Postpartum Assessment and Interventions: A Review for Nurses, Exams of Nursing

Download Postpartum Assessment and Interventions: A Review for Nurses and more Exams Nursing in PDF only on Docsity! Saunders Postpartum Period Assessment Questions with Solutions The postpartum nurse is taking the vital signs of a Client who delivered a healthy newborn 4 hours Ago. The nurse notes that the client's temperature Is 100.2°F. What is the priority nursing action? 1. Document the findings. 2. Retake the temperature in 15 minutes. 3. Notify the health care provider (HCP). 4. Increase hydration by encouraging oral fluids. - 4 Rational le: The client's temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4°F (38°C) in the first 24 hours after birth often are related to The dehydrating effects of labor. The appropriate action is to Increase hydration by encouraging oral fluids, which should Bring the temperature to a normal reading. Although the nurse Also would document the findings, the appropriate action Would be to increase hydration. Taking the temperature in Another 15 minutes is an unnecessary action. Contacting the HCP is not necessary. Test-Taking Strategy: Note the strategic word, priority, and Use knowledge regarding the physiological findings in the Immediate postpartum period to answer this question. Recalling That a temperature elevation often is related to the dehydrating Effects of labor will direct you to the correct option. Also, increasing hydration relates to a physiological Client need. Review: Normal postpartum assessment findings The nurse is assessing a client who is 6 hours postpartum After delivering a full-term healthy newborn. The client complains to the nurse of Feelings of faintness and dizziness. Which nursing Action is most appropriate? 1. Raise the head of the client's bed. 2. Obtain hemoglobin and hematocrit levels. 3. Instruct the client to request help when getting Out of bed. 4. Inform the nursery room nurse to avoid bringing The newborn to the client until the client's Symptoms have subsided. - Correct answer 3 Rational le: Orthostatic hypotension may be evident during the First 8 hours after birth. Feelings of faintness or dizziness are Signs that caution the nurse to focus interventions on the client's Safety. The nurse should advise the client to get Help the first few times she gets out of bed. Option 1 is not a Helpful action in this situation and would not relieve the Symptoms. Option 2 requires a health care provider's prescription. Option 4 is unnecessary. Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the subject, client safety. Option 4 is inappropriate And should be eliminated first. Elevating the client's head is Not a helpful intervention. To select from the remaining Options, recall that safety is a primary issue. Review: Postpartum nursing interventions The postpartum nurse is providing instructions to a Client after birth of a healthy newborn. Which time Frame should the nurse relay to the client regarding The return of bowel function? 1. 3 days postpartum 2. 7 days postpartum 3. on the day of birth 4. Within 2 weeks postpartum - Correct answer Rationale: After birth, the nurse should auscultate the client's Abdomen in all 4 quadrants to determine the return of bowel Sounds. Normal bowel elimination usually returns 2 to 3 days Postpartum. Surgery, anesthesia, and the use of opioids and Pain control agents also contribute to the longer period of Altered bowel functions. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Focus on the subject and use general Principles related to postpartum care. Eliminate options 2 And 4 first because of the length of time stated in these options. From the remaining options, eliminate option 3 because it Would seem unreasonable that bowel function would return That quickly in the postpartum woman. Review: Normal gastrointestinal function in the postpartum Client The nurse is planning care for a postpartum client Who had a vaginal delivery 2 hours ago? The client Required an episiotomy and has several hemorrhoids. What is the priority nursing consideration? For this client? 1. Client pain level 2. Inadequate urinary output 3. Client perception of body changes 4. Potential for imbalanced body fluid volume - Correct answer 1 Rationale: The priority nursing consideration for a client who Delivered 2 hours ago and who has an episiotomy and hemorrhoids For follow-up? 1. The client with mild after pains 2. The client with a pulse rate of 60 beats/minute 3. The client with colostrum discharge from both Breasts 4. The client with lochia that is red and has a foul-smelling Odor - Correct answer 4 Rationale: Lochia, the discharge present after birth, is red for The first 1 to 3 days and gradually decreases in amount. Normal Lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, And these findings are not normal. The other options are normal Findings for a 1-day postpartum client. Test-Taking Strategy: Note the strategic words, need for follow-up. These words indicate a n negative event query and the need To select the abnormal assessment finding. Note the words foul-smelling In the correct option. Review: Normal assessment findings in the postpartum client When performing a postpartum assessment on a Client, the nurse notes the presence of clots in the Lochia. The nurse examines the clots and notes that They are larger than 1 cm. Which nursing action is? Most appropriate? 360 UNIT VI Maternity Nursing 1. Document the findings. 2. Reassess the client in 2 hours. 3. Notify the health care provider (HCP). 4. Encourage increased oral intake of fluids. - Correct answer 3 Rationale: Normally, a few small clots may be noted in the Lochia in the first 1 to 2 days after birth from pooling of blood In the vagina. Clots larger than 1 cm are considered abnormal. The cause of these clots, such as uterine agony or retained placental Fragments, needs to be determined and treated to prevent Further blood loss. Although the findings would be Documented, the appropriate action is to notify the HCP. Reassessing The client in 2 hours would delay necessary treatment. Increasing oral intake of fluids would not be a helpful action in This situation. 362 UNIT VI Maternity Nursing Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the words larger than 1 cm. Think about the significance Of lochia clots in the postpartum period to answer Correctly. Review: Normal findings in the postpartum client The nurse is monitoring the amount of lochia Drainage in a client who is 2 hours postpartum And notes that the client has saturated a perinea Pad in 15 minutes. How should the nurse respond? To this finding initially? 1. Document the finding. 2. Encourage the client to ambulate. 3. Encourage the client to increase fluid intake. 4. Contact the health care provider (HCP) and Inform the HCP of this finding. - Correct answer 4 Rational le: Lochia is the discharge from the uterus in the postpartum Period; it consists of blood from the vessels of the placental Site and debris from the decidua. The following can be Used as a guide to determine the amount of flow: scant¼less Than 2.5 cm (< 1 inch) on menstrual pad in 1 hour; light¼less Than 10 cm (< 4 inches) on menstrual pad in 1 hour; moderate¼ Less than 15 cm (< 6 inches) on menstrual pad in 1 hour; heavy¼ Saturated menstrual pad in 1 hour; and excessive¼menstrual Pad saturated in 15 minutes. If the client is experiencing excessive Bleeding, the nurse should contact the HCP in the event that Postpartum hemorrhage is occurring. It may be appropriate to Encourage increased fluid intake, but this is not the initial action. It is not appropriate to encourage ambulation at this time. Documentation should occur once the client has been stabilized. Test-Taking Strategy: Note the strategic word, initially. Focus On the data in the question, a saturated perinea pad in 15 minutes. Next, determine if an abnormality exists. The Data and the use of guidelines to determine the amount of Lochia flow will help you to determine that this is abnormal And warrants notification of the HCP. Review: Assessment of the amount of lochia The nurse has provided discharge instructions to a Client who delivered a healthy newborn by cesarean Delivery. Which statement made by the client Indicates a n eyed for further instruction? 1. "I will begin abdominal exercises immediately." 2. "I will notify the health care provider if I Develop a fever." 3. "I will turn on my side and push up with my Arms to get out of bed." 4. "I will lift nothing heavier than my newborn Baby for at least 2 weeks." - Correct answer 1 Rationale: A cesarean delivery requires an incision made Through the abdominal wall and into the uterus. Abdominal Exercises should not start immediately after abdominal surgery; The client should wait at least 3 to 4 weeks postoperatively to Allow for healing of the incision. Options 2, 3, and 4 are appropriate Instructions for the client after a cesarean delivery. Test-Taking Strategy: Note the strategic words, need for further Instruction. These words indicate a negative event query and Ask you to select an option that is an incorrect statement. Keeping In mind that the client had a cesarean delivery and noting The word immediately in the correct option will assist in directing You to this option. Review: Home care instructions for a client after cesarean Delivery After a precipitous delivery, the nurse notes that the New mother is passive and touches her newborn Infant only briefly with her fingertips. What should The nurse do to help the woman process the Delivery? 1. Encourage the mother to breast-feed soon After birth. 2. Support the mother in her reaction to the newborn Infant. 3. Tell the mother that it is important to hold the Newborn infant. 4. Document a complete account of the mother's Reaction on the birth record. - Correct answer 2 Rationale: Precipitous labor is labor that lasts 3 hours or less. Women who have experienced precipitous labor often describe Feelings of disbelief that their labor progressed so rapidly. To Assist the client to process what has happened, the best option Is to support the client in her reaction to the newborn infant. Options 1, 3, and 4 do not acknowledge the client's feelings. Test-Taking Strategy: Use therapeutic communication techniques. The correct option is the only option that acknowledges The client's feelings. Review: Use of therapeutic communication techniques following Delivery The nurse is monitoring a client in the immediate Postpartum period for signs of hemorrhage. Which Sign, if noted, would be an early sign of excessive Blood loss? 1. A temperature of 100.4 °F (38 °C) 2. An increase in the pulse rate from 88 to 102 Beats/minute 3. A blood pressure change from 130/88 to 124/80 mm Hg Palpable dorsal is pedals pulses are a normal finding. Test-Taking Strategy: Eliminate option 4 first, because this is a Normal and expected finding. Next, eliminate options 1 and 2 Because they are compare able or alike. Review: Super facial van oust the rhombuses A client in a postpartum unit complains of sudden Sharp chest pain and dyspnea. The nurse notes that The client is tachycardia and the respiratory rate is Elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face Mask. - Correct answer 4 Rationale: If pulmonary embolism is suspected, oxygen Should be administered, 8 to 10 L/minute, by face mask. Oxygen Is used to decrease hypoxia. The client also is kept on bed Rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but This would not be the initial nursing action. An intravenous CHAPTER 30 Postpartum Complications 369 Line also will be required, and vital signs need to be monitored, But these actions would follow the administration of oxygen. Test-Taking Strategy: Note the strategic word, initial. Use the ABCs—airway-bra earth in g-car collation—to assist in directing You to the correct option. Review: Therapeutic management of a client with pulmonic ray Embolism Level of Cognitive Ability: Analyzing The nurse is assessing a client in the fourth stage of Labor and notes that the fundus is firm, but that Bleeding is excessive. Which should be the initial? Nursing action? 1. Record the findings. 2. Massage the fundus. 3. Notify the health care provider (HCP). 4. Place the client in Trendelenburg's position - Correct answer 3 Rationale: If bleeding is excessive, the cause may be laceration of the cervix or birth canal. Massaging the fundus if it is firm Would not assist in controlling the bleeding. Trendelenburg's Position should be avoided because it may interfere with cardiac And respiratory function. Although the nurse would record The findings, the initial nursing action would be to notify The HCP. Test-Taking Strategy: Note the star atelic word, initial. Focus On the data in the question, noting the clinical manifestations Identified in the question. Eliminate option 2 first because, if The uterus is firm, it would not be necessary to perform fundal Massage. Knowing that Trendelenburg's position interferes With cardiac and respiratory function will assist in eliminating Option 4. From the remaining options, noting the words bleeding Is excessive will assist in directing you to the correct option. Review: Nursing interventions for post par tum h emir hr. age The nurse is preparing to care for four assigned Clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby After oxytocin induction 4. A primiparous client who delivered 6 hours ago And had epidural anesthesia - Correct answer 3 Rationale: The causes of postpartum hemorrhage include uterine Agony; laceration of the vagina; hematoma development in The cervix, perineum, or labia; and retained placental fragments. Predisposing factors for hemorrhage include a previous History of postpartum hemorrhage, placenta prevail, abruption Placentae, over distention of the uterus from polyhydramnios, Multiple gestation, a large neonate, infection, multiparty, dystocia Or labor that is prolonged, operative delivery such as a Cesarean or forceps delivery, and intrauterine manipulation. The multiparous client who delivered a large fetus after oxytocin Induction has more risk factors associated with postpartum Hemorrhage than the other clients. In addition, there are no Specific data in the client descriptions in options 1, 2, and 4 That presents the risk for hemorrhage. Test-Taking Strategy: Note the strategic word, most. Focus on The subject, the client at most risk for hemorrhage. Read the Client description in each option. Noting the words large and Oxytocin in the correct option will direct you to this option. Review: Humor hr. age and post par tum cline t A postpartum client is diagnosed with cystitis. The Nurse should plan for which priority action in the Care of the client? 1. Providing sits baths 2. Encouraging fluid intake 3. Placing ice on the perineum 4. Monitoring hemoglobin and hematocrit levels - Correct answer 2 Rationale: Cystitis is an infection of the bladder. The client Should consume 3000 mL of fluids per day if not contraindicated. Sits baths and ice would be appropriate interventions For perinea discomfort. Hemoglobin and hematocrit levels Would be monitored with hemorrhage. Test-Taking Strategy: Focus on the subject, measures to treat Cystitis, and note the star atelic word, priority. Remember that Increased fluids are a priority intervention. Review: Interventions for a client with cystitis The nurse is monitoring a postpartum client who Received epidural anesthesia for delivery for the Presence of a vulvar hematoma. Which assessment Finding would best indicate the presence of a Hematoma? 1. Changes in vital signs 2. Signs of heavy bruising 3. Complaints of intense pain 4. Complaints of a tearing sensation - Correct answer 1 Rationale: Because the client has had epidural anesthesia and Is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemic in an anesthetized Postpartum client with vulvar hematoma. Option 2 (Heavy bruising) may be seen, but vital sign changes indicate Hematoma caused by blood collection in the perinea tissues. Test-Taking Strategy: Note the star atelic woo rd., best. Also note That the client received epidural anesthesia. With this in mind, Eliminate options 3 and 4. From the remaining options, use The ABCs—airway-breathing-circulation—to direct you to The correct option. Review: Signs of a vulvar h hematoma The nurse is creating a plan of care for a postpartum Client with a small vulvar hematoma. The nurse Should include which specific action during the First 12 hours after delivery? 1. Encourage ambulation hourly. 2. Assess vital signs every 4 hours. 3. Measure fundal height every 4 hours. 4. Prepare an ice pack for application to the area. - Correct answer 4 Rationale: A hematoma is a localized collection of blood in The tissues of the reproductive sac after delivery. Vulvar hematoma Is the most common. Application of ice reduces swelling Caused by hematoma formation in the vulvar area. Options 1, 2 and 3 are not interventions that are specific to the plan of Care for a client with a small vulvar hematoma. Ambulation