Chapter 17: Postpartum Adaptations and Nursing Care Flashcards
- Which patient would be most likely to have severe afterbirth pains and request a narcotic analgesic?
a.
Gravida 5, para 5
b.
Primipara who delivered a 7-lb boy
c.
Patient who is bottle feeding her first child
d.
Patient who is breastfeeding her second child
ANS: A
The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. The uterus of a primipara tends to remain contracted. Afterpains are particularly severe during breastfeeding, not bottle feeding. The non-nursing mother may have engorgement problems that will cause her discomfort. The patient who is nursing her second child will have more afterpains than her first pregnancy; however, they will not be as severe as the grand multiparous patient.
- Which maternal event is abnormal in the early postpartal period?
a.
Diuresis and diaphoresis
b.
Flatulence and constipation
c.
Extreme hunger and thirst
d.
Lochial color changes from rubra to alba
ANS: D
For the first 3 days after childbirth, lochia is termed rubra. Lochia serosa follows, and then at about 11 days, the discharge becomes clear, colorless, or white. The body rids itself of increased plasma volume. Urine output of 3000 mL/day is common for the first few days after birth and is facilitated by hormonal changes in the mother. Bowel tone remains sluggish for days. Many women anticipate pain during defecation and are unwilling to exert pressure on the
perineum. The new mother is hungry because of energy used in labor and thirsty because of fluid restrictions during labor.
- Which fundal assessment finding at 12 hours after birth requires further assessment? a.
The fundus is palpable at the level of the umbilicus.
b.
The fundus is palpable two fingerbreadths above the umbilicus. c.
The fundus is palpable one fingerbreadth below the umbilicus. d.
The fundus is palpable two fingerbreadths below the umbilicus.
ANS: B
The fundus rises to the umbilicus after birth and remains there for about 24 hours. A fundus that is above the umbilicus may indicate uterine atony or urinary retention. The fundus palpable at the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable one fingerbreadth below the umbilicus is an appropriate assessment finding for 12 hours postpartum. The fundus palpable two fingerbreadths below the umbilicus is an unusual finding for 12 hours postpartum; however, it is still appropriate.
- If the patient’s white blood cell (WBC) count is 25,000/mm3 on her second postpartum day, which action should the nurse take?
a.
Document the finding.
b.
Inform the health care provider.
c.
Begin antibiotic therapy immediately.
d.
Have the laboratory draw blood for reanalysis.
ANS: A
An increase in WBC count to 25,000/mm3 during the postpartum period is considered normal and not a sign of infection. The nurse should document the finding. There is no reason to alert the health care provider. Antibiotics are not needed because the elevated WBCs are caused by the stress of labor and not an infectious process. There is no need for reassessment as it is expected for the WBCs to be elevated.
- Postpartal overdistention of the bladder and urinary retention can lead to which complication? a.
Fever and increased blood pressure
b.
Postpartum hemorrhage and eclampsia
c.
Urinary tract infection and uterine rupture
d.
Postpartum hemorrhage and urinary tract infection
ANS: D
Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle. There is no correlation between bladder distention and blood pressure or fever. There is no correlation between bladder distention and eclampsia. The risk of uterine rupture decreases after the birth.
- A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
a.
“No, never.”
b.
“Yes, eventually.”
c.
“They will fade to silvery lines but won’t disappear completely.”
d.
“They will continue to fade and should be gone by your 6-week checkup.”
ANS: C
Stretch marks never disappear altogether, but they do gradually fade to silvery lines. Stating never is true, but more information can be added, such as the changes that will occur with the stretch marks. Stretch marks do not disappear.
- A pregnant patient asks when the dark line on her abdomen (linea nigra) will go away. The nurse knows the pigmentation will fade after birth due to
a.
increased estrogen.
b.
increased progesterone.
c.
decreased human placental lactogen.
d.
decreased melanocyte-stimulating hormone.
ANS: D
Melanocyte-stimulating hormone increases during pregnancy and is responsible for changes in skin pigmentation; the amount decreases after birth. Estrogen levels decrease after birth. Progesterone levels decrease after birth. Human placental lactogen production continues to aid in lactation. However, it does not affect pigmentation.
- Which clinical finding should the nurse suspect if the fundus is palpated on the right side of the abdomen above the expected level?
a.
Distended bladder
b.
Normal involution
c.
Been lying on her right side too long
d.
Stretched ligaments that are unable to support the uterus
ANS: A
The presence of a full bladder will displace the uterus. A palpated fundus on the right side of the abdomen above the expected level is not an expected finding. Position of the patient should not alter uterine position. The problem is a full bladder displacing the uterus.
- Which situation would require the administration of Rho(D) immune globulin?
a.
Mother Rh-negative, baby Rh-positive
b.
Mother Rh-negative, baby Rh-negative
c.
Mother Rh-positive, baby Rh-positive
d.
Mother Rh-positive, baby Rh-negative
ANS: A
An Rh-negative mother delivering an Rh-positive baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho(D) immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. When the blood types are alike as with mother Rh-negative, baby Rh-negative, no antibody formation would be anticipated. If the Rh-positive blood of the mother comes in contact with the Rh-negative blood of the infant, no antibodies would develop because the antigens are in the mother’s blood, not the infant’s.
- If the rubella vaccine is indicated for a postpartum patient, which instructions should be provided?
a.
No specific instructions
b.
Drinking plenty of fluids to prevent fever
c.
Recommendation to stop breastfeeding for 24 hours after the injection
d.
Explanation of the risks of becoming pregnant within 28 days following injection
ANS: D
Potential risks to the fetus can occur if pregnancy results within 3 months after rubella vaccine administration. The mother does need to understand potential side effects and that pregnancy is discouraged for 3 months. The mother should be afebrile before the vaccine. Small amounts of the vaccine do cross the breast milk, but it is believed that there is no need to discontinue breastfeeding.
- Which measure is optimal in order to prevent abdominal distention following a cesarean birth?
a.
Rectal suppositories
b.
Carbonated beverages
c.
Early and frequent ambulation
d.
Tightening and relaxing abdominal muscles
ANS: C
Activity can aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, do not prevent it. Carbonated beverages may increase distention. Ambulation is the best prevention. Abdominal strengthening will not prevent distention.
- To assess fundal contraction 6 hours after cesarean birth, which technique should the nurse utilize?
a.
Assess lochial flow rather than palpating the fundus.
b.
Palpate forcefully through the abdominal dressing.
c.
Place hands on both sides of the abdomen and press downward.
d.
Gently palpate, applying the same technique used for vaginal deliveries.
ANS: D
Assessment of the fundus is the same for vaginal and cesarean deliveries. Forceful palpation should never be used. The top of the fundus, not the sides, should be palpated and massaged. Assessing lochial flow is not adequate; the fundus also needs to be checked.
- The nurse has completed a postpartum assessment on a patient who delivered 1 hour ago. Which amount of lochia consists of a moderate amount?
a.
Saturated peripad
b.
10 to 15 cm (4- to 6-inch) stain on the peripad
c.
2.5 to 10 cm (1- to 4-inch) stain on the peripad
d.
Less than a 1-inch stain on the peripad
ANS: B
Because estimating the amount of lochia is difficult, nurses frequently record flow by estimating the amount of lochia in 1 hour using the following labels:
Scant—less than 2.5 cm (1-inch) stain on the peripad
Light—less than a 10 cm (4 inch) stain
Moderate—less than a 15 cm (6 inch) stain
Heavy—saturated peripad
Excessive—saturated peripad in 15 minutes
Determining the time interval that the peripad is in place is also important. Lochia is less for women who have had a cesarean birth because some of the endometrial lining is removed during surgery.
- The postpartum nurse has completed discharge teaching for a patient being discharged after an uncomplicated vaginal birth. Which statement by the patient indicates that further teaching is necessary?
a.“I may not have a bowel movement until the 2nd postpartum day.”
b.
“If I breastfeed and supplement with formula, I won’t need any birth control.”
c.
“I know my normal pattern of bowel elimination won’t return until about 8 to 10 days.”
d.
“If I am not breastfeeding, I should use birth control when I resume sexual relations with my husband.”
ANS: B
For some women, ovulation resumes as early as 3 weeks postpartum. Therefore contraceptive measures are important considerations when sexual relations are resumed for lactating and nonlactating women. Further teaching would be needed if the patient does not feel any need for birth control with breastfeeding and supplementing with formula. The first stool usually occurs within 2 to 3 days postpartum. Normal patterns of bowel elimination generally resume by 8 to 14 days after birth.
- The nurse is caring for a postpartum patient who delivered by the vaginal route 12 hours ago. Which assessment finding should the nurse report to the health care provider?
a.
Pulse rate of 50
b.
Temperature of 38C (100.4F)
c.
Firm fundus, but excessive lochia
d.
Lightheaded when moving from a lying to standing position
ANS: C
Excessive lochia in the presence of a contracted uterus suggests lacerations of the birth canal. The health care provider must be notified so that lacerations can be located and repaired. Bradycardia, defined as a pulse rate of 40 to 50 beats per minute (bpm), may occur as the large amount of blood that returns to the central circulation after birth of the placenta. A temperature of up to 38C (100.4F) is common during the first 24 hours after childbirth and may be caused by dehydration or normal postpartum leukocytosis. The resulting engorgement of abdominal blood vessels contributes to a rapid fall in BP of 15 to 20 mm Hg systolic when the woman moves from a recumbent to a sitting position. This change causes mothers to feel dizzy or lightheaded or to faint when they stand.
- To facilitate adequate urinary elimination during the postpartum period, the nurse should incorporate which intervention into the plan of care?
a.
Have the patient drink carbonated beverages to promote urinary excretion.
b.
Tell the patient that because of postpartum diuresis there is less risk to develop dehydration.
c.
Limit fluid intake to prevent polyuria.
d.
Teach the patient to perform pelvic floor exercises to combat potential stress incontinence.
ANS: D
Educating the patient to use pelvic floor exercises (Kegel exercises) will help strengthen pelvic floor muscles. Carbonated beverages will lead to increased gas and potential gastrointestinal discomfort. During the postpartum period, the patient is at greater risk for dehydration and thus should increase fluids. Limitation of fluids is not warranted during the postpartum period.
- When assessing the A of the acronym REEDA, the nurse should evaluate the a.
skin color.
b.
degree of edema.
c.
edges of the episiotomy.
d.
episiotomy for discharge.
ANS: C
In the acronym REEDA, the A refers to approximation of the edges of the episiotomy; the other letters of the acronym refer to other components of wound assessment: R = redness, E = edema, E = ecchymosis, and D = drainage.
- Which assessment finding 24 hours after vaginal birth would indicate a need for further intervention?
a.
Pain level 5 on scale of 0 to 10
b.
Saturated pad over a 2-hour period
c.
Urinary output of 500 mL in one voiding
d.
Uterine fundus 2 cm above the umbilicus
ANS: D
By the second postpartum day, the fundus descends by approximately 1 cm/day and should be 1 cm below the umbilicus; pain level of 5, saturated pad over a 2-hour time period, and urinary output of 500 mL in one voiding are normal findings in the postpartum patient.