Coursepoint: Nursing Care of a Family Experiencing a Postpartum Complication Flashcards
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?
Teach that adequate hydration helps clear the infection quicker.
Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 ml of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth.
The nurse is administering a postpartum woman an antibiotic for mastitis. Which statement by the mother indicates that she understood the nurse’s explanation of care?
“I can continue breastfeeding my infant, but it may be somewhat uncomfortable.”
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.
What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage?
Oxytocin
Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding.
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.
When completing the morning postpartum data collection, the nurse notices the client’s perineal pad is completely saturated. Which action should be the nurse’s first response?
Ask the client when she last changed her perineal pad.
If the morning assessment is done relatively early, it’s possible that the client hasn’t yet been to the bathroom, in which case her perineal pad may have been in place all night. Secondly, her lochia may have pooled during the night, resulting in a heavy flow in the morning. Vigorous massage of the fundus, which is indicated for a boggy uterus, wouldn’t be recommended as a first response until the client had gone to the bathroom, changed her perineal pad, and emptied her bladder. The nurse wouldn’t want to call the primary care provider unnecessarily. If the nurse were uncertain, it would be appropriate to have another qualified individual check the client but only after a complete assessment of the client’s status.
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.
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema.
Which nursing diagnosis would be most appropriate for a client with a postpartum hematoma?
Impaired urinary elimination
Due to the nature and location of a postpartum hematoma, impaired urinary elimination would be the best choice. Urination is impaired from swelling.
In addition to Risk for injury and pain, another appropriate nursing diagnosis would be Risk for impaired urinary elimination related to pressure from the hematoma on urinary structures.
Nursing diagnoses associated with postpartum lacerations
Ineffective tissue perfusion and impaired tissue integrity
Nursing diagnosis associated with postpartum hemorrhage
Deficient fluid volume
A nurse is assessing a postpartum client. Which finding causes the nurse the greatest concern?
Acute onset of sharp, stabbing chest pain with shortness of breath
Acute onset of sharp, stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires immediate action.
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.
A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program?
Inspecting the placenta after delivery for intactness
A nurse is making a follow up visit to a new parent and 3-month-old infant. The nurse is talking with the client about her role as a mother and caring for her infant. Which statement by the client would lead the nurse to immediately call the health care provider?
“I am so angry with myself, I just want to give up my life right now.”
The client’s statement about being angry at herself and wanting to give up suggests postpartum psychosis. This information would need to be reported, because there is a threat to the mother’s safety and possibly the infant’s safety. The nurse should not leave the client alone. Postpartum psychosis generally surfaces within 3 months of giving birth and is manifested by sleep disturbances, fatigue, depression, and hypomania. The mother will be tearful, confused, and preoccupied with feelings of guilt and worthlessness. Early symptoms resemble those of depression, but they may escalate to delirium, hallucinations, extreme disorganization of thought, anger toward herself and her infant, bizarre behavior, delusions, disorientation, depersonalization, delirium-like appearance, manifestations of mania, and thoughts of hurting herself and the infant.
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.
