Postpartum Nursing

After delivering a 9 lb 10 oz infant vaginally, a client who is gravida 5 para 5 is admitted to the postpartum unit. Priority nursing care for the client should be to:

• palpate the fundus because she is at risk for uterine atony

• offer fluids, since multiparas generally dehydrate faster during labor

• perform passive range of motion on extremities because she is at risk for thromboembolism

• assess the client's diet because she is at risk for anemia

The nurse notes the following maternal attachment behaviors. Which behavior indicates the need for further observation?

• Talks to the baby during feedings

• Hold the baby in the en face position

• Does not pick up the baby when he or she cries to avoid "spoiling"

• Refers to the baby as "my little angel"

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?

• A temperature of 100.4 F

• Increase in the pulse from 88 to 102 bpm

• Increase of respiratory rate from 18 to 22

• A blood pressure change from 130/88 to 124/82

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?

• "I need to take antibiotics, and I should begin to feel better in 24-48 hours.”

• “I can use analgesics to assist in alleviating some of the discomfort.”

• “I need to wear a supportive bra to relieve the discomfort.”

• "I need to stop breastfeeding until this condition resolves.”

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:

• Assess for hypovolemia and notify the health care provider

• Begin hourly pad counts and reassure the client

• Begin fundal massage and start oxygen by mask

• Elevate the head of the bed and assess vital signs

A client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains?

• Bottle-feeding

• Diabetes

• Multiple gestation

• Primiparity

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?

• Hypertension

• Cervical and vaginal tears

• Urine retention

• Endometritis

During a home visit, a postpartum client complains of a reddened, swollen, and tender breast 10 days after delivery. Based on this finding, the nurse would advise the client that

• These symptoms suggest an inflammatory or infectious process and require immediate physician notification.

• She should mention it to her physician at her 2 week check up because it will be abnormal if it continues after 2 weeks

• This is normal breast engorgement and should subside within another week.

• She has to stop breastfeeding immediately until the swelling and redness resolve on their own.

During the first prenatal assessment, the nurse discovers that the client has not had a second vaccination of measles, mumps and rubella. The best plan for this client is to

• Administer the vaccine during this visit.

• Wait until the third trimester to administer the vaccine.

• Administer the vaccine following delivery.

• Omit the vaccine because these are childhood disease not acquired by adults

Your client is concerned that her baby is not latching well. How would you educate her regarding the latch? Check all that apply

• Both your baby’s top and bottom lip are sealed and flanged (turned out)

• You are enjoying a comfortable and pain-free nursing experience

• When finished, your nipple should look similar to its pre-feeding shape (not misshapen or discolored), although some stretching is normal

• Your baby’s nose is close to your breast and your baby’s chin is against your breast

• The latch is asymmetric (off-center) to your nipple. Your nipple should be aiming towards the roof of your baby’s mouth, resulting in more of the bottom of your areola being covered by your baby’s mouth