NURS 2150 Postpartum Complications

Which nursing measure is appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?

• Roll a bath blanket and place it firmly behind the knees.
•  Limit oral intake of fluids for the first 24 hours.
• Assist woman in performing leg exercises every 2 hours.
• Ambulate the woman as soon as her vital signs are stable.

A multiparous woman is admitted to the postpartum unit after a rapid labor and birth of a 4000-gram infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the woman void and massages her fundus, but her fundus remains difficult to find and the rubra lochia remains heavy. The nurse should

• Continue to massage the fundus
•  Insert a Foley catheter
• Recheck vital signs
• Notify the physician

What temperature indicates the presence of postpartum infection?

• 99.6 °F in the first 48 hours
•  100 °F for 2 days postpartum
•  100.8 °F on the second and third postpartum days 
•  100.4 °F in the first 24 hours

A sign of thrombophlebitis is

•  Visible varicose veins
• Negative Homan’s sign
•  Local tenderness, warmth, and redness
• Pedal edema in the affected leg

The nurse is aware that because of excess blood loss during delivery, the woman is at risk for hypovolemic shock. What is one of the earliest signs that shock is occurring?

•  Increase in respirations
•  Tachycardia
• Decrease in urinary output
• Woman is anxious and confused

The nurse knows that late postpartum hemorrhage can be prevented by

•  Administering broad-spectrum antibiotics
• Manually removing the placenta
• Inspecting the placenta after delivery
•  Pulling on the umbilical cord to hasten the delivery of the placenta

The nurse is assessing a woman that delivered 1 hour ago. She noted the uterus is boggy. What should the first interventions be for this woman?

• Notify the nurse-midwife.
• Massage the uterus until firm. 
• Administer Pitocin.
• Have the woman void.

Which woman is at greater risk for early postpartum hemorrhage?

•  A gravida 1 who delivered mature twins
•  A gravida 2 who delivered a premature baby girl
• A gravida 3 who delivered a 5-pound baby girl
•  A gravida 1 who delivered a 7-pound baby boy

What drug should be readily available when a woman is receiving heparin therapy?

• Vitamin K
• Methylergonovine
• Ferrous sulfate
• Protamine sulfate

One hour after a woman gives birth vaginally, the nurse notes that her fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. Lochia rubra is moderate. Her perineum is slightly edematous, with not bruising; an ice pack is in place. The priority nursing action is to:

• chart the expected assessments.
• have the woman empty her bladder in the bathroom.
• change the perineal ice pack to a warm pack.
• increase the rate of the oxytocin infusion.