Ricci, Kyle & Carman: Maternity and Pediatric Nursing, Second Edition: Chapter 16: Nursing Management During the Postpartum Period; prep u

A mother who just given birth has difficulty sleeping despite her exhaustion from labor. What are the causes of this inability to rest? Select all that apply. crying baby inability to get adequate pain relief frequent trips to the bathroom due to diuresis excess fatigue and overstimulation by visitors The period before labor and birth can be uncomfortable for the mother, thus preventing adequate rest and creating a sleep hunger. The early postpartum period involves many adjustments that can take a toll on the mother's sleep. A nurse finds the uterus of a postpartum woman to be boggy and somewhat relaxed. This a sign of which condition? atony The uterus in a postpartum client should be midline and firm. A boggy or relaxed uterus signifies uterine atony, which can predispose the woman to hemorrhage. 01:00 01:23 Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? encouraging the woman to empty her bladder completely every 2 to 4 hours The nurse should advise the woman to urinate every 2 to 4 hours while awake to prevent overdistention and trauma to the bladder. Maintaining a good fluid intake is also important, but it is not necessary to increase fluids if the woman is consuming enough. Screening for bacteria in the urine would require a primary care provider's order and is not necessary as a prevention measure. A nurse is assessing a postpartum client. Which measure is appropriate? Instruct the client to empty her bladder before the examination. An empty bladder facilitates examination of the fundus. The client should be supine with arms at her sides and her knees bent. The arms-overhead position is unnecessary. Clean gloves should be used when assessing the perineum; sterile gloves are not necessary. The postpartum examination should not be done quickly. The nurse can take this time to teach the client about the changes in her body after birth. The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? fever more than 100.4° F (38° C) A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection. Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? dehydration Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours. A new mother tells the nurse at the baby's 3 month check-up, "When she cries, it seems like I am the only one who can calm her down." This is an example of which behavior? attachment Attachment is the development of strong affection between an infant and a significant other. It does not occur overnight. It occurs through mutually satisfying experiences. Attachment behaviors include seeking, staying close to, and exchanging gratifying experiences with the infant. Bonding is the close emotional attraction to a newborn by the parents that develops in the first 30 to 60 minutes after birth. This is not an example of being spoiled. A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." After a vaginal birth, the client should be encouraged to void every 4 to 6 hours. As a result of anesthesia and trauma, the client may be unable to sense the filling bladder. It is premature to catheterize the client without allowing her to attempt to void first. There is no need to contact the primary care provider at this time, because the client is demonstrating common adaptations in the early postpartum period. Allowing the client's bladder to fill for another 2 to 3 hours might cause overdistention. Upon assessment, a nurse notes the client has a pulse of 90 bpm, moderate lochia, and a boggy uterus. What should the nurse do next? Massage the client's fundus. Tachycardia and a boggy fundus in the postpartum woman indicate excessive blood loss. The nurse would massage the fundus to promote uterine involution. It is not priority to notify the healthcare provider, assess blood pressure, or change the peri-pad at this time. A client has been discharged from the hospital after a cesarean birth. Which instruction should the nurse include in the discharge teaching? "You should be seen by your healthcare provider if you have blurred vision." The client needs to notify the healthcare provider for blurred vision as this can indicate preeclampsia in the postpartum period. The client should also notify the healthcare provider for a temperature great than 100.4° F (38° C) or if a peri-pad is saturated in less than 1 hour. The nurse should ensure that the follow-up appointment is fixed for within 2 weeks after hospital discharge. A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? The color of the flow is red. A typical lochia flow on the first day postpartally is red; it contains no large clots; the uterus is firm, indicating that it is well contracted. When doing a health assessment, at which location would the nurse expect to palpate the fundus in a woman on the second postpartal day and how should it feel? fundus two fingerbreadths below umbilicus and firm A uterine fundus typically regresses at a rate of one fingerbreadth a day, so on the second day postpartum it would be two fingerbreadths under the umbilicus and would feel firm.