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The nurse on a postpartum unit observes a patient who delivered 2 days ago. The nurse notices extreme agitation and depressed mood. The patient states, “I think that my baby is deformed inside and we have to fix him.” Which risk factor is most strongly related to possible postpartum psychosis (PPP)?
- A. Separation from the baby’s father
- B. Personal history of bipolar disorder
- C. Prolonged labor resulting in cesarean
- D. Loss of first child from a heart defect
Correct Answer: B
Rationale: A patient history of either bipolar disorder or affective disorder can result in postpartum psychosis (PPP).
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The nurse is providing care for a patient who is 8 hours postpartum after a vaginal delivery. The patient reports severe perineal pain unaffected by pain medication. The nurse notices a 4 cm area of discoloration on the labia that is tender to the touch. Which action does the nurse take?
- A. Continue to apply ice to the area for 24 hours.
- B. Monitor vital signs and report any abnormal readings.
- C. Contact the primary care provider for further evaluation.
- D. Relieve pressure by placing patient in a side-lying position.
Correct Answer: C
Rationale: The primary care provider needs to be contacted about the assessment findings; the hematoma may need to be evaluated further and/or evacuation of the hematoma performed.
A multigravid, postpartum woman reports severe abdominal cramping whenever she nurses her baby. Which of the following responses by the nurse is appropriate?
- A. Suggest that the woman bottle feed for a few days.
- B. Instruct the patient on how to massage her fundus.
- C. Instruct the patient to feed using an alternate position.
- D. Discuss the action of breastfeeding hormones.
Correct Answer: D
Rationale: Breastfeeding stimulates the release of oxytocin, which causes uterine contractions that may lead to cramping.
What nursing intervention does the nurse include in the plan of care for a person with a wound infection?
- A. Reassure the postpartum person that infection will resolve without antibiotics.
- B. Assess for REEDA.
- C. Call health-care provider when temperature is 99.0° F.
- D. Scrub the incision vigorously with soap and water.
Correct Answer: B
Rationale: The REEDA acronym (Redness Edema Ecchymosis Discharge and Approximation) is used to assess for infection in a wound.
What is a risk factor for PPH found in the prenatal record?
- A. primipara
- B. rubella nonimmune
- C. von Willebrand disorder
- D. history of appendectomy
Correct Answer: C
Rationale: Von Willebrand disorder increases the risk of bleeding and PPH.
What is one of the initial signs and symptoms of puerperal infection in the postpartum client?
- A. Fatigue continuing for longer than 1 week
- B. Pain with voiding
- C. Profuse vaginal lochia with ambulation
- D. Temperature of 38° C (100.4° F) or higher on 2 successive days
Correct Answer: D
Rationale: One of the initial signs and symptoms of puerperal infection in the postpartum client is an elevated temperature. A temperature of 38° C (100.4° F) or higher on 2 successive days is indicative of an infection. This can be a key indicator for healthcare providers to suspect puerperal infection, also known as postpartum infection or postpartum sepsis. It is important to monitor postpartum clients closely for any signs of infection, especially in the immediate postpartum period. Prompt recognition and management of puerperal infection is crucial to prevent serious complications for the mother.