Which measure would be least effective in preventing postpartum hemorrhage?
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Solution
Massage the fundus every hour for the first 24 hours following birth.
The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax.
Options A, B, and D are all effective measures to enhance and maintain contraction of the uterus and to facilitate healing.
Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:
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Solution
Uses the peribottle to rinse upward into her vagina.
The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.
When performing a postpartum check, the nurse should:
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Solution
Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum.
While the supine position is best for examining the abdomen, the woman should keep her arms at her sides and slightly flex her knees in order to relax abdominal muscles and facilitate palpation of the fundus.
Option C: The bladder should be emptied before the check. A full bladder alters the position of the fundus and makes the findings inaccurate.
Option D: Although hands are washed before starting the check, clean (not sterile) gloves are put on just before the perineum and pad are assessed to protect from contact with blood and secretions.
The nurse examines a woman one 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 would be to:
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Solution
Massage her fundus.
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 would be to massage the fundus until firm, followed by options C and D, especially if the fundus does not become or remain firm with massage.
Option A: There is no indication of a distended bladder since the fundus is midline and below the umbilicus.
Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?
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Solution
Pain in left calf with dorsiflexion of left foot.
Pain in left calf with dorsiflexion of left foot indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.
Options A and C are expected related to circulatory changes after birth.
Option B: A temperature of 100.4°F in the first 24 hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake.
Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:
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Solution
The expected weight loss immediately after birth averages about 11 to 13 pounds.
Prepregnant weight is usually achieved by 2 to 3 months after birth, not within the 6-week postpartum period. Weight loss from diuresis, diaphoresis, and bleeding is about 9 pounds. Weight loss continues during breastfeeding since fat stores developed during pregnancy and extra calories consumed are used as part of the lactation process.
As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be:
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Solution
Soft, non-tender; colostrum is present.
Breasts are essentially unchanged for the first two to three days after birth. Colostrum is present and may leak from the nipples.
After the expulsion of the placenta in a client who has six living children, an infusion of lactated ringer’s solution with 10 units of Pitocin is ordered. The nurse understands that this is indicated for this client because:
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Solution
Multigravidas are at increased risk for uterine atony.
Multiple full-term pregnancies and deliveries result in overstretched uterine muscles that do not contract efficiently and bleeding may ensue.
Which type of lochia should the nurse expect to find in a client 2 days PP?
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Solution
Lochia rubra
Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?
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Solution
Urine retention.
Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which prevents the uterus from contracting. The uterus needs to remain contracted if bleeding is to stay within normal limits. Cervical and vaginal tears can cause PP hemorrhage but are less common occurrences in the PP period.