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Maternal Child Nursing Care Chapter 19
(Postpartum Period)
Engorgement in a breastfeeding woman requires careful management to preserve the milk supply while managing the increased blood flow to the breasts. Taking warm showers can increase milk flow. Frequent feedings will permit the breasts to empty fully and establish the supply-demand cycle that is appropriate for the infant. Cold cabbage leaves work well to reduce pain and swelling and should be applied every 4 hours. Binding the breasts is not appropriate because it decreases the milk supply. To ease the discomfort associated with sore nipples, the mother may apply topical preparations such as purified lanolin or hydrogel pads. - ✔✔The nurse is caring for a lactating patient with a body temperature of 102° F (38.9° C). The nurse finds that the patient's breasts are engorged, swollen, hard, and red. Which interventions related to patient care would be helpful in managing breast engorgement? Select all that apply.
- Taking warm showers before breastfeeding
- Nursing the baby frequently
- Using a tight supportive bra or a breast binder
- Applying cold cabbage leaves to the breasts
- Avoiding use of lanolin or hydrogel pads Ans: 4 The patient must not become pregnant for 3 months after the rubella vaccination because of its potential teratogenic effects. The rubella vaccine is made from duck eggs, so an allergic reaction may occur in the patients with egg allergies. Because the virus is not transmitted through breast milk, the patient may continue to breastfeed even after vaccination. Transient arthralgia (joint pain) and skin rashes are the common
adverse effects of the rubella vaccine. - ✔✔The nurse is preparing to administer rubella vaccine to a postpartum patient. What should the nurse tell the patient?
- "The vaccine is safe even if you have an egg allergy."
- "You cannot breastfeed for 5 days after taking the vaccine."
- "You will not have joint pains or skin rashes after the vaccination."
- "You should use proper contraception for 3 months after the vaccination." Ans: 4 Homans' sign is an assessment test used to determine whether the patient has VTE. Presence of Homans' sign indicates that the patient may have VTE. Uterine atony can be assessed by palpating the uterine fundus. Hypotensive shock can be assessed by checking the patient's vitals. Mastitis can be assessed by the examining the patient's breasts. - ✔✔On reviewing the medical reports of a postpartum patient, the nurse finds that the patient has Homans' sign. What does the nurse interpret from this finding?
- Risk of uterine atony
- Hypotensive shock
- Risk of developing mastitis
- Venous thromboembolism (VTE) Ans: 1 If 15 mL of fetal blood is detected in the maternal circulation of an Rh-negative woman, as indicated by Kleihauer-Betke test, then 300 mcg (1 vial) of Rh immune globulin is
Ans: 3 Lochia rubra and a firm fundus are normal findings in a postpartum patient. Because the assessment findings do not indicate a postpartum complication, the nurse should document the findings and continue to monitor. Because the patient has a firm fundus, she does not have postpartum hemorrhage, so prostaglandins and oxytocin should not be administered. Because the fundus is firm, massage is not needed to help the fundus contract. - ✔✔The nurse assesses a postpartum patient and finds that the patient has lochia rubra with a firm fundus at the level of the umbilicus. Which is the most important nursing intervention in this situation? 1.Administer prostaglandins. 2.Administer oxytocin. 3.Document the findings and continuing to monitor. 4.Massage the fundus every 15 minutes. Ans: 1 If the patient reports severe perineal pain after vaginal delivery, the nurse should apply ice packs in the first 24 hours to reduce edema, pain, and vulvar irritation. Administering fluids and blood compensates for blood loss in the patient, but they do not reduce pain. Postpartum hematologic studies are performed to assess the consequences of blood loss. This intervention does not reduce pain in the patient. - ✔✔A patient who underwent a vaginal delivery 3 hours earlier reports having severe perineal pain. Which would be the first step taken by the nurse in this situation? 1.Apply ice packs in the perineum. 2.Administer fluids to the patient.
3.Administer blood to the patient. 4.Refer the patient for hematologic tests. Ans: 1 The patient who has an episiotomy may have constipation due to discomfort during bowel movements. Therefore the nurse should instruct the patient to use stool softeners to help ease the passage of stools. Prenatal vitamins should be continued in all patients regardless of the episiotomy. All patients should take iron supplements to increase their hemoglobin levels. However, they do not ease the discomfort of episiotomy. Analgesics are usually prescribed for patients who underwent a cesarean. - ✔✔A postpartum patient who has an episiotomy is being discharged to home. Which instruction about medications is most important for the patient? 1.Take stool softeners regularly. 2.Continue prenatal vitamins. 3.Include iron supplements. 4.Take analgesics as prescribed. Ans: 3 Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. - ✔✔Excessive blood loss after childbirth can have several causes; however, the most common is:
who is breastfeeding. The patient reports breast irritation. Which intervention would be beneficial to the patient? 1.Apply ice packs to the breasts between feedings. 2.Place hydrogel pads to the breasts between feedings. 3.Tell the patient to wear breast shells. 4.Apply cold cabbage leaves to the breasts between the feedings. Ans: 2 A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action is to massage the fundus until firm. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage. - ✔✔The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action is to: 1.place her on a bedpan to empty her bladder. 2.massage her fundus. 3.call the physician. 4.administer Methergine, 0.2 mg IM, which has been ordered prn. Ans: 3
The recommended caloric intake for a lactating mother who breastfeeds more than one infant is more than 2700 kcal/day. If a lactating mother of twins takes less than 2200 kcal/day, she may not produce enough milk. An intake of 1800 to 2200 kcal/day is recommended for nonlactating mothers. - ✔✔A lactating patient who gave birth to twins 1 month earlier approaches the primary health care provider (PHP) for a general checkup. What suggestion does the nurse give to the patient about the recommended calorie intake? 1.Less than 1800 kcal/day 2.Less than 2200 kcal/day 3.More than 2700 kcal/day 4.Should be 1800 to 2200 kcal/day Ans: 4 To facilitate father-infant bonding, the nurse should include the father while giving instructions about newborn care. If the nurse asks the father to change the baby's diaper, the father may be anxious and may not be willing to do it. Instead, the nurse should show the father how to change the diapers and then ask the latter to return demonstrate the process. Asking the father why he is anxious or reassuring him that it will take time to get used to the newborn may not improve father-child bonding or reduce his fear about handling the newborn - ✔✔The nurse is caring for a family who has a newborn. The father appears to be very anxious and nervous when the newborn's mother asks him to bring the baby. Which nursing intervention is most beneficial in promoting father-infant bonding? 1 Hand the father the newborn and instruct him to change the diaper. 2 Ask the father why he is so anxious and nervous. 3 Tell the father that he will get used to the newborn in time.
2 Perform regular breast stimulation. 3 Wear a well-fitted support bra. 4 Use a breast binder. 5 Apply ice packs on the breasts Ans: 2 If the area of saturated pad is less than 2.5 cm, it indicates that the patient had scanty bleeding. If it is less than 10 cm, then the patient had light bleeding. If the pad is saturated within 2 hours, the patient had heavy bleeding. If it is 10 cm or more, the patient had moderate bleeding. - ✔✔The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5 cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding? 1 Light bleeding 2 Scanty bleeding 3 Heavy bleeding 4 Moderate bleeding Ans: 3 Rubella vaccine is made from duck eggs; therefore women who are allergic to duck eggs can develop a hypersensitivity reaction to the vaccine. As a result, the patient might develop rashes on her skin. The PHP would prescribe adrenaline to combat hypersensitivity reactions. Oxytocin is injected to increase the tone of the uterine muscles but not to combat hypersensitivity. Rh immune globulin suppresses the
immune system, which would worsen the condition; therefore this medication is unlikely to be prescribed. Magnesium sulfate is used for preeclampsia and is not used to minimize hypersensitivity reactions caused by rubella vaccine. - ✔✔The nurse is preparing to administer rubella vaccine to a patient during the postpartum period. At the follow-up visit, the patient reports to the nurse that she has rashes on her skin. What does the nurse expect the primary health care provider (PHP) to prescribe in this situation? 1 Oxytocin (Pitocin) 2 Rh immune globulin 3 Adrenaline (Epinephrine) 4 Magnesium sulfate Ans: 3 The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage. Test-Taking Tip: Stay away from other nervous students before the test. Stop reviewing at least 30 minutes before the test. Take a walk, go to the library and read a magazine, listen to music, or do something else that is relaxing. Go to the test room a few minutes before class time so that you are not rushed in settling down in your seat. Tune out what others are saying. Crowd tension is contagious, so stay away from it. - ✔✔Which measure is least effective in preventing postpartum hemorrhage? 1 Administering Methergine, 0.2 mg every 6 hours for four doses, as ordered 2 Encouraging the woman to void every 2 hours
Kegel exercises strengthen and increase the elasticity of the pubococcygeus muscle, which is the main perineal muscle. They improve vaginal tone and also help prevent stress incontinence and hemorrhoids. Kegel exercises do not prevent urine retention, relieve lower back pain, or tone abdominal muscles. - ✔✔The nurse is helping prepare a patient for discharge after childbirth. During a teaching session, the nurse instructs the patient to do Kegel exercises. What is the purpose of these exercises? 1 To prevent urine retention 2 To provide relief of lower back pain 3 To tone the abdominal muscles 4 To strengthen the perineal muscles Ans: 1 Applying a covered ice pack to the perineum from front to back during first 24 hours decreases edema and increases comfort. Using two or more perineal pads would be helpful in absorbing the heavy menstrual flow but will not reduce the pain or promote perineal healing. Sitz baths and Kegel exercises are important measures to provide pain relief and comfort to the patient with a fourth-degree laceration. Therefore the nurse should not advise the patient to avoid taking sitz baths and performing perineal (Kegel) exercises. - ✔✔While assessing a postpartum patient, the nurse finds that the patient has a fourth-degree laceration. What immediate interventions should the nurse perform while caring for the patient? 1 Apply an ice pack to limit edema during the first 12 to 24 hours. 2 Instruct the patient to use two or more perineal pads. 3 Teach the patient to avoid taking sitz baths. 4 Remind the patient to avoid doing perineal (Kegel) exercises.
Ans: 2 A patient who has had a cesarean birth and has remained in the bed for more than 8 hours is at risk of venous thromboembolism. If a thrombus is suspected, as evidenced by warmth, redness, or tenderness in the leg, the nurse should notify the PHP immediately. Meanwhile, the patient should remain in bed with the affected limb elevated on pillows. Applying heat increases discomfort because the affected limb is already warm. Applying antiinflammatory ointment to the leg at the reddened site would not be useful because the redness is caused by embolism, not inflammation. - ✔✔A patient who has had a cesarean birth has been on bed rest for 8 hours after surgery and has warmth and redness in the left lower limb. Which interventions taken by the nurse would be most beneficial to the patient? Select all that apply. Advise the patient to apply a hot compress at the reddened site. Inform the primary health care provider (PHP) about the patient's condition immediately. 1 Advise the patient to apply an antiinflammatory ointment at the reddened site. 2 Have the patient sit upright and lower the reddened leg. 3 Have the patient remain in bed with reddened limb elevated on pillows. Ans: 3 The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action is to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. This is not an expected finding, and emptying the bladder is required.
Ans 4 After receiving the first dose of Varivax, the patient must take the second dose 4 to 8 weeks later. The patient must use contraception for 1 month after being vaccinated to avoid pregnancy because the vaccine has teratogenic effects. Mothers who receive the varicella vaccine can continue to breastfeed because the vaccine is not transmitted to the fetus through breast milk. Postpartum women usually have low immunity, so one dose is not sufficient. Stopping of all medications is not necessary and can endanger the patient. - ✔✔The primary health care provider (PHP) has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine? Select all that apply. 1 "Stop breastfeeding after receiving the vaccine." 2 "You need not return to the hospital because one dose is enough for you." 3 "Stop taking all medications after returning home." 4 "You must return for a second dose in 4 to 8 weeks." 5 "Use contraception for 1 month to avoid pregnancy." Ans: 3 If a patient with excessive postpartum hemorrhage shows signs such as grayish, cool, and clammy skin, the patient is at risk of developing hypovolemic shock. If the patient has foul-smelling lochia, then the patient might be at risk of infection. Every patient experiences pain after giving birth; however, a change in skin color does not result from pain. If the patient has not voided urine within 8 hours after birth, then the patient might be at risk of impaired urinary elimination. - ✔✔The nurse is caring for a patient with excessive postpartum hemorrhage. The nurse observes that the patient's skin has turned grayish. What does the nurse infer from this finding?
1 Risk of infection 2 Evidence of severe pain 3 Potential risk of hypovolemic shock 4 Potential risk of impaired urinary elimination Ans: 2 A postpartum patient should be closely monitored for hemorrhage. If the perineal pad soaks in 15 minutes, the patient is hemorrhaging and needs immediate medical attention. Excessive hemorrhaging is not a normal finding after childbirth. Lochial discharge occurs after childbirth but is different from active bleeding. Hypotension may not increase bleeding in the postpartum patient. - ✔✔The nurse finds that a postpartum patient's perineal pad is soaked after 15 minutes. What should the nurse infer from the finding? 1 Normal finding after childbirth 2 Sign of excessive hemorrhage 3 Presence of lochial discharge 4 Sign of postpartum hypotension Ans: 3 A patient who complains of abdominal discomfort and gas pains should be encouraged to use a rocking chair because it stimulates the passage of flatus and relieves discomfort. The patient should not be encouraged to drink coffee because the caffeine present in it intensifies the pain by increasing bowel movements. Analgesic medication
- Drink plenty of water and eat foods containing fiber
