Ask the client to void. Show
Place the client in supine position. Place one hand on the abdomen just above the symphysis pubis. Place one hand around the top of the fundus. Rotate the upper hand to massage the uterus until firm. Gently press the fundus between the hands using slight downward pressure. 2. On the third and fourth PP days, the lochia becomes a pale pink or brown and contains old blood, serum, leukocytes, and tissue debris. This type of lochia usually lasts until PP day 10. Lochia rubra usually last for the first 3 to 4 days PP. Lochia alba, which contain leukocytes, decidua, epithelial cells, mucus, and bacteria, may continue for 2 to 6 weeks PP Sets found in the same folderA G2 TPAL 2002 patient experienced a precipitous birth 90 minutes ago. Her infant weighed 4,200 g, and a repair of a second-degree laceration was needed following the birth. The nurse assesses that the patient's uterus is boggy and deviated to the right. The patient's vaginal bleeding has increased. Which action by the nurse takes priority? 1. ANS: 1 As the primary caregiver, the registered nurse may be the first person to identify excessive blood loss and to initiate immediate actions. While another member of the team calls the physician or nurse-midwife, the nurse should first locate the uterine fundus and initiate fundal massage. A diabetic patient is 1 day postpartum after an uncomplicated vaginal birth. She wants to know why her blood sugar levels are so much lower than usual. What explanation by the nurse is best? 1. ANS: 2 After childbirth, levels of hormones that exert an anti-insulin effect, such as estrogen, progesterone, human placental lactogen, cortisol, growth hormone, and insulinase, all decline. This leads to a drop in blood glucose in the few days following childbirth. A new mother is concerned that her 3-year-old child is not adapting well to the birth of a new sibling 1 month ago. What suggestion can the nurse provide to best help this mother? 1. ANS: 3 Often siblings have a rough time adapting to the arrival of a new sibling. Some suggestions for the parents are to talk to the child about her feelings, teach the child how to play with the baby, praise age-appropriate behaviors and do not criticize regressive behaviors (regression is common), set aside special time each day for the older child, and give the older child a special chore to be a "big helper for Mommy." A special chore, such as bringing diapers when the baby needs changing, can help boost her self-esteem and make her feel important to the family. A nurse assesses a woman's temperature 6 hours after a vaginal birth and finds it to be 100.4°F (38°C). What action by the nurse is best? 1. ANS: 2 Dehydration and exertion often cause a transient increase in body temperature up to 100.4 °F (38 °C) during the first 24 hours after birth. Increased fluids usually help restore normothermia. The nurse should first encourage the woman to drink increased fluids. The findings should be documented, but the provider does not need to be notified. Coughing and deep breathing are good strategies to relieve atelectasis, but this is not the most common cause of elevated temperature after childbirth. The patient may or may not want acetaminophen, but drinking more fluids is the priority over giving an antipyretic medication. A nurse has brought a newborn to his mother's room. What action by the nurse takes priority? 1. ANS: 2. The safety and security of the infant must be maintained at all times. When bringing the baby to the mother, the nurse ensures proper identification by comparing and matching information on both the mother's and the baby's identification band. Having the mother wash her hands before taking the baby is a good practice to reduce the risk of infection, but security takes priority. A nurse is assisting a postpartum woman to get up for the first time after an unmedicated vaginal birth. What action by the nurse is best? 1. ANS: 4. Orthostatic hypotension can occur in the postpartum woman. The nurse should instruct the woman to change positions slowly and sit on the edge of the bed prior to standing up. A gait belt is not necessary. Checking for lower extremity sensation would be important after spinal or epidural anesthetic. Obtaining orthostatic blood pressures is not necessary unless this is an ongoing problem. A nurse is caring for a woman after a cesarean birth. Prior to ambulating her for the first time, which action by the nurse takes priority? 1. ANS: 2. After a cesarean birth with spinal or epidural anesthesia, the nurse must assess sensation in the woman's legs. She will not be allowed out of bed until sensation returns. Discontinuing the IV line may or may not be appropriate. Coughing and deep breathing are always important for a postoperative patient, but this action is not related to ambulating for the first time. Sitting on the edge of the bed prior to getting up would only be done if the woman had full sensation in her legs. A nurse is caring for a patient who has excessive blood loss post-delivery from uterine atony. The perinatal nurse notifies the health-care provider while another nurse performs uterine massage. Which medication does the nurse anticipate to be given as the priority? 1. 2. If the cause of the hemorrhage is uterine atony, continual fundal massage with lower uterine segment support is mandatory. While one member of the team massages the fundus, another nurse establishes intravenous access with a large-bore needle and administers oxytocic drugs, starting with oxytocin. The other options are all useful in controlling postpartum hemorrhage, but oxytocin should be administered first. A perinatal clinic nurse develops concerns about a postpartum woman and her infant at the first well-baby checkup. The nurse has assessed several risk factors for depression. Which action by the nurse is most appropriate? 1. ANS: 4. If the nurse believes that the new mother is demonstrating signs and symptoms of postpartum depression, several depression screening tools are available, including the Edinburgh Postnatal Depression Scale, Postpartum Depression Predictors Inventory, Center for Epidemiological Studiesâ€"Depression, and Beck Depression Inventory II. Because they are highly predictive, these scales are valuable tools that can be combined with the informal interview during a routine post-birth checkup. A postpartum woman is complaining of a headache that is worsening despite having taken Tylenol (acetaminophen) an hour ago. She delivered yesterday with epidural anesthesia. What action by the nurse is best? 1. ANS: 1. Headache is not uncommon after childbirth. Patients who received epidural or spinal anesthesia may complain of headaches, especially on assuming an upright position. Because this patient had an epidural, the nurse should first assess for this situation. Asking for stronger pain medication should not be done unless the nurse has completed a comprehensive pain assessment. The health-care provider does not need to be notified right away unless the patient has other symptoms, such as blurred vision. Documentation should be thorough, but the nurse needs to take further action first. A postpartum woman presents to the perinatal clinic complaining of extreme breast tenderness and an inability to express milk on the left side when breastfeeding. What nonpharmacological comfort measure does the nurse teach this patient? 1. ANS: 3. This woman has the manifestations of mastitis and will be treated with antibiotics and analgesics. Comfort measures include applying either warm or cold packs to the breasts. If the woman wishes to continue breastfeeding, she should empty her breasts every 2-4 hours. Elevation and menthol-based lotions are not warranted. A postpartum woman who had a cesarean birth complains of warmth and pain in one of her calves. Which assessment should the nurse perform as the priority? 1. ANS: 2. Several clinical manifestations exist for DVT, including pain, calf tenderness, and leg swelling. The nurse can also assess warmth, redness, and possibly a palpable cord. The most accurate assessment is to measure and compare calf circumference; a 2-cm or greater increase on the painful side is an objective finding for DVT. Homans' sign is an assessment for DVT but may be inaccurate in as many as 50% of patients with DVT. Pulses may or may not be decreased, and the popliteal pulse is difficult to find in most patients. Because the patient did not complain of respiratory problems, listening to lung sounds and obtaining a pulse oximeter measurement is not the priority. A postpartum woman who experienced a spontaneous vaginal birth 12 hours ago describes a headache that is worsening. The patient was given two regular-strength acetaminophen (Tylenol) tablets approximately 30 minutes ago but has had no relief from the pain. The most appropriate nursing action at this time is to do which of the following? 1. ANS: 4. The nurse should perform routine, comprehensive pain assessments to include onset, location, intensity, quality, characteristics, and aggravating and alleviating factors of the discomfort to provide interventions in a timely manner and to enhance effectiveness of medications. The nurse should also ask the patient to rate her pain on a standard 0-to-10 pain scale before and after interventions and to identify her own acceptable comfort level on the scale. The other actions are not warranted at this time. A woman gave birth 12 hours ago. The patient complains of severe abdominal cramping when she breastfeeds her infant. The perinatal nurse should document this condition as which of the following? 1. ANS: 2. Afterpains (afterbirth pains) are intermittent uterine contractions that occur during the process of involution. Afterpains are more pronounced in patients with decreased uterine tone due to overdistension, which is associated with multiparity and macrosomia. Breastfeeding and the administration of exogenous oxytocin usually produce pronounced afterpains because both cause powerful uterine contractions. Patients often describe the sensation as a discomfort similar to menstrual cramps. The clinic nurse sees a patient and her infant in the clinic for their 2-week follow-up visit. The woman appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant. Which question would be most appropriate for the nurse to ask? 1. ANS: 1. The woman's appearance and interaction with her baby are clues to postpartum depression. The nurse needs to assess the woman further. A nonthreatening way to open the dialogue might be to say: "Tell me about the first few days at home." This statement provides the new mother with an opportunity to share both positive and negative impressions. Approximately 8 hours ago, a woman gave birth after 2.5 hours of pushing. She required an episiotomy and an assisted birth (forceps). The perinatal nurse assesses a slight bulge in the perineum and the presence of ecchymosis to the right of the episiotomy. The area feels "full" and is approximately 4 cm in diameter. The patient describes this area as "tender." What intervention does the nurse anticipate for this situation? 1. ANS: 2. This patient has a perineal hematoma. If the hematoma is less than 3 to 5 cm in diameter, the physician usually orders palliative treatments, such as ice to the area for the first 12 hours along with pain medication. After 12 hours, sitz baths are prescribed to replace the application of ice. However, a hematoma larger than 5 cm may require incision and drainage with the possible placement of a drain.
A woman is considering abandoning breastfeeding attempts because of severe after pains. What actions by the nurse are most helpful? (Select all that apply.) 1. ANS: 1,2,4,5 Because breast milk is the perfect food for baby, the nurse should support a woman's decision to breastfeed and help remove any obstacles to this practice. Breastfeeding women should take pain medication 30 minutes prior to nursing to achieve maximum pain relief and to minimize the amount of medication that is transferred in the breast milk. Ambulation also helps to decrease afterpains. To ease discomfort, the woman can be assisted into a prone position and a small pillow can be placed under her abdomen. Initiating a sitz bath after breastfeeding may be helpful in decreasing discomfort. Switching to formula and bottle feeding should be a last resort after all other interventions have been tried A woman is 1 day post-cesarean birth. The nurse auscultates crackles in her lung bases. Which action by the nurse is best? 1. ANS: 3. Rales are not uncommon postoperatively and indicate atelectasis. The nurse should have the woman use her spirometer, cough, and deep breathe. The other interventions are not warranted. The perinatal nurse accurately defines postpartum hemorrhage to a group of nursing students by including a decrease in hematocrit levels from prebirth to postbirth by which percentage? 1.
ANS: 2. Postpartum hemorrhage can be defined as a blood loss of greater than 500 mL after a vaginal birth or greater than 1,000 mL after a cesarean birth, a decrease in hematocrit levels by 10% from prebirth to postbirth levels, and the need for transfusion. The nursing faculty member who is explaining uterine atony to nursing students informs them of risk factors contributing to this condition. Which factors would place a woman at higher risk of uterine atony? (Select all that apply.) 1. ANS: 1,2,3,5 Multiple factors increase the risk of uterine atony, including trauma during birth from forceps or vacuum devices; uterine overdistention from multi-fetal gestation, hydramnios, or macrosomia; and the use of both oxytocin and magnesium sulfate. (Other risk factors can be found in Box 16-1.) A trial of labor after a prior cesarean birth is not a risk factor for uterine atony. The perinatal nurse demonstrates the correct technique of postpartum uterine palpation for a student nurse. The nurse explains that support for the lower uterine segment is critical, because without it there is an increased risk of which complication? 1. ANS: 4. The uterine fundus is palpated by placing one hand on the base of the uterus immediately above the symphysis pubis and the other hand at the level of the umbilicus. The nurse presses inward and downward with the hand positioned on the umbilicus until the fundus is located. The uterus should never be palpated without supporting the lower uterine segment. Failure to do so may result in uterine inversion and hemorrhage. The perinatal nurse describes infant feeding cues to a new mother. These feeding cues include which of the following behaviors? (Select all that apply.) 1. 2.
3. 4. 5. ANS: 1,2,4 The infant demonstrates readiness for feeding when he or she begins to stir, bobs the head against the mattress or the mother's neck or shoulder, makes movements of the mouth, makes hand-to-mouth or hand-to-hand movements, exhibits sucking or licking, exhibits rooting, and demonstrates increased activity with the arms and legs flexed and the hands in a fist. The perinatal nurse routinely screens pregnant women for postpartum depression. Which woman does the nurse screen as the priority? 1. ANS: 4. Recognized risk factors for postpartum depression include an undesired/unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness. Ambivalence is not unusual, especially in the first trimester. First pregnancy is not a risk factor. Two days after an uncomplicated vaginal birth, the nurse notes that the patient's hemoglobin is 13 mg/dL and the hematocrit is 48%. What does the nurse conclude about these values? 1. ANS: 3. After a vaginal birth, the hemoglobin can drop about 1 gram, or 2 grams following a cesarean birth (normal for women is 12.1-15.1 mg/dL). Due to diuresis, hemoconcentration can occur, resulting in a rise in the hematocrit (normal in women is 36.1-44.3%). Therefore, these findings are normal after an uncomplicated vaginal birth. The perinatal nurse teaches the postpartum woman about warning signs regarding the development of postpartum infection. The nurse teaches that fever and which of the following symptoms need to be assessed by a health-care provider? 1. ANS: 2. During the immediate postpartum period, the most common site of infection is the uterine endometrium. This infection presents with a temperature elevation over 101 °F (38.4 °C), often within the first 24 to 48 hours after childbirth, followed by uterine tenderness and foul-smelling lochia. The postpartum nurse is aware that following childbirth there is an increased risk of maternal perineal infection related to which of the following factors? (Select all that apply.) 1. 2. 3. 4. 5. ANS: 2,3,4,5 The proximity of the perineum to the anus increases the risk of a laceration or surgical incision becoming contaminated with fecal material, and the continuous drainage of blood coupled with impaired tissue integrity creates a favorable medium for the proliferation of bacteria. Urinary stasis and retention can lead to urinary tract infections. Weakness and fatigue would not lead to an increased risk for infection. Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on third day postpartum?Which behavior should the nurse anticipate for a new mother with an uncomplicated vaginal birth on the third postpartum day? B. By the third postpartum day, the new mother should start to take hold of caring for her infant, by asking questions about infant care and initiating care of her infant.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
Which of the following behaviors characterizes the postpartum mother in the taking in phase?Which of the following behaviors characterizes the PP mother in the taking in phase? Passive and dependant. During the taking in phase, which usually lasts 1-3 days, the mother is passive and dependent and expresses her own needs rather than the neonate's needs.
What action should the nurse implement with the family when an infant is born with?What action should the nurse implement with the family when an infant is born with anencephaly? Ensure that measures to facilitate the attachment process are offered. Prepare the family to explore ways to cope with the imminent death of the infant.
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