352 UNIT V Maternity Nursing

CLINICAL JUDGMENT: TAKE

ACTION
Maternity

A nurse is monitoring a client in the postpartum period.

Three hours after the delivery of the newborn, the nurse
notes that the client is restless and dicult to rouse. The
client’s color is ashen and skin feels cool and clammy. The
nurse notes that the client’s peripad and the underpad are
saturated with bright red blood. The nurse calls for assis-
tance and takes vital signs, which reveal a pulse of 128 beats
per minute, shallow respirations at 24 breaths per minute, a
blood pressure of 88/50 mm Hg, and a pulse oximetry read-
ing of 90%. The nurse takes the following actions:
■ Ensures a patent airway.
FIG. 27.3 Mastitis.
■ Administers oxygen by nonrebreather face mask at 8 to 10
L/min.
■ Noties the obstetrician (OB); stays with the client and 10. Antipyretics and analgesics may be prescribed.
asks another nurse to contact the OB. 11. Administer antibiotics according to identied
■ Elevates the client’s legs to at least a 30-degree angle. organism, as prescribed.
■ Checks the uterus. If atonic, massages rmly to cause it
to contract. After giving birth many birthing parents are dis-
■ Starts an intravenous infusion per standing orders. charged home before an infection develops. Teach the
■ Administers uterotonic medications (e.g., oxytocin, pros- birthing parent about the ways to prevent infections, the
taglandins) as prescribed to increase uterine tone.
■
common signs and symptoms, and when it is necessary
Provides additional or maintains an existing intravenous
to call the primary health care provider.
(IV) infusion of lactated Ringer’s solution or normal
saline solution to restore circulatory volume (the client
should have two patent IV lines; the second IV line should
be a 16- to 18-gauge IV catheter). VI. Mastitis
■ Monitors vital signs and inserts an indwelling urinary A. Description
catheter to monitor perfusion of kidneys. 1. Mastitis is inammation of the breast/chest as a
■ Administers blood or blood products as prescribed. result of a blocked duct and infection.
■ Administers emergency medications as prescribed. 2. Mastitis occurs primarily in breast-feeding/chest-
■ Prepares for possible surgery or other emergency treat- feeding parents 2 to 3 weeks after delivery but
ments or procedures. may occur at any time during lactation.
■ Records event, interventions instituted, and the client’s
B. Assessment (Fig. 27.3)
response to interventions.
■ Prepares for transfer to a critical care unit for stabilization
1. Localized heat and swelling
and ongoing care and monitoring if required. 2. Pain; tender axillary lymph nodes
3. Elevated temperature
4. Complaints of ulike symptoms
C. Interventions C. Interventions
1. Monitor vital signs and temperature every 2 to 4 1. Instruct the client in good handwashing and
hours. breast/chest hygiene techniques.
2. Make the client as comfortable as possible; po- 2. Promote comfort.
sition the client to promote vaginal drainage. 3. Apply heat to the site as prescribed.
3. Keep the client warm if chilled. 4. Instruct the client that uid intake should be
4. Isolate the newborn from the client only if the 2500 to 3000 mL per day.
client can infect the newborn, such as with an 5. Maintain lactation in breast-feeding/chest-
airborne illness. feeding parent.
5. Provide a nutritious high-calorie, high-protein diet. 6. Encourage manual expression of human milk or
6. Encourage uids to 3000 to 4000 mL/day, if not use of a breast/chest pump every 3 to 4 hours.
contraindicated. 7. Encourage the client to support the breasts/chest
7. Encourage frequent handwashing and frequent by wearing a supportive bra; avoid wearing an un-
voiding and perinatal hygiene. derwire bra and avoid continuous pressure on the
8. Monitor intake and output. breast/chest from tight bras and infant carriers.
9. Monitor culture results if cultures were pre- 8. Administer analgesics as prescribed.
scribed. 9. Administer antibiotics as prescribed.