POSTPARTUM

A nurse is caring for a client who is 36 hr postpartum and has a distended bladder. The client reports saturating four perineal pads in the past hour. Which of the following actions should the nurse take? (Select all that apply.)

• Palpate the fundus for location and tone.

• Check the client's blood pressure and pulse

• Place the client in reverse Trendelenburg position.

• Administer intravenous infusion of 0.9% sodium chloride

• Look under the client's buttocks

Answer explanation

Palpate the fundus for location and tone is correct. The uterus should be firm and midline and at the appropriate fundal height for the postpartum period. Some causes of a boggy or displaced uterus include a distended bladder, uterine atony, or a retained placenta.Check the client's blood pressure and pulse is correct. The client's vital signs should be carefully monitored for indications of hypovolemic shock due to excessive blood loss. Maternal hemorrhage continues to be the leading cause of maternal mortality.Place the client in reverse Trendelenburg position is incorrect. The client should be tilted on her side or have her right hip elevated. Her legs should be elevated to at least a 30° angle.Administer intravenous infusion of 0.9% sodium chloride is correct. Intravenous fluids will help to restore or maintain circulatory blood volume.Look under the client's buttocks is correct. An important nursing action includes monitoring and visualizing the amount of lochia. The nurse should monitor the amount of lochia on the perineal pad and observe for any pooling of lochia under the buttocks. A perineal pad saturated in 15 min or less could be an indication of postpartum hemorrhage

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

• Apply an ice pack to the perineum

• Prepare a warm sitz bath

• Place a soft pillow under the client's buttocks

• Position a heating lamp toward the episiotomy

Answer explanation

During the first 24 hr, ice packs and cool water sitz baths should be used. This should reduce edema and reduce discomfort. The client can also apply witch hazel compresses to reduce edema. The nurse should also teach the client to use prescribed creams, sprays, and ointments.

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

• Lack of appetite

• Expressions of excitement

• Focus on the family unit and its members

• Eagerness to learn newborn care skills

Answer explanation

Expressing excitement and being talkative are characteristic of this phase

A nurse is collecting data from a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication?

• Chills shortly following delivery

• Fundus at umbilicus level

• ​Urinary output 3,000 mL/12 hr

• Heart rate 110/min

Answer explanation

A rapid or increasing heart rate can be a sign of fluid volume depletion related to hemorrhage. The nurse should further evaluate the client for postpartum hemorrhage

A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30-min period. Which of the following actions should the nurse take first?

• Check the consistency of the client’s uterine fundus.

• Have the client use the bedpan to urinate

• Prepare to administer oxytocic medication.

• ​Increase the client’s fluid intake

Answer explanation

​Although the nurse should expect moderate bleeding in the first 2 hr after delivery, saturating a perineal pad in 15 min or less indicates excessive blood loss. The first action the nurse should take, using the nursing process, is to collect data from the client. Therefore, the nurse should determine the consistency of the client’s fundus first. If it is boggy, fundal massage might control the bleeding.

A nurse is caring for a postpartum client who saturates a perineal pad in 10 min. Which of the following actions should the nurse take first?

• Check the client’s blood pressure

• Observe for pooling of blood under the buttocks.

• Massage the client’s fundus

• Administer oxytocin.

Answer explanation

The nurse’s priority action is to increase uterine tone by massaging the client’s fundus. A boggy fundus leads to an increase in uterine bleeding.

A nurse is collecting data from a postpartum client and notes the client’s fundus is boggy and displaced to the right. Which of the following actions should the nurse take?

• Encourage the client to perform Kegel exercises

• Position the client on her left side

• Ask the client to rate her pain

• Assist the client to the bathroom to void.

Answer explanation

The nurse should assist the client to the bathroom to void as uterine atony can be caused by bladder distention. A full bladder prevents the uterus from contracting and displaces it to one side

A nurse is collecting data from a client who is postpartum 2 hr following delivery of a healthy newborn. Which of the following findings indicates the client’s bladder is distended?

• Increased uterine contractions

• Decreased lochia

• ​Elevated fundus level

• Heart rate 52/min

Answer explanation

If the bladder is distended, it will push the uterus up out of the pelvis above the umbilicus, thus elevating the level of the fundus.

A nurse is caring for a client who is postpartum and asks, "When will my breast milk come in?" Which of the following responses should the nurse make?

• ​Within 2 days after delivery

• ​In 3 to 5 days after delivery

• In 6 to 8 days after delivery

• In about 10 days after delivery

Answer explanation

​By day 3 to 5, most clients who are breastfeeding begin to produce copious amounts of breast milk.

A nurse is preparing to administer methylergonovine IM for a client who had a vaginal delivery earlier that day. The nurse should explain to the client that this medication will help prevent which of the following?

• ​Postpartum infection

• Hypertension

• Postpartum hemorrhage

• Thromboembolic events

Answer explanation

​Methylergonovine is an oxytocic. It causes uterine contractions to help control postpartum bleeding.