Which nursing interventions can help prevent abdominal distention and gas discomfort for a postpartum woman who delivered by cesarean birth quizlet? 2024

Xem Which nursing interventions can help prevent abdominal distention and gas discomfort for a postpartum woman who delivered by cesarean birth quizlet? 2024

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Terms in this set (53)

-redness, pain, inflammation o
Persistent abdominal tenderness
Feelings of pelvic fullness or pressure
Persistent perineal pain
Frequency, urgency, or burning on urination
Abnormal change in character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor)
Localized tenderness, redness, edema, or
warmth of the legs
Redness, separation of, or foul drainage from an abdominal incision

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The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours. Her fundus was boggy, and firmed with massage to 1 FB ↓ U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1-10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this
patient?

A. Acute pain related to perineal trauma
B. Risk for deficient fluid volume related to uterine bleeding and nausea
C. Readiness for enhanced family coping
D. Knowledge deficit related to newborn care

B. Risk for deficient fluid volume related to uterine bleeding and nausea

Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority nursing diagnosis. Pain is a lower priority than is risk for fluid
volume deficit. Family coping is a lower priority than is risk for fluid volume deficit. A knowledge deficit is a psychosocial issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.

During a home care visit, the new mother complains of breast engorgement. Which intervention is most appropriate for recommendation by the home care nurse?

A. “Apply an ice compress to your breast before nursing.”
B.
“Encourage your baby to suckle for an average of 5 minutes per feeding.”
C. “Apply warm compresses to your breast after you finish feeding your baby.”
D. “When you aren’t nursing, wear a well-fitted nursing bra at all times, even when you sleep.”

D. “When you aren’t nursing, wear a well-fitted nursing bra at all times, even when you sleep.”

The mother should wear a well-fitted nursing bra 24 hours a day to support the breasts and prevent
discomfort from tension. Warm compresses before nursing stimulate let-down and soften the breast so that the infant can grasp the areola more easily. Cool compresses after nursing can help slow refilling of the breasts and provide comfort to the mother. For women with breast engorgement, the infant should suckle for an average of 15 minutes per feeding and should feed at least 8 to 12 times in 24 hours.

The postpartum patient delivered 4 hours
ago. She has a mediolateral episiotomy and large hemorrhoids. She is rating her pain at 7 on a scale of 1-10. She has a history of anaphylactic reaction to Tylenol (acetaminophen). Which nursing action would be best?

A. Offer the patient 800 mg Advil (ibuprofen) orally with food
B. Provide two Percocet (oxycodone with acetaminophen) by mouth
C. Encourage use of Dermoplast topical anesthetic spray
D. Run very warm water into the tub and assist her into the bath

A. Offer the patient 800 mg Advil (ibuprofen) orally with food

This is the best option, because the patient is experiencing moderately severe pain with inflammation. Ibuprofen is a nonsteroidal anti-inflammatory drug that both reduces inflammation and provides pain relief. This medication is contraindicated because of the patient’s allergic reaction to acetaminophen. Topical anesthetic sprays can be a helpful adjunct in pain relief, but are not sufficient when a patient has
moderately severe pain. Ice packs would be better at this stage, because they will cause vasoconstriction to reduce edema and pain relief.

On the second day postpartum, the patient experiences engorgement. To relieve her discomfort, the nurse should encourage the patient to:

A. Remove her bra
B. Apply heat to her breasts
C. Apply ice packs to her breasts
D. Limit breastfeeding to twice daily

C.
Apply ice packs to her breasts

Applying ice packs to the breasts relieves discomfort through the numbing effect of ice. Removing her bra will only serve to increase breast milk production. Applying heat will promote breast milk production. Limiting breastfeeding to b.i.d. actually would decrease the flow of breast milk eventually, and would not serve to decrease the discomfort of mother or infant.

The nurse is caring for a patient who had a
cesarean birth 4 hours ago. Which of the following interventions would the nurse implement at this time? (Select all that apply.)

A. Administer analgesics as needed
B. Encourage the patient to ambulate to the bathroom to void
C. Encourage leg exercises every 2 hours
D. Encourage the patient to cough and deep-breathe every 2-4 hours
E. Encourage the use of breathing, relaxation, and distraction

A. Administer analgesics as needed

Administering
analgesics as needed, encouraging leg exercises every 2 hours, encouraging the patient to cough and deep-breathe every 2-4 hours, and encouraging the use of breathing, relaxation, and distraction all address the patient’s nursing care needs, which are similar to those of other surgical patients. Encouraging her to ambulate to the bathroom to void might be an intervention done on the first or second day postpartum, but not in the first 4 hours.

The
community health nurse is presenting a seminar to new mothers about breastfeeding. When discussing weaning, which new mother’s statement suggests a need for further teaching?

A. “Slow weaning should take place over a period of several months.”
B. “By weaning my baby slowly, I’m giving him time to change his eating method at his own pace.”
C. “If I wean my baby slowly, I am less likely to develop breast engorgement.”
D. “Slowly weaning my baby is recommended to allow time for
psychological adjustment.”

A. “Slow weaning should take place over a period of several months.”

During slow weaning, over a period of several weeks the mother substitutes more cup feedings or bottle feedings for breast feedings. The slow method of weaning prevents breast engorgement, allows infants to alter their eating methods at their own rates, and provides time for psychological adjustment.

The
hospital is developing a new maternity unit. What aspects should be included in the planning of this new unit to best promote family wellness?

A. Normal newborn nursery centrally located to all patient rooms
B. A kitchen with refrigerator stocked with juice and sandwiches
C. Small, cozy rooms with a patient bed and rocking chair
D. A nursing model based on providing couplet care

D. A nursing model based on providing couplet care

Couplet
care, where the nurse cares for both the mother and the infant, best promotes family wellness. Having one nurse care for the mother and another nurse care for the baby is much less family-centered. Rooming-in better promotes family wellness than does having newborns in the nursery. Although having snacks is good for postpartum patients, some cultures prohibit drinking cold liquids after birth; warm liquids must also be available for optimal family wellness. Small rooms can become overly crowded
when siblings and grandparents come to visit. Larger rooms that facilitate family attachment are better.

The patient having her second child is scheduled for a cesarean birth because the baby is in a breech presentation. The patient states, “I’m wondering what will be different this time compared with my first birth, which was vaginal.” What response is best?

A. “We’ll take good care of you and your baby. You’ll be home before you know
it.”
B. “You’ll be wearing long stockings to prevent blood clots from forming in your legs.”
C. “You will have a lot of pain, but there are medications that we give when it gets bad.”
D. “You won’t be able to nurse until the baby is 12 hours old, because of your epidural.”

B. “You’ll be wearing long stockings to prevent blood clots from forming in your legs.”

Anti-embolism stockings are used until the patient is up and walking to prevent
thrombus formation. This response focuses on the nurse, and does not provide specific information to answer the patient’s question. This is a poor response. Focusing on the pain is a negative emphasis. In addition, pain medications work best when they are taken as the pain is intensifying; medication should not be delayed until the pain is severe, as less relief will be obtained. Epidural anesthesia prevents leg function, and therefore ambulation, but does not impact a mother’s ability to
breastfeed. She might need some assistance with positioning the infant due to bed rest, but should be encouraged to breastfeed as soon as possible.

The nurse is caring for a patient who delivered by cesarean birth. The patient received a general anesthetic. The nurse would encourage which of the following in order to prevent or minimize abdominal distention? (Select all that apply.)

A. Increased intake of cold beverages
B. Leg exercises
every 2 hours
C. Abdominal tightening
D. Ambulation
E. Eating a high-protein general diet

B. Leg exercises every 2 hours
C. Abdominal tightening
D. Ambulation

Leg exercises every 2 hours, abdominal tightening, and ambulation all serve to prevent or minimize abdominal distention in a surgical patient who received a general anesthetic. Increased intake of cold beverages and eating a high-protein general diet would increase the distention
through increase of gas and constipation. Increased intake of cold beverages and eating a high-protein general diet would increase the distention through increase of gas and constipation.

The nurse is caring for a 15-year-old patient that gave birth to her first child yesterday. What action is the best indicator that the nurse understands the parenting adolescent?

A. The patient’s mother is included in all discussions and demonstrations
B.
The father of the baby is encouraged to change a diaper and give a bottle
C. The nurse explains the characteristics and cues of the baby during the assessment
D. A discussion on contraceptive methods is the first topic of teaching

C. The nurse explains the characteristics and cues of the baby during the assessment

This helps the patient learn about her baby and understand him as an individual, and facilitates maternal-infant attachment. This is
the highest priority. Although the parents of adolescents are often involved with child care and childrearing, this action is only appropriate if the patient desires to have her mother present for teaching and discussions. Involvement of the father is important, but having the mother learn more about her new baby and what the behavior cues are is a higher priority. Young teens are statistically more likely to have another child during their adolescence, but establishing a rapport and
facilitating understanding of and attachment to the newborn is a higher priority.

The nurse is preparing to receive a newly delivered patient. The patient is a young single mother who is relinquishing custody of her newborn through an open adoption. What action is most important?

A. Assign the patient a room on the GYN surgical floor instead of the postpartum floor
B. Prepare to have teaching done in time for discharging the patient at 24
hours post-delivery
C. Make an effort to not bring up the topic of the baby, and discuss the mother’s health instead
D. Ask the patient if she wants to feed her baby, and how much contact she wants to have

D. Ask the patient if she wants to feed her baby, and how much contact she wants to have

Assess the patient’s preferences by respectfully asking questions and making no assumptions to facilitate a more positive experience for the birth mother.
Patients relinquishing their newborns should be given options for what their contact with the infant will be and where they would feel most comfortable. Make no assumptions, but assess instead. Not all patients who relinquish their infants want early discharge. Make no assumptions, but assess instead. The patient’s preferences determine how much she wants to talk about her birth, her newborn, or her decision to relinquish the child. Make no assumptions, but assess instead.

The nurse is caring for a patient who plans to relinquish her baby for adoption. The nurse would implement which of the following approaches to care? (Select all that apply.)

A. Encourage the patient to see and hold her infant
B. Encourage the patient to express her emotions
C. Respect any special requests for the birth
D. Acknowledge the grieving process in the patient
E. Allow for access to the infant if the patient requests it

B. Encourage the patient to express her emotions
C. Respect any special requests for the birth
D. Acknowledge the grieving process in the patient
E. Allow for access to the infant if the patient requests it

Encouraging the patient to express emotions, respecting any special request for the birth, acknowledging the grieving process, and allowing for access to the infant at patient’s requests all are aspects of providing care for the patient who decides to
relinquish her infant. Encouraging the patient to see and hold her infant does not respect the patient’s right to refuse interaction, and might make her feel guilty for not wanting to see the infant.

The maternal home care nurse is orienting a new nurse. During orientation, they are discussing maternal psychological adaptations and stressors. Which statement by the maternal home care nurse reflects the correct approach to addressing potential
and actual postpartum depression in maternal patients?

A. “Because emotional disorders and imbalances are a very sensitive subject, we try not to offend patients by routinely bringing up the topic of postpartum depression.”
B. “For women with a history of depression, we include education about postpartum depression.”
C. “Teaching about postpartum depression is a routine part of education for all maternal patients.”
D. “If we suspect a woman may have developed postpartum
depression, then we provide specialized education about that topic.”

C. “Teaching about postpartum depression is a routine part of education for all maternal patients.”

Teaching content should include information on role changes and psychological adjustments as well as skills. Risk factors and signs of postpartum depression should be reviewed with all women.

During a home care visit, a couple
expresses a desire for cosleeping, or sleeping in the same bed with their newborn baby. Which nursing response is most appropriate?

A. “Current research suggests there are no physical risks related to cosleeping, and this recommended as a healthy psychological approach to family bonding.”
B. “Cosleeping is a safe and healthy practice, as long as you make sure your baby is sleeping on his stomach.”
C. “Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping
need to following specific safety guidelines.”
D. “If you practice cosleeping, your baby should be placed on a comforter, as opposed to directly on the mattress.”

C. “Cosleeping is considered a risk factor for SIDS, so families who practice cosleeping need to following specific safety guidelines.”

The American Academy of Pediatrics does not
recommend cosleeping because it is considered a risk factor for SIDS. Some families and cultures, however,
may still participate in this
practice and thus warrant appropriate teaching measures. Cosleeping families should be counseled to follow specific safety
guidelines.

A new parent is concerned about spoiling her newborn. The home care nurse teaches the mother that:

A. Spoiling occurs when an infant is rocked to sleep every night
B. Newborns can be manipulative, so caution is advised
C. Crying is good for a baby, and letting them cry
it out is advised
D. Meeting the infant’s needs develops a trusting relationship

D. Meeting the infant’s needs develops a trusting relationship

Meeting the infant’s needs develops a trusting relationship. Picking babies up when they cry teaches them that adults try to meet their needs and are responsive to them. This helps build a sense of trust in humankind.

Which of the following safety devices is
most appropriate for the nurse making home visits?

A. Cell phone
B. Map of the area
C. Personal handgun
D. Can of mace

A. Cell phone

Cell phones provide a means of contact, and are advisable for the nurse to carry.

The nurse instructs the postpartum client that she can resume light housekeeping after the:

A. Six-week postpartum checkup
B. First week at home
C. Second day at
home
D. Second week at home

D. Second week at home

The postpartum client can resume light housekeeping after the second week at home. It’s not necessary to wait until after the six-week postpartum checkup to resume light housekeeping. Within the first week is too early to resume even light housekeeping activity. The second day is too early to resume even light housekeeping activity.

Which nursing interventions can help prevent abdominal distention and gas discomfort for a postpartum woman who delivered by cesarean birth?

Which nursing intervention is appropriate to help prevent thrombophlebitis in a postpartum woman who delivered by cesarean birth quizlet?

Which interventions are appropriate to promote comfort and healing for a woman during the first 24 hours after a cesarean delivery?

Which can the nurse do to help prevent thrombophlebitis?

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