Silvestri Chapter 24 Ed#554

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 024 (edited file)—"The Postpartum Period and Associated Complications" 10/14/08, Page 1 of 10, 2 Figure(s), 0 Table(s), 4 Box(es)

24: The Postpartum Period and Associated Complications PRACTICE QUESTIONS 1. A nurse palpates the fundus and checks the character of the lochia of a postpartum client in the fourth stage of labor. The nurse expects the lochia to be: 1. White 2. Pink 3. Serosanguineous 4. Red Answer: 4 Rationale: The color of the lochia during the fourth stage of labor is bright red. This may last from 1 to 3 days. The color of the lochia then changes to a pinkish brown that lasts 4 to 10 days. Finally, the lochia changes to a creamy white color that lasts approximately 10 to 14 days. Test-Taking Strategy: Focus on the key words, fourth stage of labor. This will direct you to option 4. Review postpartum expected findings if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 193. 2. After episiotomy and delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. The nurse determines that: 1. This is a normal expectation after episiotomy. 2. The perineal assessment should be performed more frequently. 3. The bright red bleeding is abnormal and should be reported. 4. The mother should be allowed bathroom privileges only. Answer: 3 Rationale: Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Test-Taking Strategy: Note the key words, bright red. This should be an indication that the flow is not normal. Review lochial flow and complications associated with episiotomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 204. 3. A nurse is assigned to care for a client in the postpartum period. The client asks the nurse

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 024 (edited file)—"The Postpartum Period and Associated Complications" 10/14/08, Page 2 of 10, 2 Figure(s), 0 Table(s), 4 Box(es)

what the term involution means. The nurse responds to the client, knowing that involution is: 1. A progressive descent of the uterus into the pelvic cavity occurring approximately 1 cm/day 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity occurring at a rate of 2 cm/day 4. The inverted uterus returning to normal Answer: 1 Rationale: Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs approximately one fingerbreadth, or approximately 1 cm/day. Test-Taking Strategy: Use medical terminology to help you in defining the word “involution.” This will assist in directing you to the correct option. Review the process of involution if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 384. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 465. 4. A mother is breast-feeding her newborn baby and experiences breast engorgement. The nurse encourages the mother to do which of the following measures to provide comfort for the engorgement? 1. Breast-feed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3. Massage the breasts before feeding to stimulate let-down. 4. Avoid the use of a bra while the breasts are engorged. Answer: 3 Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding. Test-Taking Strategy: Use the process of elimination to answer the question. Eliminate option 1 because of the absolute word “only.” From the remaining options, recalling the self-care measures to promote comfort to the mother with breast engorgement will assist in directing you to option 3. Review these measures if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 185. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 587-588. 5. A nurse is assisting in developing a plan of care for a client in the fourth stage of labor. Which of the following problems is most likely to occur during this stage? 1. Pain because of the process of labor or birth 2. Anxiety related to childbirth

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3. Fatigue resulting from physical exertion during labor 4. Urinary retention caused by the loss of sensation to void and rapid bladder filling Answer: 4 Rationale: The fourth stage of labor is the first hour postpartum, when the woman’s body begins to readjust and relax. Options 1 and 2 relate to the first stage of labor. Option 3 relates to the second stage of labor. Option 4 is related to the third and fourth stages of labor. Test-Taking Strategy: Use the process of elimination. Focus on the key words, fourth stage of labor. Remembering that the fourth stage of labor is the last stage will direct you toward the correct option. Review the stages of labor if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 92. 6. After delivery, a nurse checks the height of the uterine fundus. The nurse expects that the position of the fundus would most likely be noted: 1. At the level of the umbilicus 2. Above the level of the umbilicus 3. One fingerbreadth above the symphysis pubis 4. To the right of the abdomen Answer: 1 Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. Test-Taking Strategy: Note the key words, after delivery. Remember that, 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. Review expected postdelivery findings if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 192. Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.).St. Louis: Mosby, p. 619. 7. A nurse is caring for a postpartum client. Four hours postpartum, the client’s temperature is 102˚ F (38.9˚ C). The appropriate nursing action would be to: 1. Continue to monitor the temperature. 2. Notify the registered nurse, who will then contact the physician. 3. Apply cool packs to the abdomen. 4. Remove the blanket from the client’s bed. Answer: 2 Rationale: In the postpartum period, the mother’s temperature may be elevated during the first

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 024 (edited file)—"The Postpartum Period and Associated Complications" 10/14/08, Page 4 of 10, 2 Figure(s), 0 Table(s), 4 Box(es)

24 hours as a result of dehydration. However, if the temperature is more than 2˚ F above normal, this may indicate infection, and the physician will need to be notified. Test-Taking Strategy: Use the process of elimination. Focus on the key words 4 hours and 102˚ F. Noting that the temperature is extreme compared with the normal temperature will direct you to option 2. Review the expected findings in the postpartum period if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 208, 292. 8. A nurse is assigned to care for a client in the immediate postpartum period who received epidural anesthesia for delivery, and the nurse monitors the client for complications. Which of the following would best indicate a hematoma? 1. Complaints of a tearing sensation 2. Complaints of lower abdominal discomfort 3. Changes in vital signs 4. Signs of heavy bruising Answer: 3 Rationale: Changes in vital signs indicate hypovolemia in the anesthetized postpartum woman with vulvar hematoma. Options 1 and 2 are inaccurate for a client who is anesthetized. Heavy bruising may be noted, but vital sign changes are most likely to indicate the presence of a hematoma. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 first. Because the woman is anesthetized, she cannot feel pain or lower abdominal discomfort. Option 4 (heavy bruising) may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues. Review the signs of a hematoma if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 287. Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.). St. Louis: Mosby, p. 1038. 9. A nurse is assisting in planning care for the postpartum woman who has small vulvar hematomas. To assist in reducing the swelling, the nurse should: 1. Check the vital signs every 4 hours. 2. Prepare a heat pack for application to the area. 3. Measure the fundal height every 4 hours. 4. Prepare an ice pack for application to the area. Answer: 4 Rationale: Application of ice will reduce swelling caused by hematoma formation in the vulvar

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 024 (edited file)—"The Postpartum Period and Associated Complications" 10/14/08, Page 5 of 10, 2 Figure(s), 0 Table(s), 4 Box(es)

area. Options 1, 2, and 3 will not reduce the swelling. Test-Taking Strategy: Use the process of elimination. Focus on the issue of the question, “reducing the swelling.” This will assist in eliminating options 1 and 3. Recalling the principles related to heat and cold will direct you to option 4 from the remaining options. Review nursing care of the client with a hematoma if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 287. 10. A client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client’s systolic blood pressure (BP) drops 20 points, the diastolic BP drops 10 points, and the pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse would plan to: 1. Monitor fundal height. 2. Apply perineal pressure. 3. Prepare the client for surgery. 4. Reassure the client. Answer: 3 Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Options 1, 2, and 4 would not assist in controlling the bleeding in this emergency situation. Test-Taking Strategy: Focus on the information provided in the question. Noting the signs and symptoms in the question indicates the presence of bleeding. This should direct you to option 3. Review nursing interventions related to vulvar hematomas if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.). St. Louis: Mosby, pp. 1040-1041. 11. A nurse is assigned to care for a client after cesarean section. To prevent thrombophlebitis, the nurse encourages the woman to: 1. Ambulate frequently. 2. Apply warm, moist packs to the legs. 3. Remain on bed rest with the legs elevated. 4. Wear support stockings. Answer: 1 Rationale: Stasis is believed to be a major predisposing factor in the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis. Options 2, 3, and 4 are implemented if thrombophlebitis occurs.

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Test-Taking Strategy: Focus on the issue of the question, prevention of thrombophlebitis. Options 2, 3, and 4 are implemented if thrombophlebitis occurs. Ambulating frequently (option 1) is a preventive measure. Review content related to the prevention of thrombophlebitis in the postoperative period if you had difficulty with this question Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 291. 12. A postpartum client has developed thrombophlebitis. The nurse knows that the affected extremity should be elevated by: 1. Elevating it on two pillows 2. Elevating the foot of the bed only 3. Placing the bed in reverse Trendelenburg position 4. Placing the bed in Trendelenburg position Answer: 4 Rationale: Placing the bed in Trendelenburg position rather than flexing the leg at the hip promotes venous drainage. The reverse Trendelenburg position will not aid in promoting venous return. Elevating the extremity by using a pillow or elevating the foot of the bed will cause flexion at the hip, thus impeding venous drainage. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination. Eliminate option 2 first because of the absolute word “only.” From the remaining options, recalling that flexion at the hip area restricts venous flow will direct you to option 4. Review these concepts if you had difficulty answering this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.). St. Louis: Mosby, p. 1046. 13. A nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check: 1. Level of consciousness (LOC) 2. Fundal height 3. Presence of Homans’ sign 4. Vital signs Answer: 4 Rationale: Pulmonary embolism is a complication of thrombophlebitis. Vital signs will be one of the first changes to occur with pulmonary embolism as pulmonary blood flow is compromised. LOC may change as the condition worsens and would indicate hypoxia. Homans’ sign is an indicator of thrombophlebitis. Fundal height is unrelated to the issue of the question. Test-Taking Strategy: Note the key word, initially. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 4. Review the complications of thrombophlebitis

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if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.). St. Louis: Mosby, p. 1046. 14. A nurse suspects that a client has a pulmonary embolism. The most important nursing action is to: 1. Administer oxygen by face mask, as prescribed. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Monitor vital signs. Answer: 1 Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Options 2 and 4 may be a component of the plan of care but are not the most important action. The nurse would not increase the IV rate without a physician’s order to do so. Test-Taking Strategy: Note the key words, most important, and use the ABCs—airway, breathing, and circulation. This will direct you to option 1. Review care of the client in the event of a pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 291. 15. A nurse notes that the 4-hour postpartum client has cool, clammy skin, and is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then: 1. Encourages ambulation 2. Checks vital signs 3. Begins fundal massage 4. Encourages the client to drink fluids Answer: 2 Rationale: Symptoms of hypovolemia include cool, clammy, pale skin, feelings of anxiety, restlessness, and thirst. The nurse would check the vital signs. The nurse would not ambulate the client or encourage fluids until specific orders are given to do so. There is no information in the question to indicate the need for fundal massage. Test-Taking Strategy: Focus on the symptoms in the question. Use the ABCs—airway, breathing, and circulation—to assist in directing you to option 2. Review nursing care for the client with hypovolemia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum

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Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 287. 16. A new mother attempting breast-feeding for the first time has developed mastitis. She states, “My breasts look terrible and I think that I will stop breast-feeding.” The nurse plans care, knowing that the client’s statement relates to: 1. Body image 2. Newborn nutrition 3. Feelings of inadequacy 4. Infection Answer: 1 Rationale: Inflammation and engorgement are symptoms of mastitis that may alter the new breast-feeding mother’s body image. The client’s statement does not relate to a problem with newborn nutrition, inadequacy, or infection. Test-Taking Strategy: Focus on the information in the question and use the process of elimination. Noting the key words, My breasts look terrible, will direct you to option 1. Review the psychosocial issues related to mastitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 41, 293. 17. Breast-feeding instructions for the postpartum mother should include avoidance of soaps on the nipples, frequent changing of breast pads, intermittent exposure of nipples to air, and hand washing before handling the breast and before breast-feeding. The nurse understands that these measures are specific to the prevention of: 1. Engorgement 2. Newborn colic 3. “Let-down” reflex 4. Mastitis Answer: 4 Rationale: Mastitis is an infection frequently associated with a break in the skin surface of the nipple. The measures described in the question are personal hygiene measures to help prevent mastitis. The data in the question is unrelated to options 1, 2, and 3. Test-Taking Strategy: Use the process of elimination and knowledge of the cause and prevention of mastitis to answer this question. Focusing on the data in the question will assist in directing you to option 4. Review the preventive measures for mastitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 294. 18. The new breast-feeding mother is being discharged from the hospital after being treated for

Silvestri, 3/e, ISBN 1-1460-0052-6 Chapter 024 (edited file)—"The Postpartum Period and Associated Complications" 10/14/08, Page 9 of 10, 2 Figure(s), 0 Table(s), 4 Box(es)

mastitis. The nurse knows that the mother needs further teaching when the mother states: 1. “I need to change my breast pads when they are wet.” 2. “I will wash my breasts gently with plain water.” 3. “My left breast is sore, so I will offer only my right breast frequently for breast-feeding.” 4. “When my breasts feel engorged, I will use an ice pack for the pain.” Answer: 3 Rationale: Failure to nurse equally on both sides will decrease the flow of milk through the breast, causing engorgement of the breast that has been offered less frequently. Options 1, 2, and 4 are appropriate measures. Test-Taking Strategy: Note the key words, needs further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Use knowledge regarding the treatment for mastitis and the process of elimination to select the correct option. Review the concepts related to breast-feeding and mastitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 294. 19. A postpartum client with a pulmonary embolism has been separated from her newborn infant for 2 days. Which observation by the nurse indicates a potential client need? 1. The client nurses her newborn infant in the side-lying position. 2. The client needs the head of the bed elevated for comfort. 3. The newborn infant prefers the bottle over breast milk. 4. The client turns herself from side t side. Answer: 3 Rationale: Breast-feeding will be compromised and the newborn infant may begin to prefer the bottle over the breast if the mother and newborn are separated for an extended period. When the mother’s condition is stable after being separated, reestablishing breast-feeding should be a nursing priority. Options 1, 2, and 4 do not indicate the need for intervention. Test-Taking Strategy: Use the process of elimination, focusing on the key words, separated from her newborn infant for 2 days. This should easily direct you to option 3. Review the concepts related to maternal-infant bonding if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity and pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 153, 223. 20. A nurse is assisting in caring for a postpartum client experiencing uterine hemorrhage. In planning to meet the psychosocial needs of the client, the nurse would: 1. Keep the client and her family members informed of progress. 2. Monitor vital signs every 2 hours. 3. Maintain strict bed rest.

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4. Perform firm fundal massage every 2 hours. Answer: 1 Rationale: Keeping the client and her family informed of her condition will help minimize fear and apprehension. Options 2, 3, and 4 identify physiological interventions. Test-Taking Strategy: Use the process of elimination. Focus on the key words, meet the psychosocial needs. Option 1 is the only option that addresses psychosocial needs. Review the interventions that will meet the psychosocial needs of a client if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity and woman’s health care (8th ed.). St. Louis: Mosby, p. 44. 21. A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Select all instructions that would be included on the list. ____Take the prescribed antibiotics until the soreness subsides. ____Wear a supportive bra. ____Avoid decompression of the breasts by breast-feeding or breast pump. ____Rest during the acute phase. ____Continue to breast-feed if the breasts are not too sore. Answers: Wear a supportive bra Rest during the acute phase Continue to breast-feed if the breasts are not too sore Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, maintaining a fluid intake of at least 3000 mL/day, and analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. Antibiotics are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs and wearing a supportive bra. Continued decompression of the breast by breast-feeding or breast pump is important to empty the breast and prevent the formation of an abscess. Test-Taking Strategy: Think about the pathophysiology associated with mastitis. Recalling that supportive measures include rest, moist heat or ice packs, antibiotics, analgesics, breast support, and decompression of the breasts will assist in answering the question. Review the measures to treat mastitis if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 792-793.