Author Question: A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On ... (Read 41 times)

tuffie · **on:** Jun 28, 2018

A 37-year-old gravid 8 para 7 woman was admitted to the postpartum unit at 2 hours postbirth. On admission to the unit, her fundus was U/U, midline, and firm, and her lochia was moderate rubra.

An hour later, her fundus is midline and boggy, and the lochia is heavy with small clots. Based on this assessment data, the first nursing action is:
a. Massage the fundus of the uterus.
b. Assist the woman to the bathroom and reassess the fundus.
c. Notify the physician or midwife.
d. Start IV oxytocin therapy as per standing orders.

Question 2

The clinic nurse sees Xiao and her infant in the clinic for their 2-week follow-up visit. Xiao appears to be tired, her clothes and hair appear unwashed, and she does not make eye contact with her infant.

She is carrying her son in the infant carrier and when asked to put him on the examining table, she holds him away from her body. The clinic nurse's most appropriate question to ask would be:
a. What has happened to you?
b. Do you have help at home?
c. Is there anything wrong with your son?
d. Would you tell me about the first few days at home?

Ahernandez18 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: a
Feedback
a. Correct. Based on the assessment data that the uterus is midline and boggy, the woman is experiencing uterine atony.
b. Assisting the woman to the bathroom would be a nursing action if the uterus was not midline.
c. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.
d. Oxytocin would be given and the primary health provider would be notified if the uterus did not respond to uterine massage.

Answer to Question 2

ANS: d
The well-baby checkup that generally takes place 1 to 2 weeks following the hospital discharge may offer the first opportunity to assess the motherbaby dyad. In this setting, the nurse needs to be alert for subtle cues from the new mother, such as making negative comments about the baby or herself, ignoring the baby's or other children's needs, as well as the mother's physical appearance. In a private area, the nurse should take time to explore the new mother's feelings. A nonthreatening way to open the dialogue might be to say: Tell me how the first few days at home have gone. This statement provides the new mother with an opportunity to share both positive and negative impressions.