A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?
-
Solution
Changes in vital signs.
Changes in vitals indicate hypovolemia in the anesthetized PP woman with vulvar hematoma.
Options A and B: Because the woman has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation.
Option D: Heavy bruising may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.
Select all of the physiological maternal changes that occur during the PP period.
-
Solution
Answer: A and C. In the PP period, cervical healing occurs rapidly and cervical involution occurs.
After 1 week the muscle begins to regenerate and the cervix feels firm and the external os, is the width of a pencil. The fundus begins to descent into the pelvic cavity after 24 hours, a process known as involution.
Option B: Although the vaginal mucosa heals and vaginal distention decreases, it takes the entire PP period for complete involution to occur and muscle tone is never restored to the pregravid state.
Option D: Despite blood loss that occurs during delivery of the baby, a transient increase in cardiac output occurs. The increase in cardiac output, which persists about 48 hours after childbirth, is probably caused by an increase in stroke volume because Bradycardia is often noted during the PP period.
Option E: Soon after childbirth, digestion begins to begin to be active, and the new mother is usually hungry because of the energy expended during labor.
A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:
-
Solution
3 days PP.
After birth, the nurse should auscultate the woman’s abdomen in all four quadrants to determine the return of bowel sounds. Normal bowel elimination usually returns 2 to 3 days PP. Surgery, anesthesia, and the use of narcotics and pain control agents also contribute to the longer period of altered bowel function.
A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:
-
Solution
Eight peripads per day.
The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads per day. The average number of peripads is 6 per day.
When performing a PP 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 of the following nursing actions is most appropriate?
-
Solution
Notify the physician.
Normally, one may find a few small clots 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 atony or retained placental fragments, needs to be determined and treated to prevent further blood loss. Although the findings would be documented, the most appropriate action is to notify the physician.
The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:
-
Solution
Indicates the presence of infection.
Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Foul smelling or purulent lochia usually indicates infection, and these findings are not normal.
Option A: Normal lochia has a fleshy odor.
Options C and D: Encouraging the woman to drink fluids or increase ambulation is not an accurate nursing intervention.
A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?
-
Solution
Ask the mother to urinate and empty her bladder.
Before starting the fundal assessment, the nurse should ask the mother to empty her bladder so that an accurate assessment can be done.
Options A and B: When the nurse is performing a fundal assessment, the nurse asks the woman to lie flat on her back with the knees flexed.
Option D: Massaging the fundus is not appropriate unless the fundus is boggy and soft, and then it should be massaged gently until firm.
The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?
-
Solution
Instruct the mother to request help when getting out of bed.
Orthostatic hypotension may be evident during the first 8 hours after birth. Feelings of faintness or dizziness are signs that should caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed.
Option A: Obtaining an H/H requires a physician’s order.
A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2*F. Which of the following actions would be most appropriate?
-
Solution
Increase hydration by encouraging oral fluids.
The mother’s temperature may be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38 C) in the first 24 hours after birth are often related to the dehydrating effects of labor. The most appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading.
Option C: Although the nurse would document the findings, the most appropriate action would be to increase the hydration.
A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman’s vital signs:
-
Solution
Every 15 minutes during the first hour and then every 30 minutes for the next two hours.