What postpartum client should the nurse monitor most closely for signs of a postpartum infection? Show
A client who conceived following fertility treatments A client who had a nonelective cesarean birth The major risk factor for postpartum infection is a nonelective cesarean birth. Antepartum risk factors include history of infection; history of chronic conditions, such as diabetes, anemia, or poor nutrition; infections of the genital tract; smoking; and obesity. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? Assess the woman's vital signs. Assess the woman's fundus. Why are postpartal women prone to urinary retention? Catheterization at the time of delivery reduces bladder tonicity. Decreased bladder sensation results from edema because of pressure of birth. As the fetal head passes behind the bladder, bladder edema with loss of sensation can result. The nurse determines that a woman is experiencing postpartum hemorrhage after a vaginal birth when the blood loss is greater than which amount? 100 mL 500 mL Which intervention would be helpful to a bottle-feeding client who is experiencing hard or engorged breasts? applying ice applying ice 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. A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "If you don't attempt to void, I'll need to catheterize you." "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. It is discovered that a new mother has developed a puerperal infection. What is the most likely expected outcome that the nurse will identify for this client related to this condition? Client's temperature remains below 100.4° F or 38° C orally.
Client's temperature remains below 100.4° F or 38° C orally. A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first? Assess the fundus. Assess the fundus. The nurse is reviewing orders written for a postpartum patient with a fourth-degree perineal laceration. Which order should the nurse question before implementing? Administering acetaminophen and codeine for pain Administering an enema A fourth-degree perineal laceration involves the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum. Any patient who has a fourth-degree laceration should not have an enema prescribed because the hard tips of equipment could open sutures near to or including those of the rectal sphincter. The nurse is instructing a postpartum patient on observations to report to the health care provider which signifies retained placental fragments. Which patient statement indicates that teaching has been effective? "I will have large amount of vaginal drainage for at least several months." "If the drainage changes from clear to bright red, I am to call the doctor." Because the hemorrhage from retained fragments may be delayed until after the patient is home, instruct to observe the color of lochia and to report any tendency for the discharge to change from lochia serosa or alba back to rubra. A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? firm uterus with a steady stream of bright red blood Large uterus with painless dark red blood mixed with clots The presence of a large uterus with painless dark red blood mixed with clots indicates retained placental fragments in the uterus. This cause of hemorrhage can be prevented by carefully inspecting the placenta for intactness. A firm uterus with a trickle or steady stream of bright red blood in the perineum indicates bleeding from trauma. A soft and boggy uterus that deviates from the midline indicates a full bladder, interfering with uterine involution. A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. bizarre behavior inability to concentrate In reviewing the postpartum G3, P3 woman's history the nurse notes it is positive for obesity and smoking. The nurse recognizes this client is at risk for which complication? uterine atony deep venous thrombosis Factors that can increase a woman's risk for DVT include prolonged bed rest, diabetes, obesity, cesarean birth, progesterone-induced distensibility of the veins of the lower legs during pregnancy, severe anemia, varicose veins, advanced maternal age (older than 35), and multiparity. Effective nursing management involves many aspects and being aware of subtle changes in the client. Which finding should alert the nurse to a potential infection in the client? temperature of 38° C or higher after the first 24 hours after birth temperature of 38° C or higher after the first 24 hours after birth A postpartum client with a history of deep vein thrombosis is being discharged on anticoagulant therapy. The nurse teaches the client about the therapy and measures to reduce her risk for bleeding. Which statement by the client indicates the need for additional teaching? "I should brush my teeth vigorously to stimulate the gums." "I should brush my teeth vigorously to stimulate the gums." The client is at risk for bleeding and as such should gently brush her teeth with a soft toothbrush to prevent injury. An increase in lochia warrants notification of the health care provider. Aspirin and aspirin-containing products should be avoided. If the client experiences a cut that bleeds, she should apply direct pressure to the site for 5 to 10 minutes. The nurse palpates a postpartal woman's fundus 2 hours after birth and finds it located to the right of midline and somewhat soft. What is the correct interpretation of this finding? The soft fundus indicates that the woman's uterus is filling up with blood. The clien's bladder is distended and is causing the uterus to deviate to the right. If a postpartal client's bladder becomes full, the client's uterus is displaced to the side. The client should be taught to void on demand to prevent the uterus from becoming soft and increasing the flow of lochia. 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? Advise her to take acetaminophen to ease symptoms. 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 other choices are also options but address the symptoms and not the root cause. The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection. The nurse is assisting a new mother who is several hours postpartum. Which reaction by the new mother should the nurse prioritize? Returns baby to the nursery because of fatigue Ignores the newborn crying After birth the woman would be excited and interested in the birth and the infant. Ignoring the newborn's crying may be an indication of malattachment and should be further evaluated and brought to the attention of the RN and/or health care provider. If this is a new mother, she may be hesitant to change the diaper because she is unsure of how to do it or fears she might hurt her newborn; she would need encouragement and instruction on how to do this. The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize? Initiate
Ringer's lactate infusion. Assess the woman's fundus. The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider? Tearful during appointment
Restless and agitated, concerned with self and not the infant On the third day postpartum, which temperature is internationally defined as a postpartal infection? 99.6° F (37.5° C) 100.4° F (38° C) A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? uterine subinvolution 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. A nurse is assigned to care for a client with deep vein thrombosis who has to undergo anticoagulation therapy. Which instruction should the nurse offer the client as a caution when the client receives anticoagulation therapy? Sit with legs crossed over each other. Avoid products containing aspirin. The nurse should caution the client to avoid products containing aspirin, which inhibits the synthesis of clotting factors and can further prolong clotting time and precipitate bleeding. The nurse should instruct the client to avoid crossing the legs as a preventive measure. The nurse should not instruct the client to refrain from performing any leg exercises; instead, the nurse should instruct the client to perform leg exercises such as flexion and extension of the feet and pushing the back of the knees into the mattress and then flexing slightly to promote venous return. The nurse should instruct the client to avoid prolonged straining during defecation and to avoid heavy lifting and exercises. Which situation should concern the nurse treating a postpartum client within a few days of birth? The client would like to watch the nurse give the baby her first bath. The client feels empty since she gave birth to the neonate. A client experiencing postpartum blues may say she feels empty now that the infant is no longer in her uterus. She may also verbalize that she feels unprotected now. The other options are considered normal and would not be cause for concern. Many first-time mothers are nervous about caring for their neonates by themselves after discharge. New mothers may want a demonstration before doing a task themselves. A client may want to get some uninterrupted sleep, so she may ask that the neonate be taken to the nursery. Which recommendation should be given to a client with mastitis who is concerned about breast-feeding her neonate? She should continue to breast-feed; mastitis will not infect the neonate. She should continue to breast-feed; mastitis will not infect the neonate. The client with mastitis should be encouraged to continue breast-feeding while taking antibiotics for the infection. No supplemental feedings are necessary because breast-feeding does not need to be altered and actually encourages resolution of the infection. Analgesics are safe and should be administered as needed. After delivery, a patient is diagnosed with postpartal gestational hypertension. What care will the nurse provide to this patient? Select all that apply. Administer antihypertensive medication as prescribed. Maintain on bed rest. A postpartum patient is prescribed methylergonovine 0.2 mg for uterine subinvolution. Which action should the nurse take before administering the medication to the patient? Measure blood pressure. Measure blood pressure. Methylergonovine can increase blood pressure and must be used with caution in patients with hypertension. The nurse should assess the blood pressure prior to administrating and about 15 minutes afterward to detect this side effect. Methylergonovine does not affect ambulation, urine output, or hematocrit level. A postpartum patient is receiving antibiotics for endometritis. What should the nurse instruct the patient to observe in the infant with breast-feeding? Jaundice White plaques in the mouth The patient who is breast-feeding should not be prescribed antibiotics that are incompatible with breast-feeding. The patient should be instructed to observe for problems in their infant, such as white plaques or thrush in their infant's mouth that can occur when a portion of the maternal antibiotic passes into breast milk and causes an overgrowth of fungal organisms in the infant. Antibiotics will not typically cause jaundice. Irritability may or may not be because of the mother taking antibiotics. Decreased sleep levels are not typically associated with maternal antibiotic use. A nurse is caring for a postpartum client diagnosed with von Willebrand disease. What should be the nurse's priority for this client? Check the lochia. Check the lochia. The nurse should assess the client for prolonged bleeding time. von Willebrand disease is a congenital bleeding disorder, inherited as an autosomal dominant trait, that is characterized by a prolonged bleeding time, a deficiency of von Willebrand factor, and impairment of platelet adhesion. A fever of 100.4° F (30.0° C) after the first 24 hours following birth and pain indicate infection. A client with a postpartum fundal height that is higher than expected may have subinvolution of the uterus. What medication would the nurse administer to a client experiencing uterine atony and bleeding leading to postpartum hemorrhage? Oxytocin Oxytocin Oxytocin causes the uterus to contract to improve uterine tone and reduce bleeding. Magnesium sulfate is administered to clients with preeclampsia or eclampsia or hypertension problems. Domperidone is used to increase lactation in women. Calcium gluconate is an antagonist used in clients experiencing side effects of magnesium sulfate. The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates? Height, level of orientation, support systems Blood pressure, pulse, reports of dizziness The nurse recognizes that the postpartum period is a time of rapid changes for each client. What is believed to be the cause of postpartum affective disorders? lack of social support from family or friends drop in estrogen and progesterone levels after birth Plummeting levels of estrogen and progesterone immediately after birth can contribute to postpartum mood disorders. It is believed that the greater the change in these hormone levels between pregnancy and postpartum, the greater the change for developing a mood disorder. Lack of support, medications, and preexisting conditions may contribute but are not the main etiology. A postpartal woman is developing a thrombophlebitis in her right leg. Which assessment would the nurse use to assess for thrombophlebitis? Select all that apply. Ask if her pain that is relieved with walking. Assess for redness and warmth in the affected leg. A nurse is assessing a postpartum client who is at home. Which statement by the client would lead the nurse to suspect that the client may be developing postpartum depression? "I just feel so overwhelmed and tired." "I'm feeling so guilty and worthless lately." In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "How much blood was on the two pads?" While assessing a postpartum woman, the nurse palpates a contracted uterus. Perineal inspection reveals a steady stream of bright red blood trickling out of the vagina. The woman reports mild perineal pain. She just voided 200 mL of clear yellow urine. Which condition would the nurse suspect? uterine atony laceration Lacerations typically present with a firm contracted uterus and a steady stream of unclotted bright red blood. Hematoma would present as a localized bluish bulging area just under the skin surface in the perineal area, accompanied by perineal or pelvic pain and difficulty voiding. Uterine inversion would present with the uterine fundus at or through the cervix. Uterine atony would be manifested by a noncontracted uterus. After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? "Postpartum depression develops gradually, appearing within the first 6 weeks." "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. 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 she 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? postpartum panic disorder ... Which instruction should the nurse offer a client as primary preventive measures to prevent mastitis? Avoid frequent breast-feeding. Perform handwashing before breast-feeding. Various medications are available to help control hemorrhage in the postpartum client. When reviewing the client's history, the nurse notes she has a history of asthma. Which medication would be contraindicated in her case? methylergonovine carboprost Carboprost is contraindicated with asthma due to the risk of bronchial spasms. Oxytocin should be given undiluted as a bolus injection, misoprostol should not be given to women with active CVD, pulmonary or hepatic disease, and methylergonovine should not be given to a woman who is hypertensive. Which instruction would the nurse include in the teaching plan for a postpartum woman with mastitis? "Limit the amount of fluid you drink so your breasts don't get much fuller." "Try applying warm compresses to your breasts to encourage the milk to be released." Warm compresses promote the let-down reflex, encouraging the milk to be released. They also provide comfort. With mastitis, breastfeeding is encouraged to empty the breasts and reverse milk stasis and to maintain the milk supply. Lactation is not suppressed. Fluid intake is important to ensure adequate milk supply. In addition, fluid intake is important when infection is present. A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? administration of platelet transfusions as prescribed administration of platelet transfusions as prescribed When caring for a client with ITP, the nurse should administer platelet transfusions as ordered to control bleeding. Glucocorticoids, intravenous immunoglobulins, and intravenous anti-Rho D are also administered to the client. The nurse should not administer NSAIDs when caring for this client since nonsteroidal anti-inflammatory drugs cause platelet dysfunction. The nurse is giving an educational presentation to the local Le Leche league chapter. One woman asks about mastitis. What would be the nurse's best response? Risk factors include complete emptying of the breast. ... Which of the following would be a risk factor for developing a postpartum infection?General risk factors
The following increase the risk for postpartum infections: History of cesarean delivery. Premature rupture of membranes. Frequent cervical examination (Sterile gloves should be used in examinations.
Which is one of the first symptoms of puerperal infection to assess for in the postpartum woman?It is historically referred to as puerperal fever and is divided into early (within 24–48 h) and late (>48 h) postpartum. Fever is often the first sign, with uterine tenderness, bleeding, and foul smelling lochia as additional signs.
What are two of the first symptoms of postpartum infection to assess for in the postpartum woman select all that apply?Symptoms and signs may include: fever. pain in the lower abdomen or pelvis caused by a swollen uterus. foul-smelling vaginal discharge.
Which situation should concern the nurse treating a postpartum client within a few days of birth quizlet?Terms in this set (195) Which situation should concern the nurse treating a postpartum client within a few days of birth? The client feels empty since she gave birth to the neonate.
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What postpartum client should the nurse monitor most closely for signs of a postpartum infection?
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