Chapter 21 Nursing Care during the fourth trimester Flashcards Preview

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Flashcards in Chapter 21 Nursing Care during the fourth trimester Deck (26):

A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of postpartum hemorrhage in this woman is:
a. Retained placental fragments. c. Uterine atony.
b. Unrepaired vaginal lacerations. d. Puerperal infection.

This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding, but it typically would be detected 24 hours after delivery.


On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse’s first action is to:
a. Begin an intravenous (IV) infusion of Ringer’s lactate solution.
b. Assess the woman’s vital signs.
c. Call the woman’s primary health care provider.
d. Massage the woman’s fundus.

The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse’s first action. The physician would be notified after the nurse completes the assessment of the woman.


The _________________________ test is used to detect the amount of fetal blood in the maternal circulation.

ANS: Kleihauer-Betke


A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman:
a. Discusses her labor and birth experience excessively.
b. Believes that her baby is more attractive and clever than any others.
c. Has not given the baby a name.
d. Has a partner or family members who react very positively about the baby.

If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis might be impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby’s sex. The client might voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.


With regard to rubella and Rh issues, nurses should be aware that:
a. Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus.
b. Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for 1 month after vaccination.
c. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant.
d. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore might thwart the rubella vaccination.


During the immediate postpartum period, saturation of one pad within 2 hours is considered ____________________ blood loss.

ANS: Heavy


If a mother and her family have freely chosen early discharge from the hospital, the nurse and the health care provider are not legally responsible if complications occur and her condition had not been stabilized within normal limits.

Even if the mother chose to leave, the medical and nursing staffs still could be sued for abandonment.


Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins:
a. At the time of admission to the nurse’s unit.
b. When the infant is presented to the mother at birth.
c. During the first visit with the physician in the unit.
d. When the take-home information packet is given to the couple.

Discharge planning, the teaching of maternal and newborn care, begins on the woman’s admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.


If a woman is at risk for thrombus and is not ready to ambulate, nurses might intervene by doing all of these interventions except:
a. Putting her in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots.
b. Having her flex, extend, and rotate her feet, ankles, and legs.
c. Having her sit in a chair.
d. Notifying the physician immediately if a positive Homans’ sign occurs.

Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear might.TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans’ sign (calf muscle pain or warmth, redness, or tenderness) requires the physician’s immediate attention.


Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse might try is:
a. Pouring water from a squeeze bottle over the woman’s perineum.
b. Placing oil of peppermint in a bedpan under the woman.
c. Asking the physician to prescribe analgesics.
d. Inserting a sterile catheter.

Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain pills). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. It is easy, noninvasive, and should be tried early. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means could be tried first, but medications still come before insertion of a catheter.


A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to:
a. Improve the accuracy of blood loss estimation, which usually is a subjective assessment.
b. Determine which pad is best.
c. Demonstrate that other nurses usually underestimate blood loss.
d. Reveal to the nurse supervisor that one of them needs some time off.

Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It’s possible the nurse if trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything. It is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation.



Regardless of her obstetric status, no woman should be discharged from the recovery area until she has completely recovered from the effects of anesthesia and has been cleared by a member of the anesthesia care team.

It takes several hours to recover from anesthesia. Obstetric recovery areas are held to the same standard of care expected for any postanesthesia recovery.


Which finding could prevent early discharge of a newborn who is now 12 hours old?
a. Birth weight of 3000 g
b. One meconium stool since birth
c. Voided, clear, pale urine three times since birth
d. Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast.

Infant breastfed once with some difficulty latching on and sucking and once with some success for about 5 minutes on each breast indicates that the infant is having some difficulty with breastfeeding. The infant needs to complete at least two successful feedings (normal sucking and swallowing) before an early discharge. Birth weight of 3000 g; one meconium stool since birth; and voided, clear, pale urine three times since birth are normal infant findings and would not prevent early discharge.


Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to:
a. Formally initializing individualized care by confirming the woman’s and infant’s identification (ID) numbers on their respective wrist bands. (“This is your baby.”)
b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. (“It’s a dangerous world out there.”)
c. Including other family members in the teaching of self-care and child care. (“We’re all in this together.”)
d. Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

Many professionals believe that the nurse’s nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. “Mothering the mother” is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.


Excessive blood loss after childbirth can have several causes; the most common is:
a. Vaginal or vulvar hematomas.
b. Unrepaired lacerations of the vagina or cervix.
c. Failure of the uterine muscle to contract firmly.
d. Retained placental fragments.

Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.


While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of:
a. Health maintenance organizations (HMOs) and private insurers.
b. Consumer demand.
c. Hospitals.
d. The federal government.

The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Secondarily consumers have demanded less medical intervention and more family-centered experiences. Hospitals are obligated to follow standards of care and federal statutes regarding discharge policies. The Newborns’ and Mothers’ Health Protection Act provided minimum federal standards for health plan coverage for mothers and their newborns. Under this act couples were allowed to stay in the hospital for longer periods.


A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath TID, and a stool softener. What information is most closely correlated with these orders?
a. The woman is a gravida 2, para 2.
b. The woman had a vacuum-assisted birth.
c. The woman received epidural anesthesia.
d. The woman has an episiotomy.

These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.


The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data?
a. Rubella vaccine should be given.
b. A blood transfusion is necessary.
c. Rh immune globulin is necessary within 72 hours of birth.
d. A Kleihauer-Betke test should be performed.

This client’s rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.


A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by:
a. Running warm water on her breasts during a shower.
b. Applying ice to the breasts for comfort.
c. Expressing small amounts of milk from the breasts to relieve pressure.
d. Wearing a loose-fitting bra to prevent nipple irritation.

Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (since she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.


In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with:
a. The father of the infant.
b. Her mother (the infant’s grandmother).
c. Her eldest daughter (the infant’s sister).
d. The nurse.

In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant care.


In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she:
a. Has recovered from epidural or spinal anesthesia.
b. Has hidden bleeding underneath her.
c. Has regained some flexibility.
d. Is a candidate to go home after 6 hours.

If the numb or prickly sensations are gone from her legs after these movements, she likely has recovered from the epidural or spinal anesthesia.


Under the Newborns’ and Mothers’ Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth.
a. 24, 73 c. 48, 96
b. 24, 96 d. 48, 120

The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.


The trend in the United States is for women to remain hospitalized no longer than 1 or 2 days after giving birth for all of the following reasons except:
a. A wellness orientation rather than a sick-care model.
b. A desire to reduce health care costs.
c. Consumer demand for fewer medical interventions and more family-focused experiences.
d. Less need for nursing time as a result of more medical and technologic advances and devices available at home that can provide information.

Nursing time and care are in demand as much as ever; the nurse just has to do things more quickly. A wellness orientation seems to focus on getting clients out the door sooner. Less hospitalization means lower costs in most cases. People believe the family gives more nurturing care than the institution.


What would prevent early discharge of a postpartum woman?
a. Hemoglobin

The mother’s hemoglobin should be above 10 g for early discharge. The birth of an infant at term is not a criterion that would prevent early discharge. A normal voiding volume is 200 to 300 ml per void and does not indicate that the woman should not be discharged early. A normal episiotomy would show slight redness and edema and would be dry and approximated and would not prevent a woman from being discharged early.


A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged?
a. The woman leaves the infant on her bed while she takes a shower.
b. The woman continues to hold and cuddle her infant after she has fed her.
c. The woman reads a magazine while her infant sleeps.
d. The woman changes her infant’s diaper and then shows the nurse the contents of the diaper.

Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant’s elimination patterns.


A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse’s most appropriate response is to ask the woman:
a. “Didn’t you like your lunch?”
b. “Does your doctor know that you are planning to eat that?”
c. “What is that anyway?”
d. “I’ll warm the soup in the microwave for you.”

“I’ll warm the soup in the microwave for you” shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response.
Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. “What is that anyway?” does not show cultural sensitivity.