day, 20 grams of protein per day, 400 mg of calcium per day, and 2 to 3 quarts of fluid per day. 29. The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the clientÕs fundus? ‣ One finger breadth 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. 30. A new mother has been reluctant to hold her newborn. Which action by the nurse would help promote this motherÕs attachment to her newborn? ‣ Bringing the newborn into the room ➡ Proximity of the newborn and the mother can promote interest in the newborn and a desire to hold the infant. Exposure to other mothers and their behaviors can only serve to set up unrealistic and fearful situations for a reluctant mother. 31. 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 providerÕs order and is not necessary as a prevention measure. 32. In a class for expectant parents, the nurse discusses the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. ‣ Women on antithyroid medications ‣ Women on antineoplastic medications ‣ Women using street drugs ➡ While breastfeeding is known to have numerous health benefits for the infant, it is also known that some substances can pass from the mother into the breast milk that can harm the infant. These include antithyroid drugs, antineoplastic drugs, alcohol, and street drugs. Also women who are HIV positive should not breastfeed. Other contraindications include inborn error of metabolism or serious mental health disorders in the mother that prevent consistent feeding schedules. 33. The client, who has just been walking around her room, sits down and reports leg tightness and achiness. After resting, she states she is feeling much better. The nurse recognizes that this discomfort could be due to which cause? ‣ Thromboembolic disorder of the lower extremities ➡ Thromboembolic disorders may present with subtle changes that must be evaluated with more than just physical examination. The woman may report lower extremity tightness or aching when ambulating that is relieved with rest and elevation. Edema in the affected leg, along with warmth and tenderness and a low grade fever, may also be noted. The woman's complaints do not reflect a normal hormonal response, infection, or the body converting back to the prepregnancy state. 34. Two days ago, a woman gave birth to her third infant; she is now preparing for discharge home. After the birth of her second child, she developed an endometrial infection. Nursing goals for this discharge include all of the following except: ‣ Maintaining previous household routines to prevent infection. ➡ The nurse does not know whether previous routines were or were not the source of the infection. The other three options provide correct instructions to be given to this woman. 35. 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. 36. A nurse is providing care to a postpartum woman and is completing the assessment. Which finding would indicate to the nurse that a postpartum woman is experiencing bladder distention? ‣ Percussion reveals dullness ➡ A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy, and lochia would be more than usual. 37. A postpartum woman has been unable to urinate since giving birth. When the nurse is assessing the woman, which finding would indicate that this client is experiencing bladder distention? ‣ Uterus is boggy ➡ A distended bladder is dull on percussion and can be palpated as a rounded mass. In addition, the uterus would be boggy and lochia would be more than usual. 38. The nurse is screening a woman during a home visit following birth. The nurse identifies which risk factors for developing postpartum depression? Select all that apply. ‣ Low self-esteem ‣ Feeling overwhelmed and out of control ‣ Low socioeconomic status ‣ Lack of social support ➡ Risk factors for postpartum depression include low self-esteem, lack of social support, low socioeconomic status, and feeling overwhelmed and out of control. Family involvement in infant care is a positive resource and not a risk factor for postpartum depression. 39. 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. 40. 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. 41. A nurse is conducting a class for a group of pregnant women who are near term. As part of the class, the nurse is describing the process of attachment and bonding with their soon to be newborn. The nurse determines that the teaching was successful when the group states that bonding typically develops during which time frame after birth? ‣ First 30 to 60 minutes ➡ Bonding is the close emotional attraction to a newborn by the parents that develops during the first 30 to 60 minutes after birth. It is unidirectional, from parent to infant. It is thought that optimal bonding of the parents to a newborn requires a period of close contact within the first few minutes to a few hours after birth. 42. In recording a postpartum motherÕs urinary output, the nurse notes that she is voiding between 150 and 200 ml with each hourly void. How would the nurse interpret this finding? ‣ The urinary output is normal ➡ Expected urinary output for a postpartum woman is at least 150 ml with each void on an hourly basis. Therefore 150 to 200 ml is a normal volume for each void. 43. A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? ‣ ÒYou should be seen by your health care provider if you have blurred vision.Ó ➡ The client needs to notify the health care provider for blurred vision, as this can indicate preeclampsia in the postpartum period. The client should also notify the health care provider if she has a temperature great than 100.4¡ F (38¡ C) or if a peripad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is within 2 weeks after hospital discharge. 44.