Patient Scenario, Chapter 17, Nursing Care of a Postpartal

Family

A POSTPARTAL WOMAN
Faye Chang is a 28-year-old, G4P3 woman you care for in a labor-delivery-recovery
room following birth of a 6 lb, 13 oz girl.

CHIEF CONCERN:
“Pain. Sore breasts. Stomach cramps. Is it all right if I get up and walk? Do you
know I’m a vegetarian? Don’t want to see any meat on a meal tray.”

HISTORY OF CHIEF CONCERN:

The client gave birth to a 6 lb 13 oz infant girl, 37 weeks’ gestation, at 1:05 PM with
no analgesia. She is concerned new baby is abnormally small because other
children both were more than 8 lb at birth.

FAMILY PROFILE:
The client was married when she was 20 years old, but marriage ended after a
trophoblast proliferation pregnancy. She is currently living with her boyfriend and
two children in a two-bedroom house; she works as a clerk in a mail-order catalog
house. Her boyfriend works as a night club manager. Finances are reported as
“okay.” Her boyfriend appeared supportive throughout labor. She voiced pleasure at
sex and appearance of new child.

HISTORY OF PAST ILLNESSES:

Faye had a venomous snake bite at age 15 years while on a camping trip. Antivenin
was given immediately; there are no sequelae. Only hospitalization was for two
previous childbirths.

GYNECOLOGIC HISTORY:
Menarche was at age 17 years; cycle duration is 30 days. Menstrual flow duration is
7 days. Both she and sexual partner were treated for chlamydia last year. It was
relying on sexual partner to use condoms as method of reproductive life planning
prior to this pregnancy.

OBSTETRIC HISTORY:
Faye had hydatidiform mole pregnancy 8 years ago, followed for 1 year with hCG
levels. She never had any elevation in levels. She had three pregnancies: boy, 8 lb
6 oz, vaginal delivery, alive and well, 12 years ago; boy, 8 lb 8 oz, vaginal delivery,
alive and well, 10 years ago; girl, 6 lb 13 oz, vaginal delivery, 2 hours ago, no
anomalies at birth. This pregnancy was not intended but not unwelcome. She
doesn’t drink alcohol but did smoke “occasionally” during pregnancy. She took daily
prenatal vitamin.

REVIEW OF SYSTEMS:
Essentially negative

PHYSICAL EXAMINATION:
General appearance: Distressed-appearing; young adult Asian woman
HEENT: Hair: unwashed; oily; some postpartal hair loss beginning
Chest: Heart rate: 70 beats/min; no murmurs present; lungs: no adventitious
sounds present; respiratory rate: 22 breaths/min
Abdomen: Soft; fundal height 1 F under umbilicus and firm and midline; linea nigra
and striae present
Perineum: Edematous; mediolateral episiotomy line intact; lochia: rubra, moderate,
no clots
Extremities: Homans’ sign negative; no edema over tibia

Ms. Chang is diagnosed as having a usual postpartal course.

STUDY QUESTIONS:
 a. 1. Ms. Chang is 4 hours postbirth and appears to be most concerned about
her own care at the present time. When planning her immediate care, you would
choose your assessments and interventions in the knowledge that she is in which
postpartal stage?
a. Taking in
b. Taking hold
c. Letting go
d. Containment

b. 2. Based on her current health status, the best nursing diagnosis for Ms.
Chang would be which of the following?
a. Anxiety related to unexpected care of new infant
b. Pain related to breast and abdominal discomfort
c. Deficient fluid volume related to poor oral intake
d. Impaired parenting related to inexperience

a. 3. You are planning nursing interventions that will address Ms. Chang’s pain.
Which would be the best expected outcome for Ms. Chang?
a. Client voices that her pain has diminished to a tolerable level.
b. Client sleeps an acceptable amount of time and states that she feels rested.
c. Client states that she knows her pain medicine will be effective.
d. Client states that her pain is minimal and cares for self and infant.

a. 4. During your interactions with Ms. Chang, you notice that she rarely looks
directly at her newborn. How would you document this in Ms. Chang’s electronic
health record?
a. Client does not assume an enface position with newborn.
b. Client appears not to enjoy holding her new newborn.
c. Ms. Chang is having difficulty accepting mothering.
d. New mother does not hold her infant comfortably.
 b. 5. You have selected interventions that will promote Ms. Chang’s attachment,
or relating well, to her newborn. This behavior is frequently described as which of
the following?
a. Negotiation
b. Bonding
c. Concern
d. Fortitude

c. 6. Ms. Chang asks you if her older children should visit her in the hospital.
Thinking of the QSEN competency of patient-centered care, what advice is most
appropriate?
a. “It’s better if older children see their new sibling first in their own home.”
b. “Seeing a sibling in a hospital could make them think the newborn is ill.”
c. “Seeing their new brother or sister immediately should help bonding.”
d. “It’s important that your son and daughter do what makes you happiest.”

d. 7. Ms. Chang’s boyfriend tells you Ms. Chang has cried several times since
the birth of the baby. What factor most likely accounts for this emotional lability?
a. An increase in estrogen
b. An increase in prolactin
c. Loss of blood volume
d. A decrease in estrogen

b. 8. You have assessed Ms. Chang’s uterus and have noted that it is beginning
to return to its prepregnant state. How should you document this phenomenon in
the electronic health record?
a. Atrophy
b. Involution
c. Retrographic change
d. Endometrial discharge
 c. 9. Ms. Chang is breastfeeding. What effect should the nurse anticipate that
this will have on uterine size during the postpartal period?
a. It slows the process of involution by approximately 25%.
b. It promotes diuresis and limits the amount of lochia.
c. It aids uterine contraction because of oxytocin release.
d. It causes the cervix to expand because of estrogen release.

d. 10. When Ms. Chang is 1 day postpartum, which of the following descriptions
of lochia would you identify as being normal?
a. Pink with occasional red streaking
b. White because of mucous infiltration
c. Brown because blood is now old
d. Red with occasional small clots

c. 11. Assessing uterine size is important during the postpartum period. If Ms.
Chang is 1 day postpartum, you would expect to locate her uterus at what location?
a. 1 cm under her rib cage
b. 3 cm below her umbilicus
c. 1 cm below her umbilicus
d. 3 cm above her symphysis pubis

a. 12. You are preparing to palpate Ms. Chang’s abdomen for uterine position.
What nursing action should you perform?
a. Place a hand at the base of the uterus to prevent uterine inversion.
b. Insert one hand vaginally to slow the vaginal flow while palpating.
c. Mark the point of the fundus on the abdomen with a pen or marker.
d. Place ice on the abdomen to cause contraction prior to palpation.

d. 13. Suppose Ms. Chang were 3 days postpartum. What would be an expected
outcome when you are assessing her lochia?
a. Lochia is red with pinpoint clots present.
b. Lochia appears yellow because of serum.
c. Lochia’s color is now white, and texture is firm.
d. Lochia is pink with no strong odor.

c. 14. Ms. Chang tells you she seems to be voiding a large amount of urine.
What is the usual amount of urine women in the postpartum period void each 24
hours?
a. 500 to 1,200 ml
b. Approximately 1,000 ml
c. 2,000 to 3,000 ml
d. 4,000 to 5,000 ml

c. 15. Ms. Chang worries she will develop a thrombophlebitis. When assessing
her, you should be aware of what risk factor for this problem during the postpartal
period?
a. They develop fatty plaques from the stress of labor.
b. Involution causes the uterus to obstruct blood vessels.
c. Their fibrinogen level is still elevated from pregnancy.
d. Amniotic fluid mixing with plasma causes rapid clotting.

b. 16. On her first day postpartum, Ms. Chang’s temperature is 38°C (100.4°F).
How should you interpret this assessment finding?
a. She must be developing a postpartal infection.
b. This is a normal finding for the first day postpartum.
c. Her temperature should be mildly hypothermic for 24 hours.
d. She must be developing a stress reaction to parenting.

a. 17. On the third day postpartum, Ms. Chang tells the home care nurse that
her breasts feel warm and tender. How should the nurse interpret this assessment
finding?
a. She is experiencing breast engorgement, which is normal.
b. Her infant must be a particular vigorous feeder.
c. This suggests that mastitis may be developing.
d. She needs to drink more fluid to reduce inflammation.

d. 18. If Ms. Chang had an episiotomy with perineal pain, what would be the
preferred pain-relief measure for her on the third day postpartum?
a. Perineal application of ice
b. Topical hydrocortisone
c. Oral hydromorphone (Dilaudid)
d. Perineal heat application

b. 19. Ms. Chang reports she is afraid to have a bowel movement because that
may cause perineal pain. How should you advise her?
a. This problem will resolve spontaneously.
b. The use of a stool softener may be indicated.
c. She should eat soft foods for the next several days to increase bowel peristalsis.
d. She should avoid having a bowel movement until her perineum has begun to
heal.

OPEN-ENDED QUESTIONS:
20. What if Ms. Chang tells you in the hospital that she knows she had a perfect
baby so should be happy but she can’t stop crying? At what point would you
suggest counseling for her? Hormonal changes may have a big factor on why Ms.
Chang is feeling this way. So in order to make her feel good, I will suggest the use
of non-pharmacological therapy such as distraction method, providing support
through significant others and family member. If she still feels depressed I will
counsel with her primary care for referral.

21. What if Ms. Chang’s boyfriend tells you their new baby looks nothing like him
and asks you how soon he can request a DNA analysis to establish if he’s the father
or not? How would you advise him? I will explain to him that DNA analysis cannot
be done after the baby has just been born.
FILL IN THE BLANK QUESTIONS:
22. The process of a uterus returning to its prepregnant state is termed involution.

23. The uterine discharge after birth is termed lochia.

MULTIPLE RESPONSE QUESTIONS:

a.,b. 24. Which of the following are important assessments to make in the
postpartal period to keep a woman safe from hemorrhage? (Select all that apply.)
a. Blood pressure and pulse
b. Uterine tone and consistency
c. Ability to walk steadily
d. Tympanic temperature
e. Assessment of appetite

a.,c.,d. 25. Ms. Chang will be busy after she returns home because she works
outside the home in addition to caring for two other children. What discharge
instructions should you include in your health teaching? (Select all that apply.)
a. She should try to maintain a smoke-free house rather than return to smoking.
b. She should try to breastfeed for a minimum of 6 months even while working.
c. She should call and make an appointment for a health visit at 4 to 6 weeks.
d. She needs to plan rest times as exhaustion can lead to postpartal depression.