Chapter 12 (MN) - Postpartal Period: Physiological Assessments and Nursing Care

Question 39. Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? 1. Document the findings as within normal limits 2. Perform fundal massage 3. Instruct the woman to empty her bladder 4. Reassess every 5 minutes

1 Rationales Option 1: An expected finding immediately after birth is a uterine fundus that is palpated midway between the umbilicus and symphysis pubis and is firm and midline. Option 2: Fundal massage is performed for uterine atony. Option 3: A full bladder can cause the uterus to be shifted from the midline and/or above the umbilicus. Option 4: Fundal assessment should be performed every 15 minutes for the first hour following delivery. [Page reference: 368]

Question 30. A nurse is caring for a patient 2 hours post-vaginal delivery of a term neonate. The patient suddenly complains of heavy bleeding, nausea, and dizziness. Vital signs are BP 85/49, HR 110, RR 18, O2 saturation 90%, temp 98.3 F. Based on these assessment findings, what is the priority nursing intervention? 1. Administer oxygen per nasal cannula. 2. Achieve free-flowing venous access. 3. Increase frequency of vital signs. 4. Prepare for emergency dilation and curettage.

1 Rationales Option 1: An oxygen saturation of 90% is low and supplemental oxygen should be applied. Option 2: IV access should be achieved after oxygen is applied. Option 3: The nurse should increase the frequency of vital signs after increasing oxygenation. Option 4: An emergency dilation curettage is typically only done if the bleeding does not respond to medications and fundal massage and there are retained placental fragments. [Page reference: 371, 376] Test Taking Tip: When multiple answers are correct, remember the ABCS. In this situation, increasing oxygenation (breathing) was the priority nursing action.

Question 23. What statement made by a postpartum patient indicates to the nurse understanding of weight-loss after childbirth? 1. "The average woman is almost back to her pre-pregnancy weight within 6 months." 2. "Most women will experience significant weight loss during the first week postpartum." 3. "I will probably lose 10 pounds as the result of delivery." 4. "I will seat-out 2 to 3 pounds of water weight."

1 Rationales Option 1: At the end of 6 months, the average American woman is approximately 3 pounds above her pre-pregnancy weight. Option 2: Most women will experience significant weight loss during the first 2 to 3 weeks of postpartum. Option 3: Immediately after birth women lose approximately 11 to 12 pounds as the result of delivery and blood loss. Option 4: Diuresis results in the loss of approximately another 5 to 8 pounds post-delivery. [Page reference: 383]

Question 51. The postpartum nurse is educating a patient who is preparing to go home from the hospital. Which statements made by the patient indicate understanding of contraceptive use after childbirth? 1. "Just because I am breastfeeding does not mean I cannot get pregnant." 2. "I do not need to use condoms until I stop breastfeeding." 3. "I will need to use contraception once I get my period." 4. "Breastfeeding is an effective form of birth control." 5. "I do not need to use contraceptives for the first 6 weeks."

1 Rationales Option 1: Breastfeeding is not an effective contraceptive method. Option 2: Both lactating and non-lactating women should be advised to use contraception when they resume sexual intercourse. Option 3: Women should be advised to use contraception when they resume sexual intercourse because ovulation can precede return of menses. Option 4: Breastfeeding is not an effective contraceptive method. Option 5: Patients should be advised to avoid sexual intercourse for 6 weeks post-delivery. [Page reference: 383-387] Test Taking Tip: Make sure to read the answers slowly so you do not miss anything. The answer choice "breastfeeding is an effective form of birth control" could easily be misread as "is not an effective form of birth control."

Question 28. The postpartum nurse is caring for a patient who gave birth vaginally 2 hours ago. The nurse notices continued heavy bleeding with firm fundal tone. What nursing action is a priority for this patient? 1. Assess for the presence of a vaginal hematoma 2. Perform vigorous fundal massage 3. Manually extract retained placental fragments 4. Document the findings as within normal limits

1 Rationales Option 1: Continued heavy bleeding with firm fundal tone may indicate the presence of a genitourinary tract laceration or a hematoma of the vulva or vagina. Option 2: Fundal massage is performed for uterine atony. Option 3: The physician or midwife may manually remove retained placental fragments. Option 4: Heavy bleeding is not a normal finding. [Page reference: 371-372]

Question 33. The postpartum nurse is preparing to ambulate a patient who received an epidural. What is the priority nursing intervention for this patient? 1. Assess for decreased nerve sensation. 2. Assess for vaginal bleeding. 3. Assess for bladder distension. 4. Assess for spinal headache.

1 Rationales Option 1: Epidural or spinal anesthesia causes lack of sensation that may last several hours. Option 2: Vaginal bleeding is an expected finding for a woman in the immediate postpartum period. Option 3: Assessing for bladder distension is not the priority when preparing to assist a patient to ambulate for the first time after receiving an epidural. Option 4: Spinal headache does not typically present until 24 to 48 hours after delivery. [Page reference: 379] Test Taking Tip: The answer choice "assess for spinal headache" is a distractor. The student might think this is the correct answer because it pertains to the stem of the question stating the client had an epidural. The correct answer is "assess for decreased nerve sensation" and is a safety issue.

Question 38. When performing a fundal assessment on a patient, 2 hours following an uncomplicated vaginal delivery, the postpartum nurse notes a boggy uterus. What is the priority nursing action for this patient? 1. Massage the fundus with the palm of the hand 2. Place an indwelling catheter 3. Notify the physician or midwife 4. Give Oxytocin as per the physician's orders

1 Rationales Option 1: Fundal massage stimulates contraction of the uterus. Option 2: If excessive bleeding occurs, a Foley catheter may be placed to ensure an empty bladder and monitor I&O. Option 3: The nurse should notify the physician or midwife if the uterus does not respond to massage. Option 4: Oxytocin promotes uterine contractions by stimulating its smooth muscle. Oxytocin should be given if the uterus does not respond to fundal massage. [Page reference: 368] Test Taking Tip: When multiple answers are correct, think of what you would do FIRST. In this case, fundal massage should be done prior to other interventions, such as administering oxytocin or placing a Foley catheter.

Question 18. A postpartum patient asks the nurse if she needs to use contraception while breastfeeding. What is the most therapeutic response by the nurse? 1. "Yes, because breastfeeding is not an effective contraceptive method." 2. "You cannot get pregnant as long as you are breastfeeding." 3. "It takes 9 to 10 weeks for your hormone levels to allow you to get pregnant." 4. "That is a question for your doctor to answer."

1 Rationales Option 1: Lactating and non-lactating women should be advised to use contraception because breastfeeding is not an effective contraceptive method. Option 2: Breastfeeding is not an effective contraceptive method. Option 3: Hormone levels fluctuate depending on whether or not the woman is lactating. Ovulation is suppressed longer for lactating women. Option 4: This is an appropriate question for a nurse to answer. [Page reference: 378, 383] Test Taking Tip: The answer choice that, "That is a question that should be answered by your doctor" is considered "passing the buck," and should be avoided. The student can eliminate the answer choice that states "You cannot get pregnant", because giving answers with such finality should be avoided.

Question 5. A postpartum nurse is caring for a G1P1 patient 24 hours post-vaginal delivery. What is the priority action for the nurse when preparing to assess for uterine involution? 1. Assist the woman to a supine. 2. Instruct the woman to void. 3. Reassure the woman that she will not feel pain during the procedure. 4. Notify the woman that you will be visualizing her perineum.

1 Rationales Option 1: Palpitating for uterine involution should be performed with the patient in supine position. Option 2: An over-distended bladder can result in uterine displacement. The woman should void prior to uterine assessment to allow for an accurate assessment. Option 3: Many women feel discomfort with uterine palpation. Option 4: Assessment for uterine involution involves palpation of the uterine fundus. [Page reference: 367-368]

Question 49. A postpartum nurse is caring for a patient 2 hours after vaginal delivery of a large for gestational age (LGA) infant. Assessment findings include moderate lochia rubra, and a firm fundus at the midline and 1 centimeter below the umbilicus. The patient is unable to void. What is the priority nursing action? 1. Encourage fluids and try again in 1 hour 2. Perform an in-and-out catheterization 3. Notify the physician or midwife 4. Use a bladder scanner to assess urine volume

1 Rationales Option 1: Patients should be able to void within 2-4 hours of delivery. The woman may be dehydrated from labor, so fluids should be encouraged. Option 2: Catheterization should not be performed unless the patient is bleeding heavily or experiencing uterine atony. Option 3: Inability to void 2 hours post-delivery is not an abnormal finding and does not need to be reported to the health care provider. If the patient is still unable to void after 4 hours, the provider should be notified. Option 4: A bladder scanner may be used to assess for urinary retention, or to measure bladder residual volume after a void of less than 150ml. [Page reference: 377] Test Taking Tip: In the stem of this question, "LGA infant" is a distractor. The student should identify that moderate lochia rubra and a firm fundus midline and 1cm below the umbilicus is a normal finding 2 hours post vaginal-delivery.

Question 32. During a routine assessment, the nurse notes diastasis recti abdominis on a postpartum patient. What is the priority nursing intervention for this patient? 1. Continue with the assessment, as this is a normal finding. 2. Notify the physician or midwife STAT. 3. Assist the woman in applying an abdominal binder. 4. Instruct the woman to avoid using her abdominal muscles.

1 Rationales Option 1: Separation of the rectus muscle is normal and becomes less apparent as the body returns to a pre-pregnant state. Option 2: Diastasis recti is a normal finding and does not need to be reported to the health care provider. Option 3: Women with diastasis recti do not need to wear an abdominal binder. The body will return to its pre-pregnant state over time. Option 4: Women with diastasis recti do not need to avoid using their abdominal muscles. [Page reference: 379] Test Taking Tip: Do not be confused or swayed by medical terminology. In the stem of the question, "diastasis recti abdominis" is meant to distract the student. Diastasis recti abdominis is the medical term that simply means 'separation of the rectus muscle', which is a normal finding after childbirth.

Question 31. A postpartum patient reports urinary frequency, urgency, and pain with urination. What is the priority nursing intervention for this patient? 1. Assess the patient's temperature. 2. Instruct the patient to use the peri-bottle when she voids. 3. Assist the patient with a sitz bath. 4. Send a urine specimen for culture and sensitivity.

1 Rationales Option 1: Urinary frequency, urgency, and pain with urination are possible symptoms of cystitis. The nurse should assess for fever due to the possible infection. Option 2: Using the peri-bottle will help with comfort when voiding for patients with lacerations and perineal trauma. Option 3: A sitz bath cleanses the perineum and can provide relief from pain in the genital area. Option 4: This action requires a physician's order. [Page reference: 377-378]

Question 37. A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? 1. Boggy uterus 2. Bilateral lower extremity numbness 3. Uncontrollable shaking 4. Moderate vaginal bleeding

1 Rationales Option 1: Uterine atony is the number one cause of postpartum hemorrhage and should be reported to the healthcare provider. Option 2: Epidurals commonly cause numbness in the legs. Option 3: Shaking is common immediately following delivery. Option 4: Moderate lochia rubra is a normal finding in the hour following delivery. [Page reference: 368]

Question 10. A postpartum nurse is caring for a patient immediately following vaginal delivery of a term neonate. The patient reports shortness of breath and a cough, and has the following vital signs: BP 110/73, HR 121, O2 saturation 92%, temp 99.1 F. The nurse recognizes the patient could be experiencing what complication? 1. Pulmonary embolism 2. Postpartum hemorrhage 3. Preeclampsia 4. Pulmonary edema

1 Rationales Option 1: Women are at risk for thromboembolism, related to the increase of circulating clotting factors during pregnancy. Option 2: Signs of postpartum hemorrhage include vaginal bleeding, tachycardia, and hypotension. Option 3: Signs of preeclampsia are increased blood pressure and proteinuria. Option 4: Pregnant patients with preeclampsia are at risk for pulmonary edema and will often have crackles upon pulmonary auscultation. [Page reference: 382]

Question 26. A patient on the postpartum unit reports passing an egg-sized clot. What are the priority nursing interventions for this patient? Select all that apply. 1. Weigh the clot. 2. Report the findings to the physician or midwife. 3. Assist the patient to the bathroom. 4. Administer Oxytocin 10U IM. 5. Call for rapid response.

1,2 Rationales Option 1: Clots the size of an egg or larger should be weighed and the findings should be reported to the physician or midwife. Option 2: Clots the size of an egg or larger should be weighed and the findings should be reported to the physician or midwife. Option 3: Assisting the patient to the bathroom is not priority at this time. Option 4: Passing a medium-sized clot does not require Oxytocin administration unless it is accompanied by heavy bleeding or uterine atony. Option 5: Passing an egg-sized clot does not necessitate a rapid response. [Page reference: 370]

Question 40. A nurse is caring for a G2P2 patient in the initial hour after giving birth. What are the appropriate nursing interventions to be taken with this patient? Select all that apply. 1. Assess the uterus for location, position and tone of fundus every 15 minutes 2. Titrate IV Oxytocin infusion rate to uterine tone 3. Provide information regarding afterpains 4. Assess lochia for color, amount, and odor 5. Inspect the inside of the vagina for tearing

1,2,3,4 Rationales Option 1: Uterine assessment should be done every 15 minutes for the first hour after delivery. Option 2: Universal active management of third stage of labor includes administration of IV Oxytocin. Option 3: Multiparous women often experience moderate to severe cramp-like pains associated with the uterus contracting after delivery. Option 4: Lochia should be assessed at the same time the uterus is assessed. Option 5: Vaginal inspection is done by the healthcare provider after delivery of the infant. [Page reference: 368-370]

Question 41. A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient? 1. Assess the position, tone and location of the fundus 2. Massage a boggy uterus 3. Document the findings and reassess in 1 hour 4. Quantify blood loss 5. Instruct the client to void and reevaluate

1,2,4,5 Rationales Option 1: Immediate nursing actions for heavy lochia include assessing the position, tone and location of the fundus. Option 2: If the uterus is boggy, the nurse should perform fundal massage. Option 3: Reassessment should be performed more frequently than 1 hour. Option 4: The nurse should quantify blood loss by weighing all blood-soaked pads and materials. Option 5: A full bladder can cause uterine displacement and heavy bleeding. [Page reference: 368]

Question 20. A nurse is caring for a patient who reports a spinal headache. What statements made by the patient indicate an understanding of a postdural puncture headache? Select all that apply. 1. "I should drink a cola." 2. "My headache will get better when I stand up." 3. "My head hurts because the fluid around my spinal cord is decreased." 4. "Dehydration caused my headache." 5. "I should start to feel better in a few hours."

1,3 Rationales Option 1: Caffeine consumption has been shown to decrease symptoms of spinal headache. Option 2: Spinal headaches are worse when the patient is in an upright position and improved when the patient is laying down. Option 3: Spinal headaches are related to postdural puncture, and subsequent leakage of cerebrospinal fluid (CSF) leading to decreased levels of CSF. Option 4: Spinal headache is not caused by dehydration. Option 5: Spinal headache usually presents 24 to 48 hours and can take 7 to 10 days to resolve. Some patients may require intervention, such as a blood patch. [Page reference: 379]

Question 48. The postpartum nurse is preparing to administer Rh (D) Immune Globulin (RhoGAM) to a post- cesarean section patient on the mother-baby unit. What statements made by the patient indicate an understanding of RhoGAM? Select all that apply. 1. "I need this because my blood type is negative and my baby is positive." 2. "I will avoid pregnancy for 4 weeks." 3. "This medication will help protect my future babies." 4. "I only need to get this once in my lifetime." 5. "I need to receive RhoGAM within 48 hours of giving birth."

1,3 Rationales Option 1: RhoGAM is indicated for Rh-negative women who have given birth to an Rh-positive neonate. Option 2: Pregnancy is not contra-indicated followed RhoGAM administration. Option 3: Women who are Rh sensitized may experience complications in future pregnancies if the fetus is Rh positive. Option 4: RhoGAM is given to women at 28 weeks gestation and again following delivery if the baby is Rh positive. Option 5: RhoGAM must be given within 72 hours of post- birth. [Page reference: 376] Test Taking Tip: In this question, "post-cesarean section" is the distractor. RhoGAM is administered to women with Rh negative blood type within 72 hours of birth (if baby is Rh positive) no matter if the birth is vaginal or cesarean section.

Question 4. A multiparous patient asks the nurse why she is feeling contractions 8 hours after giving birth. What information should the nurse include in her teaching? Select all that apply. 1. "The intensity of the afterpains should decrease in a few days." 2. "The pains are from your abdominal muscles stretching during pregnancy." 3. "You probably don't remember feeling afterpains after your first baby." 4. "The afterpains are more intense because you are not breastfeeding." 5. "Because you had Pitocin during labor, you will feel more contractions after delivery."

1,3 Rationales Option 1: The intensity of afterpains will typically decrease after the third postpartum day. Option 2: Afterpains are caused by uterine contractions. Option 3: Primiparous women usually do not experience afterpains. Option 4: Breastfeeding causes an increase of oxytocin release, which intensifies afterpains. Option 5: Pitocin administration during labor does not cause afterpains. [Page reference: 369]

Question 54. What information is important for the postpartum nurse to include when educating a patient receiving the Measles, Mumps, and Rubella (MMR) vaccine after childbirth? Select all that apply. 1. "Avoid pregnancy for 4 weeks after receiving the vaccine." 2. "Report a temperature over 99.0 to your physician or midwife." 3. "You are receiving this vaccine because you are not immune to the rubella virus." 4. "You may experience pain, redness, and swelling around the injection site." 5. "You will only need this vaccine once in your lifetime."

1,3,4 Rationales Option 1: Women who are immunized with the MMR should avoid pregnancy for 4 weeks. Option 2: Some vaccines can cause a low-grade fever. Option 3: Women who contract rubella during the first trimester have a 90% chance of transmitting the virus to their fetus. Option 4: Possible side effects of the MMR vaccine include injection site pain, redness and swelling. Option 5: Some patients will require multiple doses of the MMR vaccine to receive immunity. [Page reference: 376-377]

Question 12. A nurse is caring for a patient 24 hours post-delivery. What information is important for the postpartum nurse to include in this patient's discharge teaching? Select all that apply. 1. "Rise slowly to a standing position." 2. "You can resume physical activity as soon as you feel up for it." 3. "Drink plenty of water or Gatorade." 4. "You might feel lightheaded when you stand because of the blood you lost during delivery." 5. "Sit down if you feel dizzy or faint."

1,3,5 Rationales Option 1: Postpartum women are at risk for orthostatic hypotension due to decreased vascular resistance. Option 2: Patients should be encouraged to rest for the first few weeks following childbirth. Option 3: Breastfeeding women should increase fluid intake. Option 4: Orthostatic hypotension is due to decreased vascular resistance, not blood loss. Option 5: Women should be educated about orthostatic hypotension and instructed to sit if she becomes dizzy or faint. [Page reference: 381]

Question 42. When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply. 1. "Wear a supportive bra or sports bra 24 hours a day." 2. "If your breasts become engorged, you should pump to relieve the pressure." 3. "Do not apply ice packs to the breasts because it will stimulation milk production." 4. "You can take an analgesic for pain." 5. "You may experience milk leakage for the first 1 to 2 weeks."

1,4 Rationales Option 1: Non-breastfeeding women should be instructed to wear a supportive bra until her breasts become soft. Option 2: Women should avoid expending milk or stimulating the breasts. Option 3: Women experiencing engorgement should apply ice to the breasts. Option 4: Women experiencing engorgement may take an analgesic for pain. Option 5: Non-breastfeeding women may experience milk leakage between 1-4 days post-delivery. [Page reference: 373-374]

Question 2. A G4P4 patient who is 6 hours post-delivery is complaining of severe cramp-like uterine pains. What is a therapeutic nursing response? 1. "The cramping should go away when you start breastfeeding." 2. "The pains are caused by your uterus contracting and should get better in a few days." 3. "Afterpains are usually the worse with your first baby." 4. "The contractions will subside over the next 6 weeks as your uterus goes back to its normal size."

2 Rationales Option 1: Afterpains are related to the increase of oxytocin released in response to infant suckling and will typically increase in intensity during breastfeeding. Option 2: Afterpains are related to the uterus working to remain contracted. The intensity of afterpains will typically decrease after the third postpartum day. Option 3: Primiparous women usually do not experience afterpains. Option 4: Afterpains typically decrease in intensity after the third postpartum day. [Page reference: 369]

Question 1. What statement made by a primiparous patient 4 hours post-delivery requires further assessment by the nurse? 1. "Is it normal for it to burn when I go pee?" 2. "My uterus is cramping really bad." 3. "I think I want to try breastfeeding." 4. "Will you take the baby to the nursery so I can nap?"

2 Rationales Option 1: Dysuria can be caused by trauma to the urethra during delivery. Option 2: Primiparous women usually do not experience discomfort related to uterine contractions during the postpartum period. Option 3: Wanting to attempt breastfeeding is a normal finding. Option 4: First-time moms are often exhausted after childbirth, especially if they experienced a long labor. [Page reference: 368-370]

Question 36. A nurse is caring for a patient in the first hour following a vaginal delivery. What is the priority nursing intervention? 1. Facilitate bonding between the mother and infant 2. Assess the fundus for location, position and tone 3. Administer pain medications 4. Inspect the perineum for tearing

2 Rationales Option 1: Facilitating bonding is the priority during the first hour following delivery. Option 2: The risk for postpartum hemorrhage is the greatest within the first hour following delivery. The fundus should be assessed for location, position and tone every 15 minutes for the first hour. Option 3: Pain medications may be ordered, but they are not the priority of the nurse at this time. Option 4: Careful inspection of the perineum is the job of the healthcare provider immediately following delivery. [Page reference: 367] Test Taking Tip: If multiple answers are correct, go back to the ABCS. In this question, the risk for postpartum hemorrhage was higher priority than any of the other answer choices.

Question 7. A postpartum nurse caring for a patient 3 days post-delivery notes brown vaginal discharge. How should the nurse document this finding in the electronic health record? 1. Lochia rubra 2. Lochia serosa 3. Lochia alba 4. Brown vaginal discharge

2 Rationales Option 1: Lochia rubra is red and bloody. Option 2: Lochia serosa is pink or brown in color. Option 3: Lochia alba is clear or whitish discharge. Option 4: Lochia is the term for discharge after birth. [Page reference: 370-371]

Question 13. A postpartum nurse is caring for a patient recovering from vaginal delivery of a term neonate 24 hours ago. The patient had an uncomplicated pregnancy and delivery. What is a priority assessment for this patient? 1. Assess the breasts for signs of mastitis 2. Assess the calf and groin areas for tenderness, edema and warmth 3. Assess the nipples for cracks and bruising 4. Assess the lower extremities for mild swelling

2 Rationales Option 1: Mastitis typically does not occur this early. Option 2: Increased coagulability associated with pregnancy continues into the post-delivery period. Option 3: A breastfeeding assessment is not the priority for this patient. Option 4: Mild edema is a normal finding after delivery, especially if the patient received IV fluids during labor. [Page reference: 375]

Question 47. A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient does the nurse assess as being at the highest risk for fluid volume overload? 1. A G1P0 who had an epidural for 6 hours during labor 2. A G3P2 who was induced with Pitocin for preeclampsia 3. A G8P2 with insulin-controlled gestational diabetes 4. A G2P2 who had a repeat cesarean section 24 hours ago

2 Rationales Option 1: Patients who have an epidural typically receive a fluid bolus prior to epidural placement; however, this patient did not have the epidural for an extended period of time and is not at high risk for fluid volume overload. Option 2: Patients with preeclampsia are at risk for fluid volume overload. Option 3: Gestational diabetes is not a risk factor for fluid volume overload. Option 4: The patient with preeclampsia is at higher risk for fluid volume overload than this patient. [Page reference: 374-376]

Question 52. A postpartum patient complains of a headache that is worse when in an upright position that improves when supine. What is the priority nursing intervention? 1. Administer Tylenol 650mg PO 2. Notify the anesthesia provider 3. Encourage the patient to lay down and rest 4. Increase IV fluids to promote rehydration

2 Rationales Option 1: Patients with spinal headache do not typically report pain relief from Tylenol. Option 2: Signs of a spinal headache, or post-dural puncture headache, are a headache that is worse in an upright position and improved when laying down. Option 3: While the patient should be encouraged to lay down and rest, the nurse must also notify the anesthesia provider so the patient can be evaluated for spinal headache. Option 4: IV fluids are not a treatment for spinal headache. [Page reference: 379]

Question 27. A postpartum nurse is caring for multiple patients on the mother-baby unit. Which patient should the nurse evaluate first? 1. A G1P1 who gave birth 30 minutes ago and reports uncontrollable shaking 2. A G6P5 who gave birth 6 hours ago and reports passing a basketball-sized blood clot 3. A G3P1 who is 3 days post-op cesarean section and reports cracked and bloody nipples 4. A G2P1 who is 2 days post-op cesarean section and reports 7/10 abdominal pain

2 Rationales Option 1: Shaking is a normal response immediately after giving birth. Option 2: Large blood clots require immediate evaluation by the nurse, as it could be a sign of uterine atony. Option 3: Cracked and bloody nipples are not an uncommon finding in women who are breastfeeding. Option 4: Moderate-severe abdominal pain in a post-op cesarean section patient is common on days 2 to 3, when the patient is more active and the spinal anesthesia has worn off. [Page reference: 370-371] Test Taking Tip: In questions that ask you to prioritize client care, remember the ABCS. In this question, the client with a large blood clot required evaluation before any of the other clients.

Question 43. A primiparous patient tells the nurse she wants to bottle-feed her baby. What is the most therapeutic response by the nurse? 1. "Have you tried breastfeeding? Let's see if we can get baby to latch." 2. "You'll want to wear a sports bra for 24 hours a day until your breasts are soft." 3. "We do not advocate bottle-feeding, so you'll need to bring your own formula." 4. "Are you sure? Breastmilk is so much healthier for your baby."

2 Rationales Option 1: The nurse should not force the patient to breastfeed if she does not want to. Option 2: Non-breastfeeding women should be instructed to wear a sports bra for 24 hours a day. Option 3: This is not a therapeutic response by the nurse. Option 4: This is not a therapeutic response by the nurse and may cause the mom to feel guilt for not breastfeeding. [Page reference: 373-374] Test Taking Tip: When answering questions that deal with therapeutic communication, avoid "blaming" answers, or answers that force the nurses opinion onto the client.

Question 9. A nurse is caring for a patient 6 hours post-vaginal delivery of a term neonate. She notes a white blood cell count of 20,000/mm. What is the priority nursing intervention for this patient? 1. Notify the physician or midwife 2. Interpret as a normal finding 3. Administer Tylenol 1,000mg PO 4. Order a repeat CBC for the next morning

2 Rationales Option 1: The physician or midwife does not need to be notified of this normal finding. Option 2: White blood cell levels may increase to 30,000/mm within a few hours of birth as the result of the stress of labor. Option 3: Tylenol is not warranted for an increased white blood cell count. Option 4: A CBC does not need to be repeated unless ordered by the provider. [Page reference: 375]

Question 44. A postpartum patient expresses concern that she will get a blood clot in her leg because her mother had one after her delivery. What is the most therapeutic response by the nurse? 1. "Blood clots do not run in families, so you have nothing to worry about." 2. "I understand your concern. Let's take a look at the back of your legs together." 3. "Women are only at risk for developing blood clots during pregnancy." 4. "I will assist you to ambulate around the hallway so that doesn't happen."

2 Rationales Option 1: This answer dismisses the patient's concern. Option 2: The nurse should validate the patient's concern and teach her how to assess her calves and groin for deep vein thrombosis. Option 3: Increase coagulability associated with pregnancy continues into the post-delivery period. Option 4: This response is not the most therapeutic. [Page reference: 374-375] Test Taking Tip: Eliminate answers that do not include therapeutic communication. Avoid dismissing a client's concern or changing the subject.

Question 11. A nurse is caring for a patient 24 hours post-cesarean section. Upon assessment, the nurse notes tachycardia, anxiousness, and oxygen saturation of 89%. What is the priority nursing action? 1. Weigh all pads and calculate quantitative blood loss. 2. Apply O2 per nasal cannula. 3. Increase IV fluids. 4. Notify rapid response team.

2 Rationales Option 1: This patient is not experiencing a postpartum hemorrhage. Weighing all pads is not needed. Option 2: Increasing oxygenation is the priority for this patient. Option 3: There is no indication to increase IV fluids. Option 4: If the patient's status continues to decline, the nurse may need to call rapid response. [Page reference: 376] Test Taking Tip: When prioritizing interventions, remember the ABCS. For this client, increasing oxygenation was the immediate priority.

Question 17. A postpartum nurse is caring for a patient 48 hours post-cesarean section. The patient's lab values are: blood type O positive, group B strep positive, rubella non-immune, hepatitis B negative. Based on these assessment findings, what order should be questioned by the nurse? 1. Measles, Mumps, and Rubella (MMR) vaccine Sub Q 2. RhoGAM 300 mcg IM 3. Hydrocodone 7.5/325 mg PO Q4hr PRN 4. Adacel 0.5 ml IM before discharge

2 Rationales Option 1: Women who are rubella non-immune should receive the MMR after childbirth. Option 2: RhoGAM is administered to Rh-negative women who have given birth to an Rh-positive neonate. Option 3: Hydrocodone is often given for post-operative pain control. Option 4: Women should be offered the tetanus, diphtheria, and pertussis vaccine before discharge. [Page reference: 376-377]

Question 16. A nurse is preparing to administer the Measles, Mumps, and Rubella (MMR) vaccine to a patient before discharge from the hospital. What question is most important for the nurse to ask prior to administering the vaccine? 1. "Do you plan on becoming pregnant again in the next 6 months?" 2. "Did you recently receive the RhoGAM?" 3. "Which arm do you prefer I give this in?" 4. "Have you ever had this vaccine before?"

2 Rationales Option 1: Women who receive the MMR vaccine should avoid pregnancy for 4 weeks. Option 2: Rh immune globulin may interfere with the immune response to live vaccinations. Option 3: Asking which arm the patient prefers is not the priority. Option 4: Some patients will require multiple doses of MMR. [Page reference: 376-377] Test Taking Tip: When multiple answers are similar, look for the one that is different. In this question, only one of the responses involved another medication.

Question 14. A nurse is educating a patient about deep vein thrombosis (DVT). What information should be included in the discharge plan? Select all that apply. 1. "Hit your call light when you are ready to get out of bed for the first time." 2. "Avoid crossing your legs while sitting." 3. "Your doctor wants you to wear compression stockings." 4. "Make sure not to walk around too much." 5. "Massage your calves daily to prevent a blood clot."

2,3 Rationales Option 1: Patients should be accompanied by the nurse during ambulation in the early postpartal period due to the possibility of orthostatic hypotension. Option 2: To decrease the possibility of DVT, patients should be instructed not to cross their legs. Option 3: Patients with a history of blood clots may be instructed to wear compression stockings per provider order. Option 4: Frequent ambulation should be encouraged to prevent venous stasis. Option 5: Massaging the calves does not prevent blood clots. [Page reference: 375]

Question 35. Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. 1. "My uterus will stay this big until I get my period again." 2. "It will take between 6-8 weeks for my uterus to return to normal size." 3. "Contractions will cause my uterus to shrink." 4. "My uterus will not be as small as it was before I had a baby." 5. "My uterus will return to the size of a volleyball."

2,3 Rationales Option 1: Menses does not affect uterine involution. Option 2: Involution of the uterus takes between 6-8 weeks post-delivery. Option 3: Uterine involution occurs through contractions, atrophy of the uterine muscles, and a decrease in the size of uterine cells" Option 4: The uterus will revert to pre-pregnancy size through the process of involution. Option 5: The typical size of a uterus is comparable to a pear. [Page reference: 366] Test Taking Tip: Do not get hung up on medical terminology. The term "uterine involution" is meant to be a distractor. The student should identify that uterine involution just means the normal "shrinking" of the uterus.

Question 46. A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. 1. "You had a fever during labor and the antibiotics have not started working yet." 2. "The hard work of labor can cause your temperature to increase." 3. "It is common for women to experience mild temperature elevation after giving birth." 4. "Your body is going through a lot of hormonal changes right now, which can increase your temperature." 5. "Do you feel hot? I will get you some Tylenol."

2,3,4 Rationales Option 1: Slight temperature elevation in the postpartal period does not indicate infection. Option 2: Slight temperature elevation postpartum is often related to muscle exertion and dehydration. Option 3: Postpartum women commonly experience temperature elevation due to muscular exertion, exhaustion, dehydration, or hormonal changes. Option 4: Postpartum women commonly experience temperature elevation due to muscular exertion, exhaustion, dehydration, or hormonal changes. Option 5: Slight temperature elevation in the postpartal period does not warrant medication. [Page reference: 377]

Question 45. A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. 1- Increase frequency of vital signs 2- Perform fundal massage 3- Notify the physician or midwife of excessive blood loss 4- Achieve free-flowing venous access

2,3,4,1 Correct Correct Feedback [Page reference: 368]

Question 19. The postpartum nurse is educating a patient about what to expect when she goes home. What information about diaphoresis is important to include in the teaching? Select all that apply. 1. "Sweating occurs in the weeks after childbirth because of increased estrogen levels." 2. "You might experience periods of profuse sweating." 3. "This is your body's way of getting rid of extra fluid." 4. "Wearing a cotton nightgown will help with comfort." 5. "If you experience profuse sweating you should take your temperature."

2,3,4,5 Rationales Option 1: Diaphoresis occurs during the first few postpartum weeks in response to decreased estrogen levels. Option 2: Diaphoresis, or profuse sweating, occurs during the first few postpartum weeks. Option 3: Diaphoresis assists the body in excreting the increased fluid accumulated during pregnancy. Option 4: The nurse should discuss comfort measures such as wearing cotton nightwear. Option 5: Feelings of warmth, sweating, and chills are a sign of fever and infection. Women with these symptoms need to differentiate between fever and diaphoresis. [Page reference: 378, 381-382]

Question 21. A nurse is caring for a postpartum patient who gave birth to her first baby 24 hours ago. What actions should the nurse perform to help promote rest and sleep? Select all that apply. 1. Administer Zolpidem 5mg PO. 2. Cluster nursing care, such as assessments and interventions. 3. Encourage woman to sleep when the baby sleeps. 4. Suggest a postpartum nanny. 5. Medicate for pain as per orders.

2,3,5 Rationales Option 1: Zolpidem (Ambien) is a sleep medication that may be ordered by the physician as PRN. The nurse should try non-pharmacologic sleep interventions first. Option 2: Clustering nurse care will minimize disruptions to the woman's sleep. Option 3: Women should be encouraged to sleep while the baby is sleeping, and to prioritize activities with a focus on both self-care and infant-care. Option 4: Suggesting a nanny may upset a woman and portray that the nurse thinks she is incapable of caring for her baby. Option 5: Pain interferes with sleep. [Page reference: 366]

Question 22. A postpartum patient is preparing to administer Colace to a patient who gave birth 12 hours ago. What information is important for the nurse to understand regarding gastrointestinal (GI) function post-birth? Select all that apply. 1. Gastrointestinal muscle tone increases post-birth. 2. Gastrointestinal motility decreases post-birth. 3. The risk for constipation decreases post-birth. 4. Gastrointestinal function returns to normal within two weeks. 5. Hemorrhoids are not common during pregnancy and birth.

2,4 Rationales Option 1: Gastrointestinal muscle tone decreases post- birth. Option 2: GI motility decreases post-birth. Option 3: Women are at risk for constipation due to decreased GI motility from the effects of progesterone, decreased physical activity, and dehydration. Option 4: GI function returns to normal by the end of the second postpartum week. Option 5: Women commonly develop hemorrhoids during pregnancy and/or the birthing process. [Page reference: 380]

Question 53. The postpartum nurse is educating a patient on bowel function post-childbirth. What information is important for the nurse to include? Select all that apply. 1. "Drink at least 2 liters of fluids a day." 2. "Eat a lot of fruits and vegetables." 3. "Avoid whole grains and legumes." 4. "Your bowels should be back to normal within 2-3 days." 5. "Try not to ambulate too much."

2,4 Rationales Option 1: Women should be instructed to increase fluid intake to at least 3,000mL a day. Option 2: A diet that includes fiber-rich foods promotes intestinal peristalsis. Option 3: A diet that includes fiber-rich foods promotes intestinal peristalsis. Option 4: Normal bowel function usually returns in 2-3 days after delivery. Option 5: Ambulation promotes intestinal peristalsis and reduces the risk for constipation. [Page reference: 380]

Question 8. A postpartum nurse is caring for multiple patients on the mother-baby unit. Which task can the nurse delegate to the Licensed Practical Nurse (LPN)? 1. Re-admit a patient 2 weeks post-op cesarean section with an infection 2. A G1P1 needing discharge teaching 3. A G2P1 who gave birth yesterday and has moderate lochia rubra 4. A G6P6 2 days post-op cesarean section at 34 weeks gestation

3 Rationales Option 1: Admission assessments must be completed by an RN. Option 2: Discharge teaching must be completed by an RN. Option 3: Moderate lochia rubra is a normal finding the day after delivery, so this task may be delegated to the LPN. Option 4: Patients with preterm babies will require teaching by an RN. [Page reference: 87] Test Taking Tip: Tasks that require admission assessments or teaching must be completed by an RN. When delegating to an LPN, choose the task or client that is the most stable.

Question 3. A G6P5 patient who is 24-hours post vaginal delivery reports severe cramp-like uterine pain. What is the priority nursing intervention for this patient? 1. Document the pain score in the electronic medical record. 2. Assess the perineum for a vaginal hematoma. 3. Encourage warm packs to the abdomen. 4. Notify the healthcare provider STAT.

3 Rationales Option 1: Documenting the pain score is not the priority action by the nurse. Option 2: Pin caused by a hematoma is typically sudden onset and one-sided. Option 3: Multiparous women may experience afterpains caused by the uterus working to remain contracted. Warm packs can help ease the pain. Option 4: Afterpains are a normal finding in a multiparous woman. [Page reference: 369]

Question 24. What statement made by a postpartum patient indicates to the nurse understanding of discharge instructions? 1. "I do not need to schedule a follow-up doctor appointment if I am not experiencing complications." 2. "I will notify my midwife if my breasts get engorged." 3. "I will call my doctor if I experience heavy lochia." 4. "I will see my doctor again in 2 weeks for a follow-up appointment."

3 Rationales Option 1: Guidelines recommend that all women attend a postpartum follow-up visit 4 to 6 weeks after birth. Option 2: Breast changes, such as engorgement, is an expected physical change postpartum. Option 3: Heavy lochia indicates possible secondary postpartum hemorrhage. Option 4: Guidelines recommend that all women attend a postpartum follow-up visit 4 to 6 weeks after birth. [Page reference: 381-382]

Question 6. A nurse is caring for a patient who gave birth 30 minutes ago. Upon fundal assessment, the nurse notes moderate vaginal bleeding and a boggy uterus that does not respond to fundal massage. What is the priority nursing action? 1. Continue fundal massage. 2. Document the findings and reassess in 5 to 10 minutes. 3. Increase IV Oxytocin rate. 4. Administer misoprostol 600mg rectally.

3 Rationales Option 1: If the uterus does not respond to fundal massage, additional nursing interventions should be implemented. Option 2: Uterine Atony is the number one cause of postpartum hemorrhage and should be treated promptly. Option 3: Universal active management of third stage of labor includes increasing the IV Oxytocin rate to assist with uterine contraction. Option 4: Misoprostol is a uterotonic and should be available in case IV Oxytocin is not effective. [Page reference: 368, 369]

Question 15. The postpartum nurse is educating a patient who is receiving the Measles, Mumps, and Rubella (MMR) vaccine. What statement made by the patient indicates the need for further teaching? 1. "My arm might be sore where I was given a shot." 2. "I will avoid pregnancy for 4 weeks." 3. "I will need to receive this vaccine again during my next pregnancy." 4. "I am being vaccinated against German measles."

3 Rationales Option 1: Possible side effects include redness, swelling and pain at the injection site. Option 2: Women who receive the MMR vaccine should avoid pregnancy for 4 weeks. Option 3: Pregnant women should not get the MMR vaccine. Option 4: Rubella is also called the German measles. [Page reference: 376-377]

Question 50. A postpartum patient asks the nurse when she can expect to get her period again. What is the correct response by the nurse? 1. "Your period will return when you stop breastfeeding." 2. "Because you are breastfeeding, you can expect to get your period 7-9 weeks post-birth." 3. "Return of your period depends on how long and how much you breastfeed." 4. "Most women get their period within 10 weeks of delivery."

3 Rationales Option 1: The average time to return to ovulation for women who breastfeed is 17 weeks post-delivery. Option 2: Menses usually begins 7-9 weeks post-birth for non-lactating women. Option 3: Return of menses depends on the length and amount of breastfeeding. Option 4: The average time to return to ovulation for women who breastfeed is 17 weeks post-delivery, and 10 weeks postpartum for non-lactating women. [Page reference: 378]

Question 29. A nurse is educating a patient on the mother-baby unit about breastfeeding. Which statements made by the patient indicate need for further teaching? Select all that apply. 1. "During the first 24 hours postpartum, my breasts should be soft and non-tender." 2. "Colostrum gives my baby protection from viruses and bacteria." 3. "Colostrum is thick and whitish in color." 4. "Colostrum has more carbohydrates than breast milk." 5. "I might feel throbbing pain in my breasts for the first 1 to 2 days."

3,4 Rationales Option 1: An expected finding during the first 24 hours is breasts that are soft and non-tender. Option 2: Colostrum contains immunoglobulins G and A that provide protection for the newborn during the early weeks of life. Option 3: Colostrum is a clear, yellowish fluid. Option 4: Colostrum is lower in carbohydrates than breast milk. Option 5: As the breasts become larger and firmer, the woman may feel a throbbing pain that subsides within 24 to 48 hours. [Page reference: 373-374]

Question 34. A perinatal nurse is educating a patient with preeclampsia about potential complications during delivery. What important information should the nurse include in the teaching? 1. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 2 weeks postpartum." 2. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 weeks postpartum." 3. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 6 months postpartum." 4. "Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum."

4 Rationales Option 1: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 2: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 3: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. Option 4: Maternal mortality is the death of a woman from complications of pregnancy and childbirth occurring up to 1 year postpartum. [Page reference: 366]

Question 25. During routine assessment, a nurse caring for a postpartum patient notes the uterus is shifted to the side. What is the priority nursing action? 1. Notify the physician or midwife. 2. Document the findings in the electronic medical record. 3. Perform gentle fundal massage. 4. Assist the woman to the bathroom.

4 Rationales Option 1: The physician or midwife does not need to be notified unless the position of the uterus does not return to normal after the bladder is empty. Option 2: The nurse should document the findings after assisting the patient to empty her bladder. Option 3: The fundus is most likely shifted due to a full bladder. Fundal massage should be performed for uterine atony. Option 4: The fundus is most likely shifted due to a full bladder. Fundal massage should be performed for uterine atony. [Page reference: 368]