A postpartum nurse has received an exchange report on the four ...

[plus1]

A postpartum nurse has received an exchange report on the four following motherbaby couplets. Based on the provided information, which couplet should the nurse first assess?
 
  a. A 25-year-old G2P1 woman who is 36 hours postbirth and is having difficulty breastfeeding her baby girl. Her fundus is firm at the umbilicus, and lochia is moderate to scant.
  b. A 16-year-old G1P0 who will be discharged in the afternoon. It was reported that she refers to her baby boy as it and that she requested to have her baby stay in the nursery so she could sleep.
  c. A 32-year-old G5P4 woman who delivered a 4500 gram baby boy 2 hours ago after a 20 hour labor that was augmented. It was reported that her fundus is 2 cm above umbilicus with moderate lochia.
  d. A 28-year-old G2P1 woman who delivered a 3800 gram baby girl by elective cesarean birth. She had spinal anesthesia and was given intrathecal preservative-free morphine for postoperative pain management. Her vital signs are B/P 115/75, P 80, R 18 T 98.

Question 2

Approximately 8 hours ago, Juanita, a 32-year-old G1 P0, gave birth after 2  hours of pushing.
 
  She required an episiotomy and an assisted birth (forceps) due to the weight and size of her baby (9 lb. 9 oz.). The perinatal nurse is performing an assessment of Juanita's perineal area. A slight bulge is palpated and the presence of ecchymoses to the right of the episiotomy is noted. The area feels full and is approximately 4 cm in diameter. Juanita describes this area as very tender. The most likely cause of these signs and symptoms is:
  a. Hematoma formation
  b. Sepsis in the episiotomy site
  c. Inadequate repair of the episiotomy
  d. Postpartum hemorrhage

[tranoy]

Answer to Question 1

ANS: c
Feedback
a. The priority need for this woman is breastfeeding assistance which does not require immediate attention.
b. The data indicate that the woman is experiencing a delay in bonding and that social services should become involved. This needs to be done prior to discharge but does not require immediate attention.
c. This woman is at risk for hemorrhage (large baby, prolonged labor, augmented labor, high parity, and immediate postpartum). This woman needs to be assessed first to determine whether the fundus is firm and if lochia is within normal limits.
d. Based on data provided, this woman is stable, but should be assessed second.

Answer to Question 2

ANS: a
A hematoma is a localized collection of blood in connective or soft tissue under the skin that follows injury of or laceration to a blood vessel without injury to the overlying tissue. The most common sign or symptom of a hematoma is unremitting pain and pressure. Upon examination of the perineal or vulvar areas, the nurse may notice discoloration and bulging of the tissue at the hematoma site. If touched, the patient complains of severe tenderness, and the clinician generally describes the tissue as full.

[plus1]

Excellent

[Liddy]

TYSM