Coursepoint: Nursing Care of a Family Experiencing a Postpartum Complication

Question 1

The nurse is caring for a postpartum client with uterine atony. Bladder drainage and massage have been ineffective. Oxytocin IV has been given but has been ineffective in maintaining uterine tone. Which medication does the nurse anticipate being prescribed as the next choice?

Answer 1

carboprost tromethamine

If oxytocin is not effective at maintaining tone, carboprost tromethamine, a prostaglandin F2-alpha derivative, or methylergonovine maleate, an ergot compound, both given intramuscularly, are the next possible options. Additional options include misoprostol, a prostaglandin E1 analogue, administered rectally to decrease postpartum hemorrhage or ranexamic acid to decrease bleeding. Heparin would increase bleeding and would not be used.

Question 2

The nurse is teaching a client with newly diagnosed mastitis about her condition. The nurse would inform the client that she most likely contracted the disorder from which organism?

Answer 2

Staphylococcus aureus

The most common cause of mastitis is S. aureus, transmitted from the neonate’s mouth. Mastitis is not harmful to the neonate. E. coli, GBS, and S. pyogenes are not associated with mastitis. GBS infection is associated with neonatal sepsis and death.

Question 3

Which intervention would be helpful to a client who is bottle feeding her infant and experiencing hard, engorged breasts?

Answer 3

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.

Question 4

A client is diagnosed with a postpartum infection. The nurse is most correct to provide which instruction?

Answer 4

Finish all antibiotics to decrease a genital tract infection.

A postpartum infection is an infection of the genital tract after delivery through the first 6 weeks postpartum. It is most important to include finishing all antibiotics in nursing instructions. Endometritis is an infection of the mucous membrane or endometrium of the uterus. Cystitis is an infection of the bladder. Infection of the perineum or episiotomy is a localized infection and not inclusive of the entire genital tract.

Question 5

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?

Answer 5

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.

Question 6

A multipara client develops thrombophlebitis after birth. Which assessment findings would lead the nurse to intervene immediately?

Answer 6

dyspnea, diaphoresis, hypotension, and chest pain

Sudden unexplained shortness of breath and reports of chest pain along with diaphoresis and hypotension suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia, apprehension, hemoptysis, syncope, and sudden change in the woman’s mental status secondary to hypoxemia. Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.

Question 7

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?

Answer 7

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.

Question 8

A client who gave birth several hours ago is experiencing postpartum hemorrhage. She had a cesarean birth and received deep, general anesthesia. She has a history of postpartum hemorrhage with her previous births. The blood is a dark red. Which cause of the hemorrhage is most likely in this client?

Answer 8

uterine atony

Uterine atony, or relaxation of the uterus, is the most frequent cause of postpartum hemorrhage; it tends to occur most often in Asian or Hispanic woman. Conditions that contribute to uterine atony include having received deep anesthesia or analgesia and a prior history of postpartum hemorrhage. A cervical laceration is less likely because the blood is dark, not bright red, and bleeding from such a laceration usually occurs immediately after detachment of the placenta. Disseminated intravascular coagulation is typically associated with premature separation of the placenta, a missed early miscarriage, or fetal death, none of which is evident in this scenario. A retained placental fragment is possible, and could contribute to the atony, but there is no evidence for this in the scenario.

Question 9

A woman recovering from cesarean birth in the hospital and who was catheterized complains of a feeling of burning on urination and a feeling of frequency. Which of the following should be the next nursing action?

Answer 9

Obtain a clean-catch urine specimen.

The client in this scenario shows classic signs of a urinary tract infection. The priority nursing action at this point is to obtain a clean-catch urine specimen to confirm the infection. The other answers are therapeutic management interventions that would take place after confirmation of the infection via the clean-catch urine specimen.

Question 10

Which statement by the nurse would be considered inappropriate when comforting a family who has experienced a stillborn infant?

Answer 10

“I know you are hurting, but you can have another baby in the future.”

Parents who have experienced a stillborn need support from the nursing staff. Statements by the nurses need to be therapeutic for the grieving parents. Statements that offer false hope or diminish the value of the stillborn child cause the parents pain. Telling them that they can have another child is both thoughtless and hurtful.

Question 11

Review of a primiparous woman’s labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition?

Answer 11

thrombophlebitis

The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased amount of time in bed, and venous pooling that occurs when the woman’s legs are in stirrups for a long period of time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or hypertension.

Question 12

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?

Answer 12

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.

Question 13

The nurse is providing care to several postpartum clients who report being able to urinate but feeling like the amount is small. The nurse suspects urinary retention and obtains an order to catheterize each client for residual. The nurse would keep the catheter in place for which client?

Answer 13

The client with 135 ml of residual urine

If the amount of urine left in the bladder after voiding (termed residual ) is greater than 100 ml, the client is retaining more than the usual amount of urine. Typically the catheter is left in place if the amount is greater than 100 ml.

Question 14

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?

Answer 14

“I need to apply pressure to any cut for 5 to 10 minutes.”

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.

Question 15

A postpartum client has continuous seepage of blood from the vagina. Upon nursing assessment, the nurse confirms a firm uterus, 1 cm below the umbilicus. The nurse increases her nursing assessment to include assessment for:

Answer 15

a cervical laceration.

Continuous seepage of blood may be due to cervical or vaginal lacerations if the uterus is firm and contracting. Retained placental fragments and uterine atony may cause subinvolution of the uterus, making it soft, boggy, and larger than expected. Urinary tract infection won’t cause vaginal bleeding, although hematuria may be present.

Question 16

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?

Answer 16

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.

Question 17

A nurse is caring for a client in the postpartum period. When observing the client’s condition, the nurse notices that the client tends to speak incoherently. The client’s thought process is disoriented, and the client frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition?

Answer 17

postpartum psychosis

The client’s 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 baby’s health and welfare. Delusions, specific to the newborn, 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 easily—often for no reason—and 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.

Question 18

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition?

Answer 18

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.

Question 19

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn?

Answer 19

infection

Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes removes the barrier of amniotic fluid, so bacteria can ascend.

Question 20

A nurse is caring for a client in the clinic. The client reports burning during urination for the past few days. Assessment reveals cloudy urine, with the presence of white blood cells (WBCs). Vital signs: temperature, 101.4°F (38.5°C); heart rate, 101 beats/min; blood pressure, 100/64 mm Hg.

The priority actions of the nurse should be to first _________________________ followed by ____________________.

Answer 20

Obtain a culture & Initiate antibiotics

The nurse should first obtain a culture for sensitivity before administering antibiotics.

Once the culture has been obtained, the nurse should administer a broad-spectrum antibiotic per provider prescription.

Rechecking the client’s temperature is not necessary. An antibiotic should not be administered until a culture has been obtained.

The priorities for this client would be to first obtain a culture, then administer a broad-spectrum antibiotic. The nurse will encourage fluid intake, but this is not the priority. A nonsteroidal anti-inflammatory drugs (NSAID) can be administered for fever, but the priority is to obtain a culture and start the client on a broad-spectrum antibiotic to start treating the infection.

Question 21

The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?

Answer 21

Ambulate the client as soon as her vital signs are stable.

The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

Question 22

The nurse notes that a client’s uterus, which was firm after the fundal massage, has become boggy again. Which intervention would the nurse do next?

Answer 22

Check for bladder distention, while encouraging the client to void.

If the nurse finds a previously firm fundus to be relaxed, displaced, and boggy, the nurse should assess for bladder distention and encourage the woman to void or initiate catheterization as indicated. Emptying a full bladder facilitates uterine contraction and decreased bleeding. The nurse should not perform vigorous fundal massage. Excessive massage leads to overstimulation of uterine muscle, resulting in excessive bleeding. The nurse should place the client in a semi-Fowler position to encourage uterine drainage in the client with postpartum endometritis. The nurse should offer analgesics as prescribed by the health care provider to minimize perineal discomfort in clients experiencing postpartum lacerations.

Question 23

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?

Answer 23

“I can continue breastfeeding my infant, but it may be somewhat uncomfortable.”

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.

Question 24

After the nurse teaches a local woman’s group about postpartum affective disorders, which statement by the group indicates that the teaching was successful?

Answer 24

“Postpartum depression develops gradually, appearing within the first 6 weeks.”

Postpartum depression usually has a more gradual onset, becoming evident within the first 6 weeks postpartum. Postpartum blues usually peaks on the 4th to 5th postpartum day and resolves by the 10th day. Postpartum psychosis generally surfaces within 3 weeks of giving birth. Treatment typically involves hospitalization for up to several months. Psychotropic drugs are almost always a part of treatment, along with individual psychotherapy and support group therapy.

Question 25

The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady trickle of bright red blood from the vagina in the presence of a firm fundus. Which potential cause should the nurse question and report to the RN or primary care provider?

Answer 25

Laceration

A steady trickle of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.