Normal Postpartum

Normal Postpartum

Multiple Choice

A rubella vaccine is administered to a client who delivered a healthy newborn infant 2 days ago. The nurse provides instructions to the client regarding the potential risks associated with the vaccination. Which statement by the client indicates and understanding of the medication?

• "I need to stay out of the sunlight for 3 days."

• "The injection site may itch, but I can scratch it if I need to."

• "I need to avoid sexual intercourse for 4-6 weeks after the vaccination."

• I need to prevent becoming pregnant for 4-6 weeks after the vaccination."

"I need to prevent becoming pregnant for 4-6 weeks after the vaccination."

Because rubella is a live vaccine, it will as as the virus and is considered a teratogen for the developing embryo. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 4-6 weeks afterward. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used. The vaccine may cause local or systemic reactions, bu all are mild and short-lived. Sunlight has no effect on the person who is vacinated.

Multiple Choice

A nurse in the postpartum unit is developing a nursing care plan for a client following a cesarean delivery. The nurse documents which intervention in the plan of care that will assist in preventing thrombophlebitis?

• Frequent ambulation

• Wearing support stockings

• Applying warm moist packs to the legs

• Remaining on bedrest with the legs elevated

Frequent ambulation

Stasis is believed to be a major predisposing factor in the development of thrombophlebitis. Because cesarean delivery is a risk factor for the development of thrombophlebitis, the mother should ambulate early and frequently to moted circulation and prevent stasis. Bedrest is discouraged. Warm moist packs will not prevent thrombophlebitis. Support stockings may be a helpful measure in treating thrombophlebitis.

Multiple Choice

A nurse is performing an assessment on a mother who just delivered a healthy newborn infant. The nurse checks the uterine fundus, expecting to note that the fundus is positioned:

• To the right of the abdomen

• At the level of the umbilicus

• Above the level of the umbilicus

• One fingerbreadth above the symphysis pubis

At the level of the umbilicus

Immediately after delivery the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus may need to be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.

Multiple Choice

A nurse is developing goals for the postpartum client who is at risk for uterine infection. Which goal would be most appropriate for this client?

• The client will verbalize a reduction of pain.

• The client will report how to treat an infection.

• The client will no longer have a positive Homan sign.

• The client will be able to identify measures to prevent infection.

The client will be able to identify measures to prevent infection.

The uterus is theoretically sterile during pregnancy until the membranes rupture. However, it is capable of invaded by pathogens after membrane rupture. Options 1 and 3 are unrelated to the subject of infection. Option 4 is a goal for the client who is at risk for infection.

Multiple Choice

A nurse teaches a postpartum client about observation of lochia. The nurse determines the client's understandin when the client says that on the second day postpartum the lochia should be:

• Red

• Pink

• White

• Yellow

Red

The uterus rids itself of the debris that remains after birth through a discharge called "lochia", which is classified according to its appearance and contents. Lochia rubra is dark red in color. It occurs from delivery to 3 days postpartum. Lochia serosa is a brownish pink discharge that occurs from days 4-10. Lochia alba is a white discharge that occurs from day 10-14 and can last up to 4-6 weeks postpartum. Lochia should not be yellow in color or contain large clots; if it does, the cause should be investigated without delay.

Multiple Choice

A nurse is caring for a pospartum client,

Which finding would make the nurse suspect endometritis in this client?

• Breast engorgement

• Elevated white blood cell count

• Lochia rubra on the second day postpartum

• Fever over 100.4 beginning 2 days postpartum

Fever over 100.4 beginning 2 days postpartum

The presence of fever of 100.4 or more 2 successive days of the first 10 postpartum days ( not counting the first 24 hours after birth) is indicative of a postpartum infection. Lochia rubra on the second day postpartum is a normal finding. The white blood cell count of a postpartum woman is normally elevated. Breast engorgement is also a normal response in the postpartum period and is not associated with endometritis.

Multiple Choice

A client is in the first hour of her recovery after a vaginal delivery. During an assessment, the lochia is moderate, bright red, and is trickling from the vagina. The nurse locates the fundus at the umbilicu: it is firm and midline with no palpable bladder. The client's bital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions?

• Increase the IV rate.

• Recheck the admission hematocrit and hemoglobin levels.

• Report the findings to the health care provider.

• Document the findings as normal

Report the findings to the health care provider.

At any point in the postpartum period, the lochia should be dark in color, rather than bright red. The volume shoul not be great enough to trickle or run from the vagina. The information provided states the fundus is firm, midline, and at the umbilicus, which are the expected outcomes at this point postpartum. These findings would indicate to the nurse that the bleeding is not coming from the uterus or from uterine atony. The bladder is not palpable, which indicates the the bleeding is not related to a full bladder, which is further validated by the fundus being at the umbilicus. The most likely etiology is cervical or vaginal lacerations or tears. The nurse is unable to do anything to stop this type of bleeding and must notify the healthcare provider.

Multiple Choice

In response to the nurse's question about how she is feeling, a postpartum client states that she is fine. She then begins talking to the baby, checking the diaper, and asking infant care questions. The nurse determines the client is in which postpartal phase of the psychological adaptation?

• Taking in

• Taking on

• Taking hold

• Letting go

Taking hold

The client is in the taking hold phase with demonstrated focus on the neonate and learning about and fulfilling infant care and needs.The taking in phase is the first period after delivery where there is emphasis on reviewing and reliving the labor and delivery process, concern with self, and needing to be mothered. Eaqqting and sleep are high priorities during this phase. Taking on is not a phase of postpartum psychological adaptation. Letting go is the process beginning about 6 weeks postpartum when the mother may be preparing to go back to work. During this time, she can have other individuals assume care of the infant and begin the separation process.

Multiple Choice

A G7 P7 client has just delivered a large for gestational age (LGA) infant. The nurse determines the client's primary risk is for:

• Knowledge deficit

• Acute pain

• Ineffective breast-feeding

• Fluid volume deficit

Fluid volume deficit

The primary risk is for fluid volume deficit related to blood loss. The client is at increased risk for uterine atony and therefore increased blood loss due to having given birth to 5 or more children and having a large infant. The client may be at risk for pain, ineffective breast-feeding, and knowledge deficit, but there is not enough information to indicate that these are priority problems at this timie

Multiple Choice

A multiparous client visits the urgent care center 5 days after a vaginal delivery experiencing persitstant locka rubra in a moderated to heavy amount. The client asks the nurse, "Why am I continuing to bleed like this?" The nurse should instruct the client that this type of postpartum bleeding is usually caused by which of the following?

• Uterine atony

• Cervical lacerations

• Vaginal lacerations

• Retained placental fragments.

Retained placental fragments.

The most likely cause of delayed postpartum hemorrhage is retained placental fragments. The client may be scheduled for a D & C to remove the remaining placental fragments. Uterine atony, cervical lacerations and vaginal lacerations are commonly associated with early not late postpartum hemorrhage.