Maternity Quiz #3 Review 2

A new nurse is assessing a client T.N. delivered a healthy male newborn 2 hours ago. She had a midline episiotomy and an epidural block for her labor and delivery. She is now admitted to the postpartum unit.

Which of the following documentation requires intervention and follow-up from the preceptor?

• BP 102/68 upon client sitting down

• Lochia rubra in color

• Fundal height and position: within normal limits

• Epidural site absence of swelling, redness, foul odor and skin is intact

Answer explanation

There is not documentation of the height of the fundus and it's relation to the midline umbilicus.

Typical assessments include:

Vital signs: BP might be low because of epidural; temperature might be slightly elevated because of exertion. With an epidural, the client has an IV line, so dehydration should not be a concern.

Fundal height and position: This patient might have an enlarged fundus because of multigravida status. The baby’s size might also be a factor.

Lochia: This might be more profuse for a multigravida and if fundus feels boggy. It should be rubra in color.

Episiotomy: Assess for swelling, discoloration, perineal pain characteristics and severity

Urinary output: She should void in 6 to 8 hours. Encourage fluid intake to promote voiding.

Bowel elimination: This might be sluggish for a few days. Stool softeners may be needed. T.N. should be coached to avoid straining when voiding or defecating.

Lower extremities: Blood pooling or clots might occur. Assess for unilateral calf swelling and tenderness.

Breasts: For tenderness and engorgement, she might need warm packs or ice packs if electing not to breastfeed.

Assess for afterpains: The uterus is contracting—it works harder with successive deliveries. If the woman is breastfeeding, oxytocin is released more frequently.

Emotional status: Assess T.N.’s feelings after delivery. Inquire whether she has any questions or concerns regarding her physical or emotional well-being. Remind her that it is important for her to also care for herself and not just her infant. This is her fifth child; inquire about her support system after discharge.

You find a boggy fundus during your assessment. What action(s) will you take?

Answer explanation

Massage uterine fundus until firm. If it does not remain firm, additional oxytocin can be given as ordered. Assess for a full bladder, which can prevent the uterus from contracting normally.

The patient complains of pain and discomfort in her perineal area. What is your next priority action?

• Inspect the perineum and episiotomy site

• Encourage sitz bath

• Apply ice to the area

• Notify the physician

Answer explanation

• Inspect her perineum and the episiotomy site.

• Apply an ice bag to perineum, use topical anesthetic spray, and give pain medications as ordered.

• Encourage sitz baths using cool water for the first 24 hours to decrease edema and warm sitz baths after 24 hours to promote circulation and healing.

The nurse reviews the hospital security guidelines with patient, T.N. The nurse points out that her baby has a special identification bracelet that matches a bracelet worn by T.N. and reviews other security procedures. Which statement by T.N. indicates a need for more teaching?

• “Nurses on this unit all wear the same purple uniforms.”

• “If I have a question about someone’s identity, I can ask about it.”

• “Each staff member who takes my baby somewhere will have a picture identification badge.”

• “If someone takes my baby for an examination, that person will carry my baby to the examination room.”

Answer explanation

It is essential to teach new parents about the importance of checking the identity of any person who comes into the room to remove the baby. Picture identification badges should be checked. Often unit staff members will wear matching uniforms. If a baby is taken to another location, the baby is wheeled in a bassinet, not carried in a staff member’s arms.

An hour after admission, you recheck T.N.’s perineal pad and notice there is a very small amount of drainage on the pad. What is your next priority?

• Ask T.N. to change her perineal pad

• Check the perineal pad again in 1 hour

• Check the pad underneath T.N.'s buttocks

• Document the findings in T.N's medical record

Answer explanation

When assessing for postpartum bleeding, it is important to check underneath the woman’s buttocks. Blood may flow between the buttocks onto the linens under the mother, and excessive bleeding might go undetected if this area is not also checked.

In the evening after the admission of your patient, T.N., the unlicensed assistive personnel assesses T.N.’s vital signs. What is the priority?

Vital Signs

Temperature

99.9° F (37.7° C) oral

Pulse rate

120 beats/min

Blood pressure

94/50 mm Hg

Respiratory rate

16 breaths/min

• Notify the physician

• Assess for signs of excessive bleeding

• Monitor VS and recheck in 1 hour

• Check the fundus

Answer explanation

The elevated pulse (tachycardia) and the hypotension (low blood pressure) may suggest hypovolemia, possibly because of excessive bleeding. During the first 24 hours of the postpartum period, the temperature may rise slightly, but a temperature elevation is not of concern unless it exceeds 100.4° F (38° C). The respirations are within the normal range.

What will you do next?

• Assess for signs of excessive postpartum bleeding. Assess the color, amount, and odor of the lochia and whether there is any blood underneath the patient’s buttocks.

• Check the uterine fundus, and, if it feels boggy, massage it until it feels firm.

• Monitor VS closely and notify provider if BP or pulse does not improve.

Two hours later, you perform another perineal pad check and note the findings in the diagram. How will you describe the amount of drainage in your note?

 

• Scant

• Light

• Heavy

• Moderate

Answer explanation

The nurse examines the extent of perineal pad saturation to assess blood loss after birth. Light saturation is estimated to be less than 10 cm of drainage.

Your patient, T.N. is now stable after her PPH. You are to provide patient teaching. T.N. is to teach back what she learned to you. Which of the following indicates that T.N. needs additional education?

• "I will wipe from front to back after voiding or defecating. I can use a squirt bottle with hot soapy water to cleanse the area."

• I should wash my hands before and after perineal care.

• I should increase my fluid intake for rehydration and to prevent constipation that could give me more complications.

• I should ambulate as often as possible to prevent blood clot formation and constipation.

Answer explanation

These are all appropriate teachings:

Perineum care: Always wipe from front to back after voiding or defecating; wash perineum with warm water using a squirt bottle, apply anesthetic ointment or spray as ordered, change perineal pads frequently, and be careful to wash hands before and after perineum care.

Fluids: Encourage fluid intake for rehydration and to prevent constipation.

Ambulation: Encourage early ambulation to prevent blood clot formation and constipation.

Feeding: Facilitate infant feeding.

Newborn care: Include aspects of cord site care, bathing, feeding, normal growth and development, vaccinations, follow-up appointments.

Danger signs: Excessive bleeding and signs and symptoms of infections (chills, fever over 100.4° F (38° F), redness of breast or incisions, foul-smelling discharge).

Postpartum exercises: Teach Kegel exercises to strengthen perineal muscles and other exercises to strengthen abdominal muscles.

Sexual activity: Without contraception, it is possible to get pregnant again a short time after delivery. She will need pelvic rest (no intercourse) until the episiotomy incision has healed. Discuss options for the woman and her partner.

Rest: Adequate rest is very important for health; encourage naps and limiting visitors.

Your patient, T.N. tells you she must go back to work in 6 weeks and is not sure she can continue breastfeeding. Which of the following options of resources would not be best for her at this time?

• Obtain a lactation specialist consult to help with transitioning

• Have her inquire at her workplace about the availability of lactation rooms

• Inform her that 'breast is best" and that she should do all that she can to make sure her baby is properly fed.

• Breast milk can be frozen and give to her baby while she is at work.

Answer explanation

• "Fed is best" is our new evidence based motto.

• Reminder her that breastfeeding is less expensive and less time-consuming because no preparation of formula is needed. Assure her that she can continue breastfeeding. Pumps are available and take little time to use.

• Have her inquire at her workplace about the availability of lactation rooms or other private areas where she can pump her breasts.

• Breast milk can be frozen and given to her baby in a bottle while she is at work.

• Babies can be brought to the workplace for feeding if appropriate.

• If she wants to stop breastfeeding, she can begin decreasing the number of breastfeedings by 1 (and increase the number of bottle-feedings by 1) every 2 or 3 days until she breastfeeds mornings and evenings only or stops altogether.

• Obtain a lactation specialist consultation to assist her with her transition back to a work schedule.

The perinatal nurse routinely screens pregnant women for postpartum depression. Which woman does the nurse screen as the priority?

• First pregnancy

• Age 35 years or older

• Ambivalent at first visit

• Adolescent

Answer explanation

Recognized risk factors for postpartum depression include an undesired/unplanned pregnancy, a history of depression, recent major life changes such as the death of a family member, moving to a new community, lack of family or social support, financial stress, marital discord, adolescent age, and homelessness. Ambivalence is not unusual, especially in the first trimester. First pregnancy is not a risk factor.