Developmental Concepts - Peds Module 4

A nurse is providing care to a postpartum woman who gave birth about 2 days ago. The client asks the nurse, "I haven't moved my bowels yet. Is this a problem?" Which response by the nurse would be most appropriate? A) "It might take up to a week for your bowels return to their normal pattern." B) "I'll get a laxative prescribed so that you can move your bowels." C) "That's unusual. Are you making sure to eat enough?" D) "Let me call your healthcare provider about this problem."

A) "It might take up to a week for your bowels return to their normal pattern."

A new mother is concerned because it is 24 hours after birth and her breasts have still not become engorged with breast milk. How should the nurse respond to this concern? A) "It takes about 3 days after birth for milk to begin forming." B) "I'm sorry to hear that. There are some excellent formulas on the market now, so you will still be able to provide for your infant's nutritional needs." C) "You may have developed mastitis. I'll ask the primary care provider to examine you." D) "You are experiencing lactational amenorrhea. It may be several weeks before your milk comes in."

A) "It takes about 3 days after birth for milk to begin forming."

A woman comes to the clinic. She gave birth about 2 months ago to a healthy term male newborn. During the visit, the woman tells the nurse, "I've noticed that I'm a bit uncomfortable now when we have sexual intercourse. Is there anything that I can do?" The woman's menstrual period has not yet resumed. Which suggestion by the nurse would be most appropriate? A) "You might try using a water-soluble lubricant to ease the discomfort." B) "It takes a while to get your body back to its normal function after having a baby." C) "This is entirely normal, and many women go through it. It just takes time." D) "Try doing Kegel exercises to get your pelvic muscles back in shape."

A) "You might try using a water-soluble lubricant to ease the discomfort."

A client gave birth to a healthy boy 2 days ago. Both mother and baby have had a smooth recovery. The nurse enters the room and tells the client that she and her baby will be discharged home today. The client states, "I do not want to go home." What is the nurse's most appropriate response? A) Ask the client why she does not want to go home. B) Inform the primary care provider that the client does not want to go home. C) Tell the client that she must go home as per hospital policy. D) Ask the client if she has any support in the home.

A) Ask the client why she does not want to go home.

A woman gave birth vaginally approximately 12 hours ago, and her temperature is now 100° F (37.8° C). Which action would be most appropriate? A) Continue to monitor the woman's temperature every 4 hours; this finding is normal. B) Notify the health care provider about this elevation; this finding reflects infection. C) Obtain a urine culture; the woman most likely has a urinary tract infection. D) Inspect the perineum for hematoma formation.

A) Continue to monitor the woman's temperature every 4 hours; this finding is normal.

A nurse is caring for a breastfeeding client who reports engorgement. The nurse identifies that the client's condition is due to not fully emptying her breasts at each feeding. Which suggestion should the nurse make to help her prevent engorgement? A) Feed the baby at least every two or three hours. B) Apply cold compresses to the breasts. C) Provide the infant oral nystatin. D) Dry the nipples following feedings.

A) Feed the baby at least every two or three hours.

A concerned client tells the nurse that her husband, who was very excited about the baby before its birth, is apparently happy but seems to be afraid of caring for the baby. What suggestion should the nurse give to the client's husband to resolve the issue? A) Hold the baby frequently. B) Speak to his friends who have children. C) Read up on parental care. D) Have the client speak to the primary care provider on her husband's behalf

A) Hold the baby frequently.

While providing care to a postpartum client on her first day at home, the nurse observes which behavior that would indicate the new mother is in the taking-hold phase? A) Showing increased confidence when caring for the newborn B) Talking about her labor experience to others around her C) Pointing out specific features in the newborn D) Having feelings of grief or guilt

A) Showing increased confidence when caring for the newborn

During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? A) Urinary elimination B) Elimination of solid wastes C) Being too tired to eat D) Breathing off fluid vapor

A) Urinary elimination

During a routine home visit, the couple asks the nurse when it will be safe to resume full sexual relations. Which answer would be the best? A) generally within 3 to 6 weeks B) whenever the couple wishes C) generally after 12 weeks D) usually within a couple weeks

A) generally within 3 to 6 weeks

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? A) lochia rubra B) lochia serosa C) lochia normalia D) lochia alba

A) lochia rubra

A nurse is assessing a woman who gave birth vaginally approximately 24 hours ago. Which finding would the nurse report to the primary care provider immediately? A) oral temperature 100.8° F (38.2° C) B) pulse rate 75 beats per minute C) respiratory rate 16 breaths/minute D) uterine fundus 1 cm below umbilicus

A) oral temperature 100.8° F (38.2° C)

The nurse who is working with parents and their newborn encourages which action to assist the bonding and attachment between them? A) touching B) talking C) looking D) feeding

A) touching

The nurse is caring for a client in the postpartum period. The client has difficulty in voiding and is catheterized. The nurse would monitor the client for which condition? A) urinary tract infection B) loss of pelvic muscle tone C) increased urine output D) stress incontinence

A) urinary tract infection

In a class for expectant parents, the nurse may discuss the various benefits of breastfeeding. However, the nurse also describes that there are situations involving certain women who should not breastfeed. Which examples would the nurse cite? Select all that apply. A) women on antithyroid medications B) women on antineoplastic medications C) women using street drugs D) women with more than one infant E) women who had difficulties with breastfeeding in the past

A) women on antithyroid medications B) women on antineoplastic medications C) women using street drugs

A mother just gave birth 3 hours ago. The nurse enters the room to continue hourly assessments and finds the client on the phone telling the listener about her fear while driving to the hospital and not making it in time. The mother finishes the call, and the nurse begins her assessment with which phrase? A) "I need to assess your fundus now." B) "It sounded like you had quite a time getting here. Would you like to continue your story?" C) "You have a beautiful baby, why worry about that now?" D) "If you plan to breast-feed, you need to calm down."

B) "It sounded like you had quite a time getting here. Would you like to continue your story?"

A client who gave birth vaginally 16 hours ago states she does not need to void at this time. The nurse reviews the documentation and finds that the client has not voided for 7 hours. Which response by the nurse is indicated? A) "If you don't attempt to void, I'll need to catheterize you." B) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness." C) "I'll contact your primary care provider." D) "I'll check on you in a few hours."

B) "It's not uncommon after birth for you to have a full bladder even though you can't sense the fullness."

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? A) "It takes a while to get your body back to its normal function after having a baby." B) "You might try using a water-soluble lubricant to ease the discomfort." C) "This is entirely normal, and many women go through it. It just takes time." D) "Try doing Kegel exercises to get your pelvic muscles back in shape."

B) "You might try using a water-soluble lubricant to ease the discomfort."

A woman is bottle-feeding her baby. When the nurse comes into the room the woman says that her breasts are painful and engorged. Which nursing intervention is appropriate? A) Assist the woman into the shower, and have her run cold water over her breasts. B) Assist the woman in placing ice packs on her breasts. C) Explain to the woman that she should breastfeed because she is producing so much milk. D) Ask if she wants a breast pump to empty her breasts.

B) Assist the woman in placing ice packs on her breasts.

The client, G5 P5, is resting comfortably with her infant after 14 hours of labor. The nurse is conducting an assessment and notes the uterine fundus is two fingers above the umbilicus and feels soft and spongy. Which action should the nurse prioritize after noting the delivery was completed 12 hours ago? A) Put on the call button to summon help B) Gently massage the fundus until it tones up C) Administer oxytocics to prevent uterine atony D) Teach the woman to perform periodic self-fundal massage

B) Gently massage the fundus until it tones up

A nurse is performing an assessment on a female client who gave birth 24 hours ago. On assessment, the nurse finds that the fundus is 2 cm above the umbilicus and boggy. Which intervention is a priority? A) Notify the primary care provider, and document the findings. B) Have the client void, and then massage the fundus until it is firm. C) Assess a full set of vital signs. D) Check and inspect the lochia, and document all findings.

B) Have the client void, and then massage the fundus until it is firm.

A woman states that she still feels exhausted on her second postpartal day. The nurse's bestadvice for her would be to do which action? A) Avoid getting out of bed for another 2 days. B) Walk with the nurse the length of her room. C) Walk the length of the hallway to regain her strength. D) Avoid elevating her feet when she rests in a chair.

B) Walk with the nurse the length of her room.

When caring for a postpartum client who has given birth vaginally, the nurse assesses the client's respiratory status, noting that it has quickly returned to normal. The nurse understands that which factor is responsible for this change? A) increased progesterone levels B) decreased intra-abdominal pressure C) decreased bladder pressure D) use of anesthesia during birth

B) decreased intra-abdominal pressure

Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? A) infection B) dehydration C) change in the temperature from the birth room D) fluid volume overload

B) dehydration

The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? A) presence of lochia rubra B) fever more than 100.4° F (38° C) C) fundus is above the umbilicus D) fundus is firm

B) fever more than 100.4° F (38° C)

The nurse is observing a client who gave birth yesterday. Where should the nurse expect to find the top of the client's fundus? A) one fingerbreadth above the umbilicus B) one fingerbreadth below the umbilicus C) at the level of the umbilicus D) below the symphysis pubis

B) one fingerbreadth below the umbilicus

Which finding would lead the nurse to suspect that a postpartum client is developing thrombophlebitis? A) edema in perineal area B) redness in lower legs C) diaphoresis D) increased lochia

B) redness in lower legs

Which factor puts a client on her first postpartum day at risk for hemorrhage? A) hemoglobin level of 12 g/dl B) uterine atony C) thrombophlebitis D) moderate amount of lochia rubra

B) uterine atony

A client who gave birth to a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client? A) "Bruising and swelling of the perineum often causes excessive urination." B) "Larger than normal amounts of urine frequently occurs due to swelling of tissues surrounding the urinary meatus." C) "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." D) "Anesthesia causes decreased bladder tone, which causes you to urinate more frequently."

C) "Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid."

A woman delivered her infant 3 hours ago and the postpartum nurse is checking the mother's uterus. She finds that the uterus is still level with the umbilicus and is not firm. What would be the first thing the nurse should check in this client? A) Her hematocrit B) The size of her infant C) Her bladder for distension D) Her episiotomy

C) Her bladder for distension

A client who has a breastfeeding newborn reports sore nipples. Which intervention can the nurse suggest to alleviate the client's condition? A) Recommend a moisturizing soap to clean the nipples. B) Encourage use of breast pads with plastic liners. C) Offer suggestions based on observation to correct positioning or latching. D) Fasten nursing bra flaps immediately after feeding.

C) Offer suggestions based on observation to correct positioning or latching.

Prior to discharge from the hospital, a nurse is checking the fundal height for a new mother who delivered 2 days ago. The nurse would anticipate which finding? A) Level with the umbilicus B) One fingerbreadth below the umbilicus C) Two fingerbreadths below the umbilicus D) At the pubic bone

C) Two fingerbreadths below the umbilicus

Seven hours ago, a multigravida woman gave birth to a 4133-g male infant. She has voided once and calls for a nurse to check because she states that she feels "really wet" now. Upon examination, her perineal pad is saturated. The immediate nursing action is to: A) inspect the perineum for lacerations. B) increase the flow of an IV. C) assess and massage the fundus. D) call the primary care provider or the nurse-midwife.

C) assess and massage the fundus.

A new mother who is breastfeeding reports that her right breast is very hard, tender, and painful. Upon examination the nurse notices several nodules and the breast feels very warm to the touch. What do these findings indicate to the nurse? A) normal findings in breastfeeding mothers B) an improperly positioned baby during feedings C) mastitis D) too much milk being retained

C) mastitis

A client gave birth 2 days ago and is preparing for discharge. The nurse assesses respirations to be 26 rpm and labored, and the client was short of breath ambulating from the bathroom this morning. Lung sounds are clear. The nurse alerts the primary care provider and the nurse-midwife to her concern that the client may be experiencing: A) mitral valve collapse. B) thrombophlebitis. C) pulmonary embolism. D) upper respiratory infection.

C) pulmonary embolism.

A woman who delivered her infant 2 days ago asks the nurse why she wakes up at night drenched in sweat. She is concerned that this is a problem. The nurse's best reply would be: A) "Many women sweat after delivery but you seem to be perspiring far more than normal. I'll call the doctor." B) "Often, when a postpartum woman perspires like you are reporting, it means that they have an infection." C) "I need to get your vital signs and check your fundus to be sure you are not going into shock." D) "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

D) "Sweating is very normal for the first few days after childbirth because your body needs to get rid of all the excess water from pregnancy."

A nurse helps a postpartum woman out of bed for the first time postpartally and notices that she has a very heavy lochia flow. Which assessment finding would best help the nurse decide that the flow is within normal limits? A) The flow contains large clots. B) The flow is over 500 mL. C) Her uterus is soft to your touch. D) The color of the flow is red.

D) The color of the flow is red.

Which nursing intervention is appropriate for prevention of a urinary tract infection (UTI) in the postpartum woman? A) increasing oral fluid intake B) increasing intravenous fluids C) screening for bacteriuria in the urine D) encouraging the woman to empty her bladder completely every 2 to 4 hours

D) encouraging the woman to empty her bladder completely every 2 to 4 hours

A woman who is breastfeeding her newborn reports that her breasts seem quite full. Assessment reveals that her breasts are engorged. Which factor would the nurse identify as the most likely cause for this development? A) cracking of the nipple B) improper positioning of infant C) inadequate secretion of prolactin D) inability of infant to empty breasts

D) inability of infant to empty breasts

The nurse is preparing discharge training for a G2P2 client who will breast-feed her infant. The client mentions she wants more children but wants to wait a couple years and asks about birth control. Which time frame for using a birth control method should the nurse point out will best help the client achieve her goals? A) when she stops breast-feeding B) within 18 months C) within 6 weeks D) when she resumes sexual activity

D) when she resumes sexual activity